Initial Comments:
Based on the findings of an unannounced onsite state re-licensure and complaint investigation survey conducted onsite February 12th and 15th of 2024 and offsite on February 13th, 14th and 20th of 2023, Bayada Hospice was found to be in compliance with the requirements of 42 CFR, Part 418.113, Subpart D, Conditions of Participation: Hospice Care-Emergency Preparedness.
Plan of Correction:
Initial Comments:
Based on the findings of an unannounced onsite state re-licensure and complaint investigation survey conducted onsite February 12th and 15th of 2024 and offsite on February 13th, 14th and 20th of 2023, Bayada Hospice was found not to be in compliance with the requirements of 42 CFR, Part 418, Subparts A, C, and D, Conditions of Participation: Hospice Care.
Plan of Correction:
418.56(b) STANDARD
PLAN OF CARE
Name - Component - 00
All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire.
Observations:
Based on review of clinical records (CR), and interview with the agency ' s administrator, the hospice failed to follow the Hospice Plan of Care and/or Physician orders for six (6) of twenty-three (23) clinical records (CR # 11, 12, 13, 16, 22 and 23).
Findings include:
A review of clinical records (CR) was conducted on 2/13/24 from approximately 8:00 AM to 3:00 PM and again on 2/14/2024 from approximately 8:00 AM to 3:00 PM revealed the following:
CR#11. Start of Care: 6/30/23. Certification period reviewed: 6/30/23 - 9/27/23. During the week of 6/30/23, there was an order for Hospice Aide visit one (1) time and no visit was conducted. During the week of 7/9/23 and 9/3/23, there was an order for Hospice aides visit three (3) times weekly and no visit was conducted each week. During the week of 7/16/23, 8/6/23, 8/20/23, 8/27/23 and 9/24/23, there was an order for Hospice aides visit three (3) times weekly and only two (2) visits were conducted each week. During the week of 9/10/2, there was an order for Hospice aides visit three (3) times and only one (1) visit was conducted each week. There was no documentation that the IDG was notified about the missed visits and there was no verbal order to update or discontinue the order.
CR#12. Start of Care: 12/31/23. Certification period reviewed:12/31/23 - 3/29/24. During the week of 12/31/23, there was an order for Skilled Nurse visit four (4) time and only three (3) visits were conducted. There was no documentation that the IDG was notified about the missed visits and there was no verbal order to update or discontinue the order.
CR#13. Start of Care: 3/27/23. Certification period reviewed: 3/27/23 - 6/24/23. During the week of 3/27/23, there was an order for Skilled Nurse visit four (4) time and only three (3) visits were conducted. During the week of 4/2/23, there was an order for Skilled Nurse visit three (3) time and only two (2) visits were conducted. During the week of 4/16/23, there was an order for Skilled Nurse visit three (3) time and only one (1) visit was conducted. During the week of 5/14/23, there was an order for Skilled Nurse visit three (3) time and only two (2) visits were conducted. There was no documentation that the IDG was notified about the missed visits and there was no verbal order to update or discontinue the order.
CR#16. Start of Care: 2/8/23. Certification period reviewed: 5/9/23 - 7/11/23. During the month of 5/9/23, there was an order for Spiritual Counselor visit three (3) time and four (4) visits were conducted. During the week of 5/9/23, there was an order for Hospice Aide visit three (3) time and no visit was conducted. During the week of 6/25/23, there was an order for Hospice Aide visit three (3) time and only two (2) visits were conducted. There was no documentation that the IDG was notified about the missed visits and extra visit and there was no verbal order to update or discontinue the order.
CR#22. Start of Care: 10/13/22. Certification period reviewed: 2/5/24 - 4/4/24. During the week of 2/5/24, there was an order for Hospice Aide visit five (5) time and only four (4) visits were conducted. There was no documentation that the IDG was notified about the missed visits and extra visit and there was no verbal order to update or discontinue the order.
CR#23. Start of Care: 12/21/23. Certification period reviewed: 12/21/23 - 3/19/24. During the week of 12/24/23, there was an order for Skilled Nurse visit two (2) time and only one (1) visit was conducted. During the week of 1/28/24, there was an order for Hospice Aide visit one (1) time and no visit was conducted There was no documentation that the IDG was notified about the missed visits and extra visit and there was no verbal order to update or discontinue the order.
An interview with the agency ' s administrator on 2/15/24 at approximately 3:00 PM confirmed the above findings.
Plan of Correction:543
Based on an analysis of the specific deficiencies cited, the corrective plan and actions taken are to address the lack of demonstrated knowledge resulting in failure to follow the Hospice Plan of Care and/or Physician orders. The plan of correction will be completed through comprehensive focused education.
By 3/22/2024, the Director/designee will educate all office and field staff on policy Provisions of Hospice Services, 0-4547 and Missed Visits/Hours, 0-6277 with emphasis on the requirement to provide services in accordance with the plan of care/physician orders, and the requirement to communicate with the physician if there is a deviation from the established visit pattern/when there are fewer or additional visits provided.
Effective 3/25/2024 for three months, the Director/designee will review weekly the records of 10 active clients to ensure services were provided at the frequency indicated on the plan of care, and if they were not, that there is documentation of notification to the physician of the missed/added visit. The expected compliance threshold will be 100%. Failure to achieve 100% will be addressed through focused education with the individual staff members by the Director/designee.
The Director has overall responsibility for implementation and oversight of the plan.
418.76(h)(1)(i) STANDARD
SUPERVISION OF HOSPICE AIDES
Name - Component - 00
(l) A registered nurse must make an on-site visit to the patient's home:
(i) No less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. The hospice aide does not have to be present during this visit.
Observations:
Based on a review of clinical records (CR), agency's policy, and an interview with the administrator, the Hospice failed to ensure a registered nurse assess the quality of care and services provided by hospice aide at a minimum of every 14 days for seven (7) of twenty-three (23) clinical records (CR #2, 4, 7, 10, 11, 16 and 20).
Findings include:
A review of policy "0-4849 Frequency of Staff Supervision - Hospice" conducted on 2/15/24 at approximately 2:00 PM revealed the following:
Policy reads in part, "Our Procedure: 3.0 HOME HEALTH AIDE SUPERVISION. Four clients are receiving Home Health Aide (HHA) Services, an RN (Registered Nurse) must make an on site visit to the client ' s home: 3.1 no less frequently than every 14 days to assess the quality of care and the services provided by the Hospice aide and to ensure that services ordered by the Hospice interdisciplinary group meet the client ' s needs. The Hospice aide does not have to be presented during this visit. "
A review of clinical records (CR) was conducted on 2/13/24 from approximately 8:00 AM to 3:00 PM and again on 2/14/2024 from approximately 8:00 AM to 3:00 PM revealed the following:
CR#2. Start of Care: 11/1/23. Certification period reviewed: 11/1/23 - 1/29/24. File contained Hospice Aide orders two (2) times a week for twelve (12) weeks effective of 11/5/23. File contains documentation that Registered Nurse conducted supervisory visits only on 11/7/23, 12/12/23 and 1/22/23.
CR#4. Start of Care: 12/6/23. Certification period reviewed: 12/6/23 - 3/4/24. File contained Hospice Aide orders one (1) time a week for nine (9) weeks effective of 12/31/23. File did not contain documentation that Registered Nurse conducted supervisory visits.
CR#7. Start of Care: 6/26/23. Certification period reviewed: 12/23/23 - 2/20/24. File contained Hospice Aide orders three (3) times a week for eight (8) weeks effective of 12/24/23. File contains documentation that Registered Nurse conducted supervisory visits only on 1/23/24, 1/25/24, 2/1/24 and 2/7/24.
CR#10. Start of Care: 10/2/23. Certification period reviewed: 10/2/23 - 12/30/23. File contained Hospice Aide orders one (1) time a week for eight (8) weeks effective of 11/5/23. File contains documentation that Registered Nurse conducted supervisory visits only on 11/9/23 and 12/7/23 although CR continued receiving Hospice Aide visit until 12/26/23.
CR#11. Start of Care: 6/30/23. Certification period reviewed: 6/30/23 - 9/27/23. File contained Hospice Aide orders one (1) time a week for one (1) week, two (2) times a week for one (1) week, three (3) times a week for eleven (11) weeks, two (2) times a week for one (1) week effective of 6/30/23. File did not contain documentation that Registered Nurse conducted supervisory visits.
CR#16. Start of Care: 2/8/23. Certification period reviewed: 5/9/23 - 7/11/23. File contained Hospice Aide orders three (3) times a week for thirteen (13) weeks effective of 5/9/23. File contains documentation that Registered Nurse conducted supervisory visits only on 5/15/23, 6/4/23, 6/28/23 and 7/10/23.
CR#20. Start of Care: 10/27/23. Certification period reviewed: 1/25/24 - 4/23/24. File contained Hospice Aide orders one (1) time a week for one (1) week, three (3) times a week for twelve (12) weeks, one (1) time a week for one (1) week effective of 1/25/24. File did not contain documentation that Registered Nurse conducted supervisory visits.
An interview with the agency ' s administrator on 2/15/24 at approximately 3:00 PM confirmed the above findings.
Plan of Correction:629
Based on an analysis of the specific deficiencies cited, the corrective plan and actions taken are to address the lack of demonstrated knowledge resulting in the failure to ensure a registered nurse assess the quality of care and services provided by hospice aide at a minimum of every 14 days. The plan of correction will be completed through comprehensive focused education.
By 3/22/2024, the Director/designee will educate all office and field staff on policy Frequency of Staff Supervision, 0-4849 with emphasis on the requirement for aide services to be supervised no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide. Education also included the requirement for a Registered Nurse to conduct the supervisory visit.
Effective 3/25/2024 for three months, the Director/designee will review weekly 10 records of clients receiving home health aide services to ensure supervisory visits are conducted no less than every 14 days by a Registered Nurse. The expected compliance threshold will be 100%. Failure to achieve 100% will be addressed through focused education with the individual staff members by the Director/designee.
The Director has overall responsibility for implementation and oversight of the plan.
Initial Comments:
Based on the findings of an unannounced onsite state re-licensure and complaint investigation survey conducted onsite February 12th and 15th of 2024 and offsite on February 13th, 14th and 20th of 2023, Bayada Hospice was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
Plan of Correction:
Initial Comments:
Based on the findings of an unannounced onsite state re-licensure and complaint investigation survey conducted onsite February 12th and 15th of 2024 and offsite on February 13th, 14th and 20th of 2023, Bayada Hospice was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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