Initial Comments:
Based on the findings of an unannounced, onsite state re-licensure survey conducted on October 18, 2023 through October 25, 2023, Bayada 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 state re-licensure survey conducted on October 18, 2023 through October 25, 2023, Bayada 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:
418.52(c)(1) STANDARD
RIGHTS OF THE PATIENT
Name - Component - 00
§418.52(c) Standard: Rights of the patient
The patient has a right to the following:
§418.52(c)(1) Receive effective pain management and symptom control from the hospice for conditions related to the terminal illness;
Observations:
Based on review of policies and procedures, medical records (MR), and an interview with the agency administrator, the agency failed to ensure the patients received effective pain management and symptom control in three (3) of seventeen (17) files reviewed. (MR # 12, # 16- # 17)
Review of Bayada Client Assessment-Hospice services policy on 10/20/23 at 10:30 AM revealed: " Our policy: The Bayada Hospice Interdisciplinary group (IDG) conducts and documents a client-specific comprehensive assessment that identified the client ' s need for hospice care and services, and the client ' s need for physical, psychosocial, emotional, and spiritual care. " ; " Our procedure: 1.0 A start of care assessment is completed .... The assessment includes: 1.4 pain assessment; 4.0 The comprehensive assessment includes consideration of: " 4.6: Drug profile, including prescriptions, over-the-counter medications, herbal remedies, and ... ...which includes identification of: effectiveness of drug therapy ... "
Review of Bayada Pain Assessment and Management policy on 10/20/23 at 12:30 PM revealed: " Our procedure: 1.0 General information: Bayada honors and protects the rights of the client to have an assessment and appropriate management of pain throughout service. " 2.0 Assessment of pain: 2.1 Admission and reassessment by Clinical Manager/Case Manager: " Pain is assessed for all clients at admission and each reassessment ... " ; 2.1.5 " When pain is assessed as a problem or not being managed effectively, goals and interventions will be established in collaboration with the client ...as follows: c. Hospice services: Nurse will communicate the client ' s status to the ....to update the plan of care and/or obtain for pain management ....All IDG members are required to report a client ' s pain to the Registered Nurse (RN) case manager ... " ; 3.0 Pain management plan: " 3.2: Actions to address the presence of pain, ..., and ineffective pain control regime include: a. calling the physician to obtain further direction or change in orders ... " ; 3.4: Clients ' satisfaction with assessment and management of pain is monitored through the client satisfaction survey process for discharged and long term clients ... "
Medical records were reviewed on 10/19/23 from approximately 2:00 PM-3:00 PM and 10/20/23 from 9:30 AM- 12:30 PM revealing:
MR # 12: Start of care (SOC): 6/14/23; date of death: 6/17/23; client ' s family filed a Consumer Assessment of Healthcare Providers and Systems (CAHPS) hospice survey complaint on 9/21/23 in regards " no comfort kit in home until noon on Saturday 6/17/23."
a.Patient had an order for oxycodone for back pain that was ordered 3/24/23 prior to hospice admission. Comfort kit was not present in home on admission (6/14/23), it was to be delivered the next business day. Verbal order was received on 6/15/23 to add Fentanyl twenty-five (25) micrograms (mcg) every seventy-two (72) hours via transdermal (patch applied to skin) due to family call stating that client " is having uncontrolled pain and is sleeping until noon. " Patient ' s family called hospice on 6/17/23 stating that they still didn ' t receive the comfort kit and patient experienced nausea the night before. Comfort kit didn ' t arrive until around 11:30 AM on 6/17/23. (three (3) days after hospice admission)
MR # 16: SOC: 3/16/23; discharged on 6/13/23 to another hospice after two (2) complaints that the hospice was not filling medication in a timely manner.
MR # 17: SOC: 3/14/23; discharged on 6/1/23 due to client ' s wife was unhappy with certain aspects of hospice services involving getting wound care patches and receiving medication refills in a timely manner.
An interview conducted with agency administrator on 10/20/23 at approximately 2:00 PM confirmed the above findings.
Plan of Correction:Based on an analysis of the specific deficiencies cited, the corrective plan and actions taken are to address the lack of demonstrated knowledge resulting in failure to ensure the client received effective pain management and symptom control. The plan of correction will be completed through comprehensive focused education.
By 12/1/2023 the Director of Clinical Operations/designee will educate all agency staff on the following:
- A review of admission procedures with emphasis on the process to order supplies and the comfort kit including documenting all steps taken to order and followup on delivery of supplies, the comfort kit, and availability of ordered medications.
- Policy Pain Assessment and Management, 0-886 and the process for pain management with emphasis on the collaborative effort between the client and/or caregiver, the physician and the clinical team to reach the goals of optimal comfort, safety, alertness and dignity. Education included actions to address the presence of pain, changes in status, and ineffective pain control regime which include:
1. Calling the physician to obtain further direction or change in orders,
2. Asking client/caregiver to keep a pain management log, to be shared with the physician, to determine cause, frequency, effectiveness of treatment, etc.,
3. Encouraging the client/caregiver to report changes in pain or changes in response treatments,
4. Educating client/caregiver regarding the correct use and administration of pain medications, treatment application and/or use of other methods of pain control.
- The medication reconciliation process with emphasis on identifying when additional medications are required to be ordered to ensure timely refill of medications.
Effective 12/4/2023 for three months, the Director/designee will review weekly all new admissions to ensure all medications and supplies (including the comfort kit) are ordered and that documentation is present in the client record of all efforts made to deliver medication and supplies in a timely manner. The goal for compliance will be 100%. Sustained improvement will be monitored through client file reviews conducted as a required component of the Organization's Quality Assurance and Performance Improvement program.
The Director has overall responsibility for implementation and oversight of the plan.
418.60(a) STANDARD
PREVENTION
Name - Component - 00
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 policies and procedures, personnel files (PF), and interview with agency administrator, it was determined that the agency failed to ensure direct care workers had a screening for mycobacterium tuberculosis and testing upon hire in eight (8) of eleven (11) files reviewed. (PF # 1-2, # 4, # 6-8 and # 10-11)
Review of Bayada tuberculosis (TB) risk assessment and exposure plan on 10/18/23 at 2:10 PM revealed: " Our policy: Bayada Home health care continually evaluates the risk for transmission of M. Tuberculosis to determine the types of ... .... and respiratory protection needed. Bayada has procedures for the proper TB screening of employees ... " " Our procedure: Note: State/program/contract specific requirements that exceed this policy must be followed ... " " TB Screening requirements: TB screening will be conducted for employees for preventing the transmission of Mycobacterium tuberculosis in health care settings. " " Employees required to be screened: TB screening is required for the following employees: all field employees, all clinical office-based employees who enter a client ' s home ..., directors, client service managers and ... who conduct home visits for " meet and greets " for new admissions or other reasons .... " ; " Initial TB screening requirements upon hire: TB screening is required and performed at the time of hire, before an employee enters a client home ...; The TB screening consists of: 1 ....3. TB test " ; TB screening procedure: TB screening requirement is satisfied in one (1) of the following three (3) ways: 1. Baseline Two-step Mantoux tuberculin skin test (TST) .... " ; State and program specific amendments: " Pennsylvania: All employees .....will receive the baseline two-step TST. If the baseline is utilized, both steps of the two-step TST must be completed before a new employee can enter a client home or provide any care ... "
The CDC guidelines state that all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) of a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screen annually. HCWs with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease. CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings, 2005. Morbidity and Mortality World Report 2005;(RR-17) .
*Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).
Review of personnel files (PF) conducted on 10/18/23 from 11:20 AM-12:20 PM and 2:45 PM-3:00 PM revealed the following:
PF #1, (DOH): 5/22/23, the file did not contain documentation that two (2) step PPD testing or a single blood assay was completed upon hire. There was a one-step PPD completed on 5/23/23.
PF #2, (DOH): 5/29/23, the file did not contain documentation that two (2) step PPD testing or a single blood assay was completed upon hire. There was a one-step PPD completed on 6/12/23 (fourteen (14) days after hire).
PF #4, (DOH): 11/16/22, the file did not contain documentation that two (2) step PPD testing or a single blood assay was completed upon hire. There was a one-step PPD completed on 12/28/22 (forty-two (42) days after hire).
PF #6, (DOH): 3/20/23, the file did not contain documentation that two (2) step PPD testing or a single blood assay was completed upon hire. There was a one-step PPD completed on 3/20/23.
PF #7, (DOH): 6/5/23, the file did not contain documentation that two (2) step PPD testing or a single blood assay was completed upon hire. There was a one-step PPD completed on 6/5/23.
PF #8, (DOH): 5/26/23, the file did not contain documentation that two (2) step PPD testing or a single blood assay was completed upon hire. There was a one-step PPD completed on 5/31/23.
PF #10, (DOH): 6/19/23, the file did not contain documentation that two (2) step PPD testing or a single blood assay was completed upon hire. There was a one-step PPD completed on 6/20/23.
PF #11, (DOH): 10/2/23, the file did not contain documentation that two (2) step PPD testing or a single blood assay was completed upon hire. There was a one-step PPD completed on 10/11/23 (nine (9) days after hire).
An interview conducted with the agency administrator on 10/18/23 at 3:00 PM confirmed the above findings.
Plan of Correction:Based on an analysis of the specific deficiencies cited, the corrective plan and actions taken are to address the lack of demonstrated knowledge resulting in failure to ensure direct care worker staff had a screening for mycobacterium tuberculosis and testing upon hire. The plan of correction will be completed through comprehensive focused education.
By 11/6/2023, all identified staff (employees #1, #2, #4, #6, #7, #8, #10, and #11) completed their blood assay screening.
By 12/1/2023 the Director of Clinical Operations/designee will educate all office staff on policy TB Risk Assessment & Exposure Plan, 0-1999 and the requirements for TB screening and assessment at hire with emphasis on completing a baseline two-step TST or one-time BAMT/IGRA before entering a client home or providing care.
Effective 12/4/2023 for three months, the Director/designee will review weekly the records of all new hires to ensure a baseline two-step TST or one-time BAMT/IGRA has been completed before the employee is scheduled to enter any client home/provide client care. Sustained improvement will be monitored through employee file reviews conducted as a required component of the Organization's Quality Assurance and Performance Improvement program.
The Director has overall responsibility for implementation and oversight of the plan.
418.100(c)(2) STANDARD
SERVICES
Name - Component - 00
(2) Nursing services, physician services, and drugs and biologicals (as specified in §418.106) must be made routinely available on a 24-hour basis 7 days a week. Other covered services must be available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family.
Observations:
Based on review of medical records (MR), policies and procedures, and an interview with agency administrator, the agency failed to ensure that drugs and biologicals were available on a twenty-four (24) hour basis seven (7) days a week to meet the needs of the patient and family in three (3) of seventeen (17) files reviewed. (MR # 12, # 16- # 17)
Review of Bayada Client Assessment-Hospice services policy on 10/20/23 at 10:30 AM revealed: " Our policy: The Bayada Hospice Interdisciplinary group (IDG) conducts and documents a client-specific comprehensive assessment that identified the client ' s need for hospice care and services, and the client ' s need for physical, psychosocial, emotional, and spiritual care. " ; " Our procedure: 1.0 A start of care assessment is completed .... The assessment includes: 1.4 pain assessment; 4.0 The comprehensive assessment includes consideration of: " 4.6: Drug profile, including prescriptions, over-the-counter medications, herbal remedies, and ... ...which includes identification of: effectiveness of drug therapy ... "
Review of Bayada Pain Assessment and Management policy on 10/20/23 at 12:30 PM revealed: " Our procedure: 1.0 General information: Bayada honors and protects the rights of the client to have an assessment and appropriate management of pain throughout service. " 2.0 Assessment of pain: 2.1 Admission and reassessment by Clinical Manager/Case Manager: " Pain is assessed for all clients at admission and each reassessment ... " ; 2.1.5 " When pain is assessed as a problem or not being managed effectively, goals and interventions will be established in collaboration with the client ...as follows: c. Hospice services: Nurse will communicate the client ' s status to the ....to update the plan of care and/or obtain for pain management ....All IDG members are required to report a client ' s pain to the Registered Nurse (RN) case manager ... " ; 3.0 Pain management plan: " 3.2: Actions to address the presence of pain, ..., and ineffective pain control regime include: a. calling the physician to obtain further direction or change in orders ... " ; 3.4: Clients ' satisfaction with assessment and management of pain is monitored through the client satisfaction survey process for discharged and long term clients ... "
Medical records were reviewed on 10/19/23 from approximately 2:00 PM-3:00 PM and 10/20/23 from 9:30 AM- 12:30 PM revealed:
MR # 12: Start of care (SOC): 6/14/23; date of death: 6/17/23; client ' s family filed a Consumer Assessment of Healthcare Providers and Systems (CAHPS) hospice survey complaint on 9/21/23 in regards " no comfort kit in home until noon on Saturday 6/17/23."
a.Patient had an order for oxycodone for back pain that was ordered 3/24/23 prior to hospice admission. Comfort kit was not present in home on admission (6/14/23), it was to be delivered the next business day. Verbal order was received on 6/15/23 to add Fentanyl twenty-five (25) micrograms (mcg) every seventy-two (72) hours transdermal (patch applied to skin) due to family call stating that client " is having uncontrolled pain and is sleeping until noon. " Patient ' s family called hospice on 6/17/23 stating that they still didn ' t receive the comfort kit and patient experienced nausea the night before. Comfort kit didn ' t arrive until around 11:30 AM on 6/17/23. (three (3) days after hospice admission)
MR # 16: SOC: 3/16/23; discharged on 6/13/23 to another hospice after two (2) complaints that the hospice was not filling medication in a timely manner.
MR # 17: SOC: 3/14/23; discharged on 6/1/23 due to client ' s wife was unhappy with certain aspects of hospice services involving getting wound care patches and receiving medication refills in a timely manner.
An interview conducted with the agency administrator on 10/20/23 at approximately 1:30 PM revealed: "We did have an issue with a Registered Nurse (RN) completing documentation and ordering supplies in a timely manner which did cause some revocations, the RN was disciplined and eventually left the hospice."
An interview conducted with agency administrator on 10/20/23 at approximately 2:00 PM confirmed the above findings.
Plan of Correction:Based on an analysis of the specific deficiencies cited, the corrective plan and actions taken are to address the lack of demonstrated knowledge resulting in failure to ensure that drugs and biological were available on a 24/7 basis. The plan of correction will be completed through comprehensive focused education.
By 12/1/2023 the Director of Clinical Operations/designee will educate all agency staff on the following:
- A review of admission procedures with emphasis on the process to order supplies and the comfort kit including documenting all steps taken to order and followup on delivery of supplies, the comfort kit, and availability of ordered medications.
- Policy Pain Assessment and Management, 0-886 and the process for pain management with emphasis on the collaborative effort between the client and/or caregiver, the physician and the clinical team to reach the goals of optimal comfort, safety, alertness and dignity. Education included actions to address the presence of pain, changes in status, and ineffective pain control regime which include:
1. Calling the physician to obtain further direction or change in orders,
2. Asking client/caregiver to keep a pain management log, to be shared with the physician, to determine cause, frequency, effectiveness of treatment, etc.,
3. Encouraging the client/caregiver to report changes in pain or changes in response treatments,
4. Educating client/caregiver regarding the correct use and administration of pain medications, treatment application and/or use of other methods of pain control.
- The medication reconciliation process with emphasis on identifying when additional medications are required to be ordered to ensure timely refill of medications.
Effective 12/4/2023 for three months, the Director/designee will review weekly all new admissions to ensure all medications and supplies (including the comfort kit) are ordered and that documentation is present in the client record of all efforts made to deliver medication and supplies in a timely manner. The goal for compliance will be 100%. Sustained improvement will be monitored through client file reviews conducted as a required component of the Organization's Quality Assurance and Performance Improvement program.
The Director has overall responsibility for implementation and oversight of the plan.
Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted October 18, 2023 through October 25, 2023, Bayada 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 October 18, 2023 through October 25, 2023, Bayada Hospice, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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