Initial Comments:
Based on the findings of an unannounced on-site hospice federal recertification survey and a state re-licensure survey completed on May 30, 2024, Advantage Home Health and 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 on-site hospice federal recertification survey and a state re-licensure survey completed on May 30, 2024, Advantage Home Health and Hospice was found not to be in compliance with the requirements of 42 CFR, Part 418, Subparts A, C &;; D, Conditions of Participation: Hospice Care.
Plan of Correction:
418.78(b) STANDARD
ROLE
Name - Component - 00
Volunteers must be used in day-to-day administrative and/or direct patient care roles.
Observations:
Based on a review of agency policy/procedure, a review of clinical records, and an interview with the agency Administrator, agency failed to ensure volunteers were used in day-to-day direct patient care roles for nine (9) of fourteen (14) clinical records (CR) reviewed (CR#2, CR#4-CR#7, CR#9-CR#11, CR#13).
Findings:
Agency policy/procedure reviewed on May 30, 2024 at approximately 11:00 a.m. 'Volunteer Services' 'Policy' "Hospice uses volunteers in administrative or direct care roles ...."'Procedure' (9) "Volunteer duties may include, but are not limited to: Patient care activities, .....Administrative support activities: ...."
Patient CRs were reviewed on May 30, 2024 between approximately 10:30 a.m. and 2:00 p.m. Patients start of care (SOC) is listed below.
CR#2, SOC 12/01/23: No documentation provided of the agency offering volunteer services and/or the patient refusing volunteer services.
CR#4, SOC 01/31/24: No documentation provided of the agency offering volunteer services and/or the patient refusing volunteer services.
CR#5, SOC 05/17/24: No documentation provided of the agency offering volunteer services and/or the patient refusing volunteer services.
CR#6, SOC 05/15/24: No documentation provided of the agency offering volunteer services and/or the patient refusing volunteer services.
CR#7, SOC 02/27/24: No documentation provided of the agency offering volunteer services and/or the patient refusing volunteer services.
CR#9, SOC 09/01/23: No documentation provided of the agency offering volunteer services and/or the patient refusing volunteer services.
CR#10, SOC 04/17/24: No documentation provided of the agency offering volunteer services and/or the patient refusing volunteer services.
CR#11, SOC 02/17/23: No documentation provided of the agency offering volunteer services and/or the patient refusing volunteer services.
CR13, SOC 07/12/23: No documentation provided of the agency offering volunteer services and/or the patient refusing volunteer services.
An interview conducted with the agency Administrator on May 30, 2024, at approximately 2:15 p.m. confirmed the above findings.
Plan of Correction:Effective week of 6/16/24 All staff will be educated concerning Section 418.78(b). Attendance will be recorded, and any clinicians absent for this training will receive 1:1 training from the Administrator or designee.
Effective week of 6/16/24 All SOC admission will be audited by the Administrator or designee for compliance. This audit will be conducted weekly until a compliance rate of 95% is reached x2. At that time, audits will become part of agency QAPI program for continued monitoring
418.78(e) STANDARD
LEVEL OF ACTIVITY
Name - Component - 00
Volunteers must provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff. The hospice must maintain records on the use of volunteers for patient care and administrative services, including the type of services and time worked.
Observations:
Based on a review of agency policy/procedure, a review of agency volunteer use records, and an interview with the agency Administrator, agency failed to ensure volunteers provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours, for one (1) of one (1) volunteer cost savings documentation (VCSD) reviewed (VD#1).
Findings:
Agency policy/procedure reviewed on May 30, 2024 at approximately 11:00 a.m. 'Volunteer Services' 'Policy' "Hospice uses volunteers in administrative or direct care roles ...."'Procedure' (2) Hospice will document the cost savings achieved through the use of volunteers and will include: ".....Hospice will document and maintain a volunteer staff sufficient to provide administrative and/or direct patient care in an amount that, at a minimum, equals 5% of the total patient care hours of all paid hospice employees and contract staff. Hospice will document a continuing level of volunteer activity. ...."
VCSD was reviewed on May 29, 2024 at approximately 11:30 a.m.
VD#1: Volunteer cost savings was requested for the past (12) months. The total cost savings equated to 3 percent.
An interview conducted with the agency Administrator on May 30, 2024, at approximately 2:15 p.m. confirmed the above findings.
Plan of Correction:
Effective week of 6/16/24 The Volunteer Coordinator will be educated concerning Section 418.78(e) A review of the Cost Savings Report Requirement will be included in the education. A record of this education will be kept. The Volunteer Coordinator will demonstrate an understanding of the Cost Savings Report formula and monthly requirement.
The Administrator or designee will review monthly Cost Savings Reports to verify the percentage is greater than 5% each month.
The administrator or designee will continue to review monthly until a percentage of 5% or greater is met by x2 months
After this the agency will continue to monitor quarterly as part of the Agencies QAPI plan
418.108(c)(1) STANDARD
INPATIENT CARE PROVIDED UNDER ARRANGEMENTS
Name - Component - 00
If the hospice has an arrangement with a facility to provide for short-term inpatient care, the arrangement is described in a written agreement, coordinated by the hospice and at a minimum specifies-
(1) That the hospice supplies the inpatient provider a copy of the patient's plan of care and specifies the inpatient services to be furnished;
Observations:
Based on a request of agency policy/procedure, a review of the hospice inpatient agreement with an outside facility, and an interview with the agency Administrator, agency failed to ensure an arrangement was established with a facility (in a written agreement), to provide for short-term inpatient care, for one (1) of one (1) facility inpatient written agreements (FA) reviewed (FA#1).
Findings:
Agency policy/procedure related to obtaining a written agreement from a facility to provide short term in-patient care was requested on May 30, 2024 at approximately 11:00 a.m. No specific policy provided.
FA was reviewed on May 29, 2024 at approximately 1:00 p.m.
FA#1: The 'Agreement for Hospice Services' between the hospice agency and the facility (hospital network in western and central Pennsylvania (Pa.) ) was dated 10/30/23 (effective date). 'Exhibit A' "The (facilities) included within this agreement shall be: "........... " (Locations (inpatient settings) listed included the following: Hershey, Pa. 17033, Reading, Pa. 19605, Enola, Pa. 17025, Lancaster, Pa. 17601).
The closest facility to the agency is approximately (32) miles, approximately (50) minutes west of the agency.
(Note: The agreement was signed by a hospice agency representative. The agreement was not signed by the facility representative.)
An interview conducted with the agency Administrator on May 30, 2024, at approximately 2:15 p.m. confirmed the above findings.
Plan of Correction:The Agency will work with local hospitals and skilled nursing homes with 24hr RN to establish at least 1 GIP contract by 7/12/2024
418.112(e)(3) STANDARD
COORDINATION OF SERVICES
Name - Component - 00
The hospice must:]
(3) Provide the SNF/NF or ICF/MR with the following information:
(i) The most recent hospice plan of care specific to each patient;
(ii) Hospice election form and any advance directives specific to each patient;
(iii) Physician certification and recertification of the terminal illness specific to each patient;
(iv) Names and contact information for hospice personnel involved in hospice care of each patient;
(v) Instructions on how to access the hospice's 24-hour on-call system;
(vi) Hospice medication information specific to each patient; and
(vii) Hospice physician and attending physician (if any) orders specific to each patient.
Observations:
Based on a request of agency policy/procedure, skilled nursing facility contracts, a review of clinical records, and an interview with the agency Administrator, agency failed to provide to the facility with the following: The most recent hospice plan of care specific to each patient nor the physician certification and/or recertification of the terminal illness for one (1) of one (1) skilled nursing facilities (SNF) visited (SNF#1).
Findings:
Agency policy/procedure related to the hospice ensuring the most recent Hospice plan of care specific to each patient and the Physician certification and/or recertification of the terminal illness was requested on May 30, 2024 at approximately 11:00 a.m. No specific policy provided.
SNF #1: Review of the agency/facility written agreement was conducted on May 30, 2024 at approximately 10:00 a.m. Documentation provided of 'Nursing Facility Agreement' dated November 3, 2023. Section 4.2.4 'Obtaining information from the Hospice:' "a. The most recent Hospice Plan of Care for each Hospice patient. ...c. Physician certification and if applicable, recertification of the terminal illness for each Hospice patient. ..." (Note: The agreement was signed by SNF#1 (Administrator). The agreement was not signed by the agency.)
During a home visit conducted at the facility on 05/29/24, the most recent hospice plan of care nor the physician certification and/or recertification of terminal illness was in the patients (CR#2) hospice chart. This was confirmed by the Hospice Vice-President of Compliance, who was present during the home visit.
An interview conducted with the agency Administrator on May 30, 2024, at approximately 2:15 p.m. confirmed the above findings.
Plan of Correction:All staff will be educated on the 418.112(e)(3) week of 6/16/2024 The updated Plan of Care for each patient will be given to the facility where they reside and to their primary care physician after each revision and IDG meeting by Administrator or designee, ensuring that the POC is faxed, or hand-delivered to the facility and PMD. Effective week of 6/16/2024 two Weekly audits will be performed by the Clinical Manager, or designee to assure all binder in facilities are up to date and accurate, until a compliance rate of 95% or greater is met x2 then we be included in the agencies QAPI plan for continued monitoring.
418.112(f) STANDARD
ORIENTATION AND TRAINING OF STAFF
Name - Component - 00
Hospice staff, in coordination with SNF/NF or ICF/IID facility staff, must assure orientation of such staff furnishing care to hospice patients in the hospice philosophy, including hospice policies and procedures regarding methods of comfort, pain control, symptom management, as well as principles about death and dying, individual responses to death, patient rights, appropriate forms, and record keeping requirements.
Observations:
Based on a request of agency policy/procedure, a review of hospice services contracts, and an interview with the agency Administrator, agency failed to assure hospice philosophy orientation for skilled nursing facility staff for one (1) of one (1) skilled nursing facility contracts (SNFC) reviewed (SNFC#1).
Findings:
Agency policy/procedure related to the hospice assuring hospice philosophy orientation for skilled nursing facility staff was requested on May 30, 2024 at approximately 11:00 a.m. No policy provided.
SNFC #1: Review was conducted on May 30, 2024 at approximately 10:00 a.m. of the agency/facility written agreement. Documentation provided of 'Nursing Facility Agreement' dated November 3, 2023. Section 5.8 'Education and In-Services' "Hospice retains the responsibility for arranging Hospice training, upon execution of this agreement, of facility personnel who will be providing patient care, and a description of the training and instructor name will be documented by Hospice. ...." (Note: The agreement was signed by SNF#1 (Administrator). The agreement was not signed by the agency.)
Documentation requested of the agency assuring hospice philosophy orientation for skilled nursing facility staff was requested on May 30, 2024 at approximately 10:30 a.m. No documentation provided.
An interview conducted with the agency Administrator on May 30, 2024, at approximately 2:15 p.m. confirmed the above findings.
Plan of Correction:All sales staff will receive education on 418.112(f) week of 6/16/2024. All facilities will be provided hospice philosophy education week of 6/16/2024.
All new facility contracts will be provided training on the hospice philosophy when contract is signed.
Administrator or designee will audit all new contracts to confirm this has been completed as part of agency QAPI plan.
Agency will continue to provide this education Q 6 months to all facilities.
Initial Comments:
Based on the findings of an unannounced on-site hospice state re-licensure survey completed on May 30, 2024, Advantage Home Health and 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 unannounced on-site hospice state re-licensure survey completed on May 30, 2024, Advantage Home Health and Hospice was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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