QA Investigation Results

Pennsylvania Department of Health
ANGELIC HOSPICE
Health Inspection Results
ANGELIC HOSPICE
Health Inspection Results For:


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Initial Comments:

Based on the findings of an unannounced onsite hospice Medicare recertification survey conducted on March 25, 2021 and April 8, 2021, and offsite on April 12, 2021, Angelic 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 hospice Medicare recertification and state licensure survey conducted March 25, 2021 and April 8, 2021 and offsite on April 12, 2021, Angelic 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 hospice policies and procedures, clinical record (CR), and interview with the agency staff, the hospice failed to ensure skilled nursing (SN) visits were provided in accordance with the frequency included on the hospice plan of care for one (1) of one (1) clinical records reviewed. (CR # 1)

Findings include:

Review of hospice policy titled "Plan of Care - Content" reviewed on April 12, 2021 at approximately 12:00 pm, states "Procedures:...2. The plan of care includes, but is not limited to:...b. a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs..."

Review of hospice policy titled "Interdisciplinary Group" (IDG) on April 9, 2021 at approximately 3:00 pm states "Policy: Angelic Hospice designates an IDG composed of qualified individuals who assess, plan, provide and evaluate the care and services provided to hospice patients/caregivers. Procedures:...3. The IDG is responsible for: a. establishing, implementing, reviewing, and revising the patient's plan of care; b. Providing or coordinating care and services in accordance to the patient's plan of care; c. Documenting all care and services provided in a timely manner in accordance with the hospice's documentation requirements..."

A review of the clinical record conducted on April 8, 2021 from approximately 9:40 am to 10:25 am, revealed the following:

CR# 1, Start of Care: 5/11/18. Date of Death: 3/29/2020. Certification period reviewed 3/2/2020 through 4/30/2020, contained orders for skilled nursing (SN) visits one to two times per week and PRN (as needed). No duration for SN visits is documented on order. No frequency or duration for SN PRN visit(s) is documented on order. No documentation of any SN visits were noted for this certification period.

An interview with the administrator and director of nursing conducted on April 8, 2021 at approximately 10:45 A.M. confirmed the above findings.











Plan of Correction:

Upon admission of Angelic Health's first patient, 100% of all clinical charts will be audited for compliance that the plan of care will include frequencies for all core hospice services as collaboratively agreed upon by IDG, and Medical Director/Attending MD. The plan of care will include the scope and frequencies of RN, HHA, SW, Chaplain and any other ancillary therapies ordered by the IDG. Audits will ensure compliance that IDG reviews and revised plan of care ensures ongoing coordination of care. Clinical audits will ensure compliance that all services are provided in a timely manner in accordance with the patient's plan of care and per our company documentation requirements. 100% of all clinical charts will be audited for 60 days with a threshold of 95%. Once this threshold is met, 25% of all active patient charts will be audited quarterly for continued compliance.


418.102(c) STANDARD
RECERTIFICATION OF THE TERMINAL ILLNESS

Name - Component - 00
Before the recertification period for each patient, as described in 418.21(a), the medical director or physician designee must review the patient's clinical information.




Observations:



Based on a review of hospice policy, review of clinical record (CR), and staff interviews, the hospice failed to ensure the physician certification of terminal illness was completed in accordance with hospice policy for one (1) of one (1) CR reviewed. (CR # 1)

Findings include:

A review of hospice policy "Recertification of Terminal Illness" reviewed on April 12, 2021 at approximately 11:00 am, states "Policy: After a patient completes the first 90-day hospice benefit period, the hospice Medical Director or physician member of the IDG signs a written statement for each subsequent benefit period, recertifying that the patient's prognosis is 6 months or less if the terminal illness follows its normal course. Procedures:...3...f. the physician's signature and the date signed..."

A review of CR was conducted on April 8, 2021, from approximately 9:40 am to 10:20 am, revealed the following:

CR #1, Start of Care: 5/11/18. Certification period reviewed March 2, 2020 through April 30, 2020. The "Hospice Physician Face-to-Face Encounter Recertification of Terminal Illness" form for the certification period reviewed had a physician signature and date of 3/6/18.

An interview with the administrator and director of nursing on April 8, 2021, at approximately 10:45 am confirmed the above findings.















Plan of Correction:

Prior to each patient recertification period (90 day, 90 day and subsequent 60 day periods), Angelic Health will ensure the medical director or physician designee will review the patient's clinical information and perform written certification of terminal illness in accordance to standard recertification of the terminal illness and Angelic Health policy. 100% of all patient charts will be audited for 90 days to ensure medical director/physician designee reviews clinical information and completes written certification recertifying that the patient has a life expectancy of six months or less if disease follows its normal course and the physician signature and date of certification are compliant (re-certifications may be completed up to 15 days prior to each benefit period). Once threshold of 100% is met, 25% of all active patient charts will be audited quarterly to ensure continued compliance.


Initial Comments:

Based on the findings of an onsite unannounced state re-licensure survey conducted March 25, 2021 and April 8, 2021, and offsite on April 12, 2021, Angelic 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 onsite unannounced state re-licensure survey conducted on March 25, 2021 and April 8, 2021, and offsite on April 12, 2021, Angelic Hospice, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).





Plan of Correction: