Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on 7/6/2021, Village In Place 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 onsite unannounced Medicare recertification and state relicensure survey completed 7/6/2021, Village In Place Hospice was found not to be in compliance with the following requirements of 42 CFR, Part 418, Subparts A, C, and D, Conditions of Participation: Hospice Care.
Plan of Correction:
418.54(c)(6) STANDARD
CONTENT OF COMPREHENSIVE ASSESSMENT
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[The comprehensive assessment must take into consideration the following factors:]
(6) Drug profile. A review of all of the patient's prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. This includes, but is not limited to, identification of the following:
(i) Effectiveness of drug therapy
(ii) Drug side effects
(iii) Actual or potential drug interactions
(iv) Duplicate drug therapy
(v) Drug therapy currently associated with laboratory monitoring.
Observations:
Based on review of agency policy, medical records (MR), observation, and staff (EMP) interviews, the agency failed to review all the patient's medications and update the medication profile for two (2) of thirteen (13) MR reviewed (MR7 and MR11).
Findings included:
Review of the agency policy and procedures on 7/6/2021 at approximately 10:00 AM revealed, "SUBJECT: MEDICATION RECONCILIATION/VERIFICATION (DRUG PROFILE)...POLICY: (Agency) will implement and maintain a process to obtain and document a complete list of patient's current medications upon admission...Medication reconciliation is a multidisciplinary process between Nursing, the Pharmacist and the Physician with patient/family involvement...PROCEDURE: Admission: The nurse completing the admission assessment will obtain and document the patient's current medications taken at home. These medications will be listed on the Medication Profile Form. If the PATIENT does not remember all of his/her medications, the family may be asked to bring all the patient's prescriptions to the (Agency). The patient's medication history may be obtained by: Family recall, Calling the patient's pharmacy, The patient's prescription containers, Recent H&P, Transfer Records, Primary physician...The following will be documented on the Medication Profile Form: Medication, Dose, Route, Frequency..."
A review of CR7 on 7/2/2021 at approximately 11:10 AM revealed, A "Plan of Care: 06/29/2021" with a start of care date of 6/29/2021. The primary diagnosis was malignant neoplasm of unspecified bronchus or lung. The plan of care order on 6/29/2021 documented under section DME the following: "...Oxygen Concentrator, Oxygen Portable Tank..." Review of the RN initial assessment dated 6/29/2021 documented under section "Treatment Preferences...Pt (patient) experiences SOB (shortness of breath) consistently. wears 6L (liters) O2 Via N/C 06/29/2021..." Oxygen was not listed on patients medication profile.
A review of CR11 on 7/2/2021 at approximately 11:55 AM revealed, A "Plan of Care Order: 04/06/2021" with a start of care date of 1/21/2020. The primary diagnosis was chronic obstructive pulmonary disease with (acute) exacerbation. The plan of care order on 4/6/2021 documented : "...O2 in Place at 3LPM (liters per minute) via NC (nasal cannula)..." Oxygen was not listed on patients medication profile.
An exit interview was conducted on 7/6/2021 at approximately 1:01 PM with the administrator, director, services director, community administrator which confirmed the above findings.
Plan of Correction:A staff meeting will be held with agency registered nurses and license practical nurses regarding the update to make sure that oxygen use is documented in the patient's medication file.
The hospice IDG team members will discuss patients on at least a 14 day basis and will talk regarding any patient utilizing oxygen therapy. It will be discussed in these meetings and checked to make sure oxygen is listed on patient's medication profile.
QA nurse will monitor all RN and LPN's charting for documentation of oxygen therapy. QA nurse will check to see if oxygen therapy is documented in medication profile. If it is not, QA nurse will notify RN case manager of the need to update medication profile. QA nurse will follow-up with update.
QAPI team will review on a monthly basis hospice patient's that are on oxygen therapy and check that medication profile is correct and updated with current oxygen orders.
418.60(a) STANDARD
PREVENTION
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The hospice must follow accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions.
Observations:
Based on review of agency policy and procedure, observation during home visits (OBV), and staff (EMP) interviews, the agency failed to ensure one (1) of three (3) staff followed infection control policy and procedure for bag technique (OBV3).
Findings included:
Review of Hopkins Medical Products " Healthcare Bag Technique " on 7/2/2021 at approximately 3:45 PM revealed, " Healthcare Bag Technique Prevent Cross-Contamination, Protect Patients, and Demonstrate Compliance ...Bag Technique Procedure 1. Select a healthcare bag that has at least three separate compartments, at least one of which should be lockable to secure patient records. 2. Designate two " clean " compartments, one for clean disposables and the other for patient records. 3. Pack the bag with necessary supplies before leaving for visits. Pack hand washing supplies near the top or in a side pocket where they are easily accessible. 4. Store the healthcare bag in clean storage container or other separate compartment in your car. 5. Do not take the healthcare bag into infested home s or homes of patients with antibiotic resistant infections such as MRSA or VRE. 6. In the home, identify a clean and safe area for the healthcare bag. Never set the health care bag on the floor. Always choose a place to set the bag that gives you enough workspace, is close to the patient, has a source of water, and is away from children and pets. 7. Plan where you will discard disposable items and sharps ahead of time. 8. Spread an impervious barrier on the surface before setting the bag down. 9. Remove hand washing supplies first. Wash and dry hands thoroughly, following proper hand washing technique. 10. Remove any items needed for patient care, including any necessary personal protective equipment. 11. Close the bag before performing patient care. 12. Wash your hands again if you need to re-enter the bag for additional supplies during patient care ... "
Review of the agency policy and procedures on 7/6/2021 at approximately revealed, "SUBJECT: NURSING BAG TECHNIQUES ...PURPOSE: To maintain a clean nursing bag and prevent transmission of infection to patients ...PROCEDURE: The bag should be placed on a barrier, i.e. disposable profession towels, paper towels, in the employee ' s care and in the patient ' s home. Skin cleansers and paper towels should be kept in an outside pocket for available access. Prior to administering care, skin cleanser, and paper towels (as needed) are removed, the bag is opened and hands are cleansed according to organization policy and procedure. After handwashing, all the clean supplies and equipment needed for the visit are removed from the bag. When the visit is completed: Contaminated supplies/equipment are contained/disposed of as necessary. Reusable equipment is cleaned using alcohol, antiseptic wipes, and/or soap and water as appropriate: Stethoscope (bell and diaphragm): Cleaned with alcohol/antiseptic wipe, Bandage scissors: Cleaned with alcohol/antiseptic wipe, Blood pressure cuff: Cleaned according to the manufacturer and whenever the cuff has ben soiled with blood or other potentially infectious materials ... "
Observations (OBV3), during a visit to MR3 residence on 7/1/2021 at 1:05 PM to 1:30 PM revealed, EMP7 provided direct patient care. EMP7 placed the bag on a clean chuck/barrier on the sofa. Then opened an outside flap of the nursing bag and placed clean reusable items from the nursing bag on the flap: pulse oximeter, thermometer, stethoscope and blood pressure cuff. After patient use of each of the reusable items each one was placed back on the same open flap from the nursing bag before the item was cleaned.
An exit interview was conducted on 7/6/2021 at approximately 1:01 PM with the administrator, director, services director, community administrator which confirmed the above findings.
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Plan of Correction:VIP Director will compare "Healthcare Bag Technique Prevent Cross-Contamination, Protect Patients, and Demonstrate Compliance... Bag Technique Procedure" with current VIP policy bag technique. VIP bag technique policy will be updated to reflect accurate bag technique steps given by the DOH.
A staff meeting will be held with all RN and LPN case managers to demonstrate proper bag technique. They will be given a hand-out with step-by-step instructions on proper bag technique. The VIP Director will do a live demonstration on how to correctly complete bag technique. The RN and LPN case managers will be individually asked to demonstrate proper bag technique with VIP director. RN and LPN case managers will be signed off with competency by VIP Director.
The QAPI team will institute a sign off on competencies with each RN and LPN on a quarterly basis of a live demonstration of proper bag technique.
Initial Comments:
Based on the findings of an onsite unannounced State relicensure survey completed 7/6/2021, Village In Place Hospice was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced State relicensure survey completed 7/6/2021, Village In Place Hospice was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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