Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification and State relicensure survey completed 3/24/2022, Penn Hospice Inc. was found not to be in compliance with the following requirement of 42 CFR, Part 418.113, Subpart D, Conditions of Participation: Hospice Care - Emergency Preparedness.
Plan of Correction:
418.113(a)(1)-(2) STANDARD
Plan Based on All Hazards Risk Assessment
Name - Component - 00
§403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2)
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:]
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*
(2) Include strategies for addressing emergency events identified by the risk assessment.
* [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
(2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.
*[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
(2) Include strategies for addressing emergency events identified by the risk assessment.
*[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.
(2) Include strategies for addressing emergency events identified by the risk assessment.
Observations:
Based on review of facility documentation, State Operations Manual Appendix Z (SOM) and staff (EMP) interviews, the facility failed to review and maintain a comprehensive emergency preparedness program based on a facility-based and community-based risk assessment, utilizing an all-hazards approach.
Findings included:
A review of facility emergency preparedness program was conducted on 3/24/2022 at approximately 10:10 AM "...All-Hazards Approach-An all-hazards approach is an integrated approach to emergency preparedness that focuses on identifying hazards and developing emergency preparedness capacities and capabilities that can address those hazards, as well as a wide spectrum of emergencies or disasters. This approach includes preparedness for natural, man-made, and/or facility emergencies that may include, but are not limited to, care related emergencies, equipment and power failures, interruptions in communications, including cyber attacks, loss of portion or all of a facility; and interruptions in the normal supply of essentials, such as water and food..."
A review of the SOM was conducted on 3/24/2022 at approximately 10:30 AM "State Operations Manual Appendix Z- Emergency Preparedness for All Provider and Certified Supplier Types Risk Assessments Using All-Hazard Approach...This approach is specific to the location of the facility considering the types of hazards most likely to occur in the area but should also include unforeseen widespread communicable diseases. Thus, all-hazards planning does not specifically address every possible threat or risk but ensures the facility will have the capacity to address a broad range of related emergencies..."
Review of facility Emergency Preparedness Plan policy and procedures conducted on 3/24/2022 at approximately 10:10 AM revealed the following: A document labeled "HAZARD VULNERABILITY" was reviewed. No date was available to confirm when the assessment was completed. No listing on the agencies hazard vulnerability assessment was found related to unforeseen widespread communicable diseases.
An exit interview with the chief operations officer and the clinical director on 3/24/2022 at approximately 2:45 PM confirmed the above findings.
Plan of Correction:1.Hazard vulnerability was corrected by adding date of 4/12/22. A listing of unforeseen widespread communicable disease was completed and added to Hazard Vulnerability list.
2. Education provided to Penn Hospice staff as to new content added to disaster plan.
3. Clinical manager/designee will ensure this will be completed by 5/1/2022
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification and state relicensure survey completed 3/24/2022, Penn Hospice Inc. 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
Name - Component - 00
[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 review all the patient's medications and update the medication profile and allergies for two (2) of eleven (11) MR's reviewed (MR3 and MR6).
Findings included:
Review of agency policy on 3/24/2022 at approximately 2:00 PM revealed, "Medications-RECONCILIATION SECTION 12.06...PROCEDURE 1. Reconciliation at admission and resumption of care: A. On accepting a patient referral, obtain the patient's list of active/current medications from the referring facility or from the primary care provider. b. Call the patient/caregiver before making the visit to perform the initial comprehensive medication assessment. c. Ask the patient /caregiver to collect all medications 1) Prescribed and over-the-counter meds 2) Vitamins and nutritional supplements 3) Meds taken routinely or as needed 4) By any route, including inhaled, injected, applied to skin, eyes, etc. 2. During the visit, record all medicines the patient has collected on the Medication Profile (or Reconciliation Form). a. Include the name, dose, route, and how frequently the patient takes each one. b. Ensure the patient understands how taking the medication corresponds with the label for each medication. c. Ensure there is a purpose/diagnosis/condition for each medication the patient takes. 3. Carefully compare the Medication List you have created from the drugs in the patient's home to the Medication List supplied by the discharging facility or by the primary care provider. a. Identify any discrepancies between these two lists. b. If the discrepancies cannot be resolved by the nurse, report and resolve the discrepancies with the primary care provider within one day. c. Amend the Medication Profile as per the primary care provider's orders..."
A review of MR3 on 3/22/2022 at approximately 1:32 PM revealed, the start of care date was 7/28/2021. The primary diagnosis was unspecified systolic (congestive) health failure. The "Skilled Nursing Visit Note" dated 3/19/2022 documented "...NARRATIVE NOTES...Pt wearing...oxygen more to help with endurance and fatigue..." Oxygen was not listed on the hospice certification and plan of care or the medication profile.
A review of MR 6 on 3/22/2022 at approximately 2:05 PM revealed, A hospice certification and plan of care and medication profile the start of care was 11/5/2021 for a current certification period starting 1/4/2022 and ending 3/4/2022. The primary diagnosis was heart failure unspecified. The allergies listed under the medication profile was "Contrast Dye, Clonidine." Within the plan of care listed a narrative statement which listed "Allergies: Clonidine, Codeine, Contrast Dye." The allergy to Codeine was not listed on the hospice certification plan of care and medication profile.
An exit interview with the chief operations officer and the clinical director on 3/24/2022 at approximately 2:45 PM confirmed the above findings.
Plan of Correction:1. Medical record 3 was corrected by adding the following item to MR3 Chart: Oxygen order dated 3/24/22. Medical record 6 Allergy cannot be corrected because she was discharged on 3/4/22.
2. A medical record reconciliation of Penn Hospice patient records was completed to ensure that all oxygen orders are on charts and all allergies match in all areas of chart.
3. Education was provided to Penn Hospice nursing staff as to importance of having the patients chart complete.
4. Clinical Manager/designee will audit the patients charts to ensure that all information is present weekly x4 then monthly x2
Date completed 5/1/2022
Initial Comments:
Based on the findings of an onsite unannounced State relicensure survey completed 3/24/2022, Penn Hospice Inc. 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 3/24/2022, Penn Hospice Inc. was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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