Initial Comments:Based on the findings of an onsite unannounced Medicare recertification and state relicense survey conducted 3/4/2024 through 3/7/2024, 365 Hospice LLC 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 relicense survey conducted 3/4/2024 through 3/7/2024, 365 Hospice LLC 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:
418.56(e)(5) STANDARD
COORDINATION OF SERVICES
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[The hospice must develop and maintain a system of communication and integration, in accordance with the hospice's own policies and procedures, to-]
(5) Provide for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions.
Observations:
Based on review of agency policy and procedure, observation (OBV), and staff (EMP) interviews, the agency failed to ensure an ongoing sharing of information between all disciplines providing care and services related to patient care for one (1) of four (4) patient observations that were conducted (OBV3).
Findings included:
Review of the agency's policy was conducted on 3/19/2024 at approximately 8:30 AM which revealed, "PROVISION OF CARE TO RESIDENTS OF SNF/NF OR ICF/MR...POLICY...Hospice will assume responsibility for professional management of the SNF/NF or ICF/MR resident's hospice services provided, in accordance with the hospice plan of care and the hospice CoPs, and make any arrangements for hospice-related inpatient care in a participating Medicare/Medicaid facility. PROCEDURE...6. The organization will provide the SNF/NF or ICF/MR the following information specific to each patient: A. Hospice election forms and Advance Directives B. Physician certification and recertification of the terminal illness...F. Hospice physician and attending physician (if any) orders...7. The organization must assure orientation of SNF/NF or ICF/MR staff furnishing care to hospice patients in the following...E. Appropriate forms and record keeping requirements."
MR3, patient visit was conducted at a facility on 3/6/2024 at approximately 10:21 AM. Start of Care was 11/22/2023. One agency folder was available with agency information. At approximately 10:45 AM the surveyor review the agency binder for the plan of care. A plan of care was in the binder with a certification end date of 2/19/2024. The surveyor and EMP3 review the facilities medical record for a current plan of care. The surveyor requested for EMP3 to review the agency patient information binder. EMP3 was not able to locate a current plan of care.
An exit interview was conducted on 3/7/2024 at approximately 2:30 PM with the executive director, chief financial officer, director of business development, human resource manager and clinical supervisor which confirmed the above information.
Plan of Correction:365 Hospice Executive Director has implemented a plan of correction related to Coordination of Care within nursing facilities as follows:
1. At start of care the admitting nurse will complete a coordination of care form and submit to the facility supervising nurse. This form will include the following: Contact information for 365 Hospice, start of care date, level of care, admitting diagnosis, medications covered by hospice, DME covered by hospice, Supplies covered by hospice, Visit Frequency: SN, HHA, Chaplain, SW, Bereavement and Volunteer.
2. A binder will be placed in the facility within the first 7 days of care to include the following: When to contact hospice, sign in sheet, Face Sheet, advance directives, consents for hospice, plan of care, CTI, medication profile, initial assessments for SN, Chaplain, SW, Volunteer, Bereavement, and HHA visits completed within this time frame (the reason for the 7 day is due to the SW, Chaplain, Volunteer have 5 days to complete initial assessments and the Plan of Care is not completed until their assessments are done)
3. The RNCM and/or marketer will ensure the binder is in the facility within 7 days.
4. The RNCM and/or marketer will be responsible to ensure all updated Medication Profiles, Plan of Cares and CTIs are in the binder along with notes.
5. The Executive Director and/or PCA will be completing 4 random facility binder audits at 4 different facilities monthly.
6. Goal is to have all facility binders 100% in compliance by the end of the 2nd quarter of 2024.
Initial Comments:
Based on the findings of an onsite unannounced State relicense survey completed 3/7/2024, 365 Hospice LLC 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 a review of agency complaint documentation, plan of care and staff (EMP) interview it was determined that the agency did not report patient safety issues to the Department of Health Event Reporting System (ERS) related to consumers health and wellbeing for one (1) of one (1) complaint.
Findings Included:
Review of the agency's policy was conducted on 3/19/2024 at approximately 8:30 AM which revealed, "INCIDENT REPORTING...PROCEDURE...D. Complete an incident report form within 24 hours of the incident...6. Incidents that conform to (Agency) definition of serious adverse events will be immediately reported to the Executive Director/Administrator for reporting to state and/or federal regulatory agencies."
Review of agency complaint binders 2022 and 2023 was conducted on 3/4/2024 at approximately 12:30 on 3/4/2024. Requested additional documentation for MR20. MR20 start of care 12/16/2021, primary diagnosis malignant neoplasm of brain unspecified. Complaint submitted on 6/14/2022 date of event 6/12/2022. Complaint "...Patient did not have a comfort pack in the home at time of visit...nurse utilized Atropine drops from her bag." Review of the "Medication Profile" confirmed order "12/16/2021 atropine 1% ophthalmic drops 1 % solution; Administer 2 drop(s) sublingually every 2 hours as needed for secretions..."
EMP1 confirmed on 3/5/2024 at approximately 9:30 AM that no report was submitted to the Department's Event Reporting System (ERS) related to complaint.
An exit interview was conducted on 3/7/2024 at approximately 2:30 PM with the executive director, chief financial officer, director of business development, human resource manager and clinical supervisor which confirmed the above information.
Plan of Correction:365 Hospice Executive Director has implemented the following plan of correction related DOH Event Reporting
Effective Immediately:
1. If an incident or complaint is received by the Patient Care Administrator (PCA), the PCA will obtain detailed information regarding the incident/complaint and provide written documentation to the Executive Director immediately. The Executive Director will research the incident/complaint and submit any reportable events to the DOH Event Reporting within 24 hours of receiving the incident/complaint. If the event falls under a category that affects patient safety, harm/abuse, neglect, medication error or involvement of Area on aging/law enforcement related to patient neglect/abuse/unfit living conditions.
2. The Executive Director and PCA will review all incidents/complaints to ensure any that met criteria as a reportable event are submitted to the DOH Event Report within the 24-hour guideline.
3. An audit will be conducted monthly on all reported incidents/complaints by the Executive Director as a double check system to ensure all reportable events have been reported.
4. This will be ongoing audit for the remainder of 2024 and will revisit in 2025 to determine if this audit needs to continue
Initial Comments:Based on the findings of an onsite unannounced State relicense survey completed 3/7/2024, 365 Hospice LLC was found to be in compliance with the requirements of 35 P.S. § 448.809 (b).
Plan of Correction:
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