Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification and State relicensure survey completed 11/18/2021, Interim Healthcare Hospice and Palliative Care 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 11/18/2021, Interim Healthcare Hospice and Palliative Care was found not to be in compliance with the following requirement 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) and staff (EMP) interviews, the agency failed to document on the medication profile and plan of care drug side effects for eleven (11) of eleven (11) MR's reviewed (MR 1 through MR11).
Findings included:
Review of the agency policy and procedures on 11/24/2021 at approximately 3:00 PM revealed,
Policy and Procedure Manual for Hospice Chapter 6 - Care Delivery ...Administrative Responsibilities for the Management of Patient/Family Care - continued
d) Ongoing evaluation by the IDG of the effectiveness of the plan of care in meeting
patient/family needs.
2. The Hospice DHCS or designee makes the following minimum resources available to
employees who provide patient/family care:
a) Care planning references specific to hospice and/or palliative care;
b) Current hospice Medicare Conditions of Participation (CoPs) and applicable state law
and regulation, including state practice acts for any discipline that provides care ... "
Review of the agency policy and procedures on 11/24/2021 at approximately 3:00 PM revealed, Provision of Hospice Services to Residents of a SNF/NF or ICF/MR
Policy (agency) Hospice provides hospice care to residents of a SNF/IF or ICF/MR
and maintains responsibility for professional management of hospice services in the
facility, in accordance with law and regulation ...The Interdisciplinary Group (IDG) plan of care reflects the needs of the patient and the provision of services by Interim HealthCare Hospice and by the facility staff, respectively.
Upon initial medical record review, the surveyor was unable to locate any of the clients allergies on the "Hosp IDT Meeting" or the "Patient Medication List." EMP1 was asked by the surveyor where a list of patient's allergies is located within the medical record. EMP1 confirmed the patient allergies are listed within the nursing notes under the "Allergen" tab. The surveyor confirmed all agency staff have access to the notes. The surveyor asked EMP1 does any of the skilled nursing facilities, personal care homes or assisted living facilities that patients receive services from have access to the agency electronic medical record system. EMP1 confirmed no facilities had access to the agency electronic medical record system.
An exit interview was conducted with the administrator, regional director, director of clinical services and human resources representative on 11/18/2021 at approximately 11:45 AM which confirmed the above findings.
Plan of Correction:1. The designated hospice RN completing the comprehensive assessment will be responsible for reviewing allergies with the patient, facility staff or patient's designee. This RN will then need to complete and sign a Medication and Allergen Review form during the initial Comprehensive Assessment of each patient, and with each recertification period, to show communication and coordination of the allergies. A screenshot of the hospice EMR system listed allergies is to be printed along with the medication profile and be provided to the facility or caregiver designee for the patient. The Medication and Allergen Review form will then be uploaded into the patient's documentation section of the EMR to show coordination. This screenshot of the allergies will need to be done until the EMR system is updated to reflect the allergies on the medication profiles. This process will be started Dec 17th 2021 and all patients will have the Medication and Allergen Review form completed, reviewed with each patient or caregiver, and uploaded in the EMR by January 14th, 2022.
2. Director of Clinical Services will educate all staff at the next scheduled Staff Meeting on Dec 17th to include obtaining list of allergies, coordination between hospice staff and the patients designated caregiver. This will ensure all allergies are communicated including the reactions, and education on the Medication and Allergen Review form to be completed with designee.
3. A focused Allergen Audit sheet will be used to monitor Medication and Allergen Review form compliance. The audits will be completed by the Director of Clinical Services 100% of all admissions and recertifications until 100% compliance is achieved x three consecutive months. Once the initial compliance is met a random audit of 20% of all admissions monthly will continue. Results of the audit will be reflected in the QAPI minutes and reviewed with the IDG quarterly.
4. Senior Strategic Projects Director continues to work with EMR representative to add allergens to the Medication List system and to the Interdisciplinary Group (IDG) to ensure coordination of care. These allergens will be reviewed on admission and with every Interdisciplinary Group Meeting held every 14 days. Production of this upgrade to begin after January 1, 2022 with a completion date of end of 1st quarter 2022.
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification and State relicensure survey completed 11/18/2021, Interim Healthcare Hospice and Palliative Care was found not to be in compliance with the following requirement of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
51.3 (f) LICENSURE
NOTIFICATION
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51.3 Notification
(f) If a health care facility is
aware of a situation or the occurrence
of an event at the facility which
could seriously compromise quality
assurance or patient safety, the
facility shall immediately notify the
Department in writing.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for its occurrence and the steps which
the health care facility shall take to
rectify the situation.
Observations:
Based on review of Pennsylvania (Pa.) Department of Health (DOH) Event Reporting System (ERS), agency policies and procedures and staff (EMP) interview the agency failed to ensure event reporting to the Pennsylvania (Pa.) Department of Health ERS system for eight (8) staff and eight (8) patients who were diagnosed COVID-19 positive from March 2020 to 11/14/2021.
Findings Include:
Review of the departments event reporting system guide on 11/18/2021 at approximately 2:00 PM revealed, "Health department Reportable Diseases COVID-19 Quick Start Guide COVID-19 records are reportable within 24 hours after being diagnosed ...Health Department Reportable Diseases (Covid-19) - If you select Event Type = Health Department Reportable Diseases and Event-Sub-type = Covid-19, the Reportable Disease Detail section will appear. You will be required to add at least one Reportable Disease Detail record before submitting the event to DOH. There are two ways to enter information. It should be noted that both methods can be used during the same event. You can manually enter data and/or upload a spreadsheet/s..."
Review of the agency policy on 11/17/2021 at approximately 11:45 AM revealed, "COVID-19 Emergency Temporary Standard ...Patient Screening and Management ...9. The Safety Coordinator or designee confers with the patient's/client's physician or allowed practitioner (e.g., NP, PA, CNS) coordinating and reporting infectious COVID-19 to the local Health department as soon as possible and in accordance with the agency policy for Coordination with the Public Health Department..."
It was identified that there had not been any reports submitted to the Pennsylvania (Pa.) Department of Health (DOH) Event Reporting System while reviewing the COVID-19 focused infection control survey tool for acute and continuing care on 11/17/2021 at approximately 11:45 AM. During an interview with EMP1 on 11/17/2021 at approximately 11:00 AM EMP1 confirmed no Covid-19 positive staff or patients were reported through the ERS system.
An exit interview was conducted with the administrator, regional director, director of clinical services and human resources representative on 11/18/2021 at approximately 11:45 AM which confirmed the above findings.
Plan of Correction:1. Director of Clinical Services will educate all staff at next scheduled Staff Meeting, Dec 20th 2021 on Interim's Policies and Procedures for reporting COVID-19. RN to be completing infection control reports and report any positive cases to the Director of Clinical Services within 24 hours of receipt of COVID 19 positive test result.
2. Director of Clinical Services to enter positive COVID 19 patients and employees into the ERS system within 24 hours of positive test results or notification of a positive test. Any COVID 19 positive employee will be logged into company's log on SharePoint to be monitored. Compliance to be 100%.
3. Hospice site log in and account created for the ERS reporting system on Dec 12th 2021. Director of Clinical Services, Regional Director of Operations and Office Manager will have access to the reporting system. Director of Clinical Services will enter the report to the ERS system within 24 hours of receipt of a patient or staff COVID 19 positive test result. In the Director of Clinical Services absence, the Office Manager or Regional Director of Operations will enter the report to the ERS system. 100% compliance to be maintained.
4. All COVID 19 positive documentation will be kept confidential and in a secured and locked cabinet. Log sheet to include patient or employee MRN, date of exposure, date of notification to staff and date entered in to the ERS system. Director of Clinical Services to complete a monthly audit to ensure that 100% of COVID 19 cases were reported within 24 hours. Results of the audit will be reflected in the QAPI minutes and reviewed with the IDG quarterly. Expectation is 100% compliance ongoing as evidence by monthly audit of Log sheets and Infection Control forms.
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification and State relicensure survey completed 11/18/2021, Interim Healthcare Hospice and Palliative Care was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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