Initial Comments:
Based on the findings of an unannounced on-site hospice re-licensure survey completed between January 17, 2024 through January 18, 2024 and continued off-site January 23, 2024, Morning Star Hospice and Palliative Care Solutions, 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 unannounced on-site hospice state re-licensure survey completed between January 17, 2024 through January 18, 2024 and continued off-site January 23, 2024, Morning Star Hospice and Palliative Care Solutions, Llc, 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:
418.56(b) STANDARD
PLAN OF CARE
Name - Component - 00
All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire.
Observations:
Based on review of medical records (MR), policies/procedures and an interview with the Agency Administrator and Director of Nursing, the agency failed to ensure the plan of care was followed in three (3) of fifteen (15) records reviewed. (MR #1- # 3)
Review of Morning Star Hospice and Palliative Care Solutions, Llc, Physician orders policy on 1/28/24 at 7:05 PM revealed: Policy: "Physician orders are obtained as needed. Verbal orders are received, processed, confirmed in writing and countersigned by the physician in accordance with state/federal laws and regulations."; "Some of the reasons orders are obtained from physicians include, but are not limited to: b. Change in visit frequency if not within the range specified in the patient's plan of care."
Review of Morning Star Hospice and Palliative Care Solutions, Llc, Plan of care policy on 1/28/24 at 7:05 PM revealed: Policy:" The interdisciplinary written plan of care is based on initial and updated patient-specific comprehensive assessments by members of the IDG and is developed with measurable goals and outcomes for planned interventions. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions."; Procedure: "3. Care provided to an individual patient is in accordance with the plan of care." "6. The Hospice written interdisciplinary plan of care is developed and individualized for each patient and family, reflects patient/family goals based upon problems identified in the initial/updated assessments, and includes all services necessary for palliation and management of the terminal illness and related conditions, including the following: l. Detail of the scope and frequency of services needed to meet the patient/family needs."
Review of Morning Star Hospice and Palliative Care Solutions, Llc, spiritual care services policy on 1/28/24 at 7:20 PM revealed: Policy:" Morning Star Hospice and Palliative Care Solutions, LLC provides counseling or arranges for counseling to meet the spiritual needs of patients/caregivers in a manner consistent with their beliefs and desires and in accordance with the patient's plan of care." Procedure: "3. Spiritual counseling services are provided in accordance with the plan of care."
Review of medical records (MR) on 1/17/24 between 2:30 PM-3:30 PM and 1/18/24 between 11:50 AM-1:00 PM revealed:
Medical record (MR) #1: Start of care (SOC): 5/4/23; certification period: 11/20/23-1/18/24; plan of care order: Chaplain: once monthly and three (3) visits as needed; record noted that the chaplain visit was missed on 12/25/23 due to the holiday but no other visit was conducted by the chaplain in the month of December.
MR # 2: SOC: 10/31/23; certification period: 10/31/23-1/28/24; plan of care order: Chaplain: once monthly and three (3) visits as needed; record noted that the chaplain visit was missed on 12/25/23 due to the holiday but no other visit was conducted by the chaplain in the month of December. Plan of care order for home health aide (HHA): 11/19/23: decrease visits to three (3) times per week. Record review revealed only one (1) HHA visit was conducted during the week of 11/26/23-12/2/23.
MR # 3: SOC: 11/13/23; certification period: 11/13/23-2/10/24; plan of care order: Chaplain: once monthly and three (3) visits as needed; record noted that the chaplain visit was missed on 12/25/23 due to the holiday but no other visit was conducted by the chaplain in the month of December.
An interview with the agency administrator and director of nursing conducted on January 18, 2024, at approximately 3:15 PM confirmed the above findings.
Plan of Correction:The Agency failed to ensure the plan of care was followed in 3 of 15 records.
The Agency will educate the Chaplain on conducting visits in a timely manner based on physician's order and policy.
The chaplain will notify DON of any changes in scheduled visits and will reschedule any missed visits to ensure the policy and order is followed.
The Agency will monitor chaplain visits twice weekly x 4 weeks, then periodically thereafter, to ensure visits are completed as scheduled.
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 personnel files (PF) and interview with the agency administrator and director of nursing, it was determined the agency failed to ensure staff were screened for and were free from active mycobacterium tuberculosis (TB) prior to assignment with clients in eight (8) of nine (9) files reviewed. (PFs #1-# 4, #6-# 9)
Findings include:
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)
http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.
Review of Morning Star Hospice and Palliative Care Solutions, Llc, Tuberculosis (TB) infectious control policy on 1/28/24 at 6:45 PM revealed: Policy: "It shall be the policy of this agency to adhere to the OSHA standards related to respiratory protection and the current CDC guidelines for tuberculosis infection control. "; Purpose: "This plan is designed to prescribe practices relating to the management of Mycobacterium Tuberculosis in an effort to minimize the risk of exposure and transmission of this disease to home care staff, patients and others."; Procedures and Responsibilities: "The Agency will follow current CDC guidelines for TB monitoring and testing. The two step Mantoux PPD test or FDA approved IGRA testing shall be required for all Agency field staff with patient contact upon hire."
Review of personnel files (PF) conducted on 1/17/24 from 12:05 PM-12:35 PM and 1:00 PM-2:00 PM revealed the following:
PF 1, Date of hire (DOH): 4/17/23; had no documentation of TB testing upon hire.
PF 2, Date of hire (DOH): 11/16/23; had no documentation of tuberculosis testing upon hire. File contained a chest x-ray dated 11/17/15 (eight (8) years prior to hire) and a Quantiferon test dated 10/20/20 (three (3) years prior to hire).
PF 3, Date of hire (DOH): 2/13/23; had no documentation of tuberculosis testing upon hire.
PF 4, Date of hire (DOH):9/11/23; had no documentation of tuberculosis testing upon hire.
PF 6, Date of hire (DOH): 1/15/24; had no documentation of two-step tuberculosis testing upon hire. File contained a one-step test dated 1/5/24.
PF 7, Date of hire (DOH): 10/12/23; had no documentation of tuberculosis testing upon hire.
PF 8, Date of hire (DOH): 3/21/22; had no documentation of tuberculosis testing upon hire.
PF 9, Date of hire (DOH): 7/24/23; had no documentation of tuberculosis testing upon hire.
An interview with the agency administrator and director of nursing conducted on January 18, 2024, at approximately 3:15 PM confirmed the above findings.
Plan of Correction:The Agency failed to ensure staff were screened for and were free from active TB prior to assignment with clients in 8 of 9 files viewed.
The Agency will ensure all 8 of 9 employees noted receive a 2 Step TB test per CDC guidelines and Agency policy.
The Agency will complete an audit of all current employee records to ensure that all current employees received a 2 Step TB test during the hiring process.
The agency will ensure that all current employees complete an annual TB screening per CDC guidelines and policy.
The Agency will monitor all new hire employees to ensure that Step one TB is completed and read prior to scheduling visits. Will monitor 2 x week x 4 weeks, then periodically thereafter.
418.104(e)(2) STANDARD
DISCHARGE OR TRANSFER OF CARE
Name - Component - 00
(2) If a patient revokes the election of hospice care, or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician, a copy of-
(i) The hospice discharge summary; and
(ii) The patient's clinical record, if requested.
Observations:
Based on review of medical records (MR), policies/procedures and an interview with the Agency Administrator and Director of Nursing, the agency failed to ensure revocation procedure was followed in one (1) of fifteen (15) records reviewed. (MR #13)
Review of Morning Star Hospice and Palliative Care Solutions, Llc, revocation of the Medicare hospice benefit policy on 1/28/24 at 7:30 PM revealed: Policy: "A patient or his/her representative may revoke election of the Medicare hospice benefit at any time and for any reason during an election period. "4. To revoke the election of hospice care, the individual or representative must file a statement with the hospice that includes the following information:
a. A signed statement that the individual or representative revokes the individual's election for Medicare coverage of hospice care for the remainder of that election period; and b. The date that the revocation is to be effective. (An individual or representative may not designate an effective date earlier than the date that the revocation is made)."
Review of medical records (MR) on 1/17/24 between 2:30 PM-3:30 PM and 1/18/24 between 11:50 AM-1:00 PM revealed:
Medical record (MR) # 13: Start of Care (SOC): 6/16/23; live discharge revocation date: 9/8/23; review revealed no revocation paperwork signed by patient or patient's family. The physician was notified, and the discharge summary was sent.
An interview with the agency administrator and director of nursing conducted on January 18, 2024, at approximately 3:15 PM confirmed the above findings.
Plan of Correction:The Agency failed to ensure revocation procedure was followed in one of fifteen records reviewed.
The Agency will educate staff on the proper documentation required for revocation of services. The Agency will ensure that new clients and families are aware of the revocation process during the initial admission process.
The agency will monitor twice weekly x 4 weeks then periodically thereafter, that all revocation documentation is completed per policy, to include:
1. Revocation form is signed by client/family/POA
2. Physician is updated on revocation request
3. Documentation by clinical team is completed.
Initial Comments:
Based on the findings of an unannounced on-site hospice state re-licensure survey completed between January 17, 2024 through January 18, 2024 and continued off-site January 23, 2024, Morning Star Hospice and Palliative Care Solutions, Llc, 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 hospice state re-licensure survey completed between January 17, 2024 through January 18, 2024 and continued off-site January 23, 2024, Morning Star Hospice and Palliative Care Solutions, Llc , was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
|