Chandler Hall Health Services Inc.

“Based on a review of the clinical records, and an interview with the administrator, the governing body and the administrator failed to develop and implement written policies and procedures governing the administration and management of patient -controlled analgesia (PCA) therapy in the home setting Findings include: Request for hospice policies pertaining to PCA pump on December 12, 2025, at approximately 3:30 P.M, revealed that the agency did not have the requested policies.An interview was conducted with the agency administrator on December 21, 2023, at approximately 4 P.M. The administrator stated, “ I do not see a CADD/PCA policy”.A review of clinical files conducted on October 1, 2025 from approximately 9:35 am to 3:30 pm and then on December 11, 2025 at approximately 2pm, revealed the following: CR #1 Start of care August 13,2025, certification period- August 13, 2025, through November 10, 2025. Hospice order for Dilaudid CADD pump infusion via PCA via midline cath. Basal 0.2mg/hr. Bolus 0.05mg q 15min prn pain on September 12, 2025. Nurses notes document the patient receiving Dilaudid via CADD PCA pump via midline catheter, from September 12, 2025 to September 23, 2025. in the patient’s residence. An interview with the Administrator on December 12, 2025, at approximately 6:00 P.M. confirmed the above findings.”

“Based on employee file (EF’s) review, and an interview with the administrator, the hospice failed to ensure and maintain documented, device specific competency for nursing staff administering or managing PCA therapy using the Continuous Ambulatory Delivery Device (CADD) for Patient Controlled Analgesia (PCA) for four (4) out of the five (5) EFs reviewed. (EF#2-5) Findings include: Request for hospice policies pertaining to PCA pump on December 12, 2025, at approximately 3:30 P.M, revealed that the agency did not have the requested policies.An interview was conducted with the agency administrator on December 21, 2023, at approximately 4 P.M. The administrator stated, “ I do not see a CADD/PCA policy”.Employee file review was conducted on October 1, 2025 from approximately 3:30pm to 4 pm, then again on December 12, from approximately 9am to 12pm, and at approximately 5pm revealed the following: EF#4 Date of hire 6/28/22: Did not contain a “Competency for CADD Pump Cassette Change”. No other documentation regarding competency specific to the CADD PCA on file. A skills check list dated 3/19/25 for PCA. EF#3 DOH 4/22/19: Did not contain a “Competency for CADD Pump Cassette Change”. No other documentation regarding competency specific to the CADD pump on file. A skills check list dated 3/25/25 for PCA on file. EF#4 DOH 2/17/21: Did not contain a “Competency for CADD Pump Cassette Change”. No other documentation regarding competency specific to the CADD pump on file. A skills check list dated 3/17/25 for PCA on file. EF#5 DoH 1/22/20: Did not contain a “Competency for CADD Pump Cassette Change”. No other documentation regarding competency specific to the CADD pump on file. A skills check list dated 3/13/25 for PCA on file. An interview with the Administrator on December 12, 2025, at approximately 6:00 P.M. confirmed the above findings”

“Based on a request of agency policy/procedure, agency emergency plan review, and an interview with the agency Administrator, it was determined that the agency failed to review and update the agency emergency preparedness plan at least every 2 years, for one (1) of one (1) emergency preparedness plan (EP) reviewed (EP#1). Findings: Agency policy related to the agency emergency plan was requested on January 11, 2024 at approximately 11:00 a.m. no specific policy was provided. A review of the agency EP was completed on January 8, 2024 at approximately 2:00 p.m. EP#1: No documentation provided of the agency reviewing and updating the agency emergency preparedness plan at least every 2 years. Per the agency Administrator on 01/10/24 at approximately 11:15 a.m., the plan was reviewed this past summer (2023) but there is no documentation available. Documentation requested for the EP review/update for 2021. No documentation provided. An interview conducted with the agency Administrator on January 11, 2024, at approximately 11:45 a.m. confirmed the above findings.”

“Based on a review of agency policy/procedure, clinical record review, and an interview with the agency Administrator, it was determined that the agency failed to forward to the patient’s attending physician a copy of the hospice discharge summary for one (1) of two (2) live discharge clinical records (CR) reviewed (CR#19). Findings: Agency policy was reviewed on January 11, 2024 at approximately 11:00 a.m. Policy# HCH 24-10 ‘Discharge from Hospice Services’ ‘Procedure’ section (9) states “A copy of the discharge summary will be sent to the physician ....” A review of CRs was completed on January 11, 2024 at approximately 11:00 a.m. CR#19 Start of Care 06/12/23: Patient revoked hospice care on 07/07/23. No documentation provided of the hospice completing a discharge summary. No documentation provided of the hospice forwarding to the patient’s attending physician a copy of a hospice discharge summary. An interview conducted with the agency Administrator on January 11, 2024, at approximately 11:45 a.m. confirmed the above findings.”

“Based on a review of agency policy/procedure, clinical record review, and an interview with the agency Administrator, it was determined that the agency failed to ensure the discharge summary included all required elements for one (1) of two (2) live discharge clinical records (CR) reviewed (CR#18). Findings: Agency policy was reviewed on January 11, 2024 at approximately 11:00 a.m. Policy# HCH 24-10 ‘Discharge from Hospice Services’ ‘Procedure’ section (10) states “At the time of discharge, other service providers who will provide care, treatment, or services to the resident/patient will be informed of the following: ...... A summary of care, treatment, or services that have been provided. ....” A review of CRs was completed on January 11, 2024 at approximately 11:00 a.m. CR#18 Start of Care 06/21/23: Patient transferred to another hospice agency on 06/30/23. The agency provided documentation of ‘Administrative Communication’ and ‘DME Communication’ notes and presented them as a discharge summary. The communication notes did not include a summary of the patient’s stay including treatments, symptoms and pain management. An interview conducted with the agency Administrator on January 11, 2024, at approximately 11:45 a.m. confirmed the above findings.”

“Based on a request/review 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 include: Agency policy related to agency providing facility staff education of the hospice philosophy was requested on January 11, 2024 at approximately 11:00 a.m. No specific policy provided. Agency ‘Hospice Services Agreement’ signed by the hospice agency and the skilled nursing facility (SNF#1) on 10/02/23 section ‘1, Responsibilities of Hospice’ (m) states “Upon execution of this agreement, hospice shall assure that facility staff furnishing care to residents who are under hospice’s care are educated in the hospice philosophy, .....” SNFC #1: No documentation provided of the hospice agency orienting the skilled nursing facility (SNF#1) staff to the hospice philosophy. (Hospice patient Clinical Record #21 currently resides/resided at this facility). An interview conducted with the agency Administrator on January 11, 2024, at approximately 11:45 a.m. confirmed the above findings.”

“Based on a review of employee files, agency policy/procedure, and an interview with the agency Administrator, it was determined that the agency failed to ensure Pennsylvania State Police criminal background checks were conducted for one (1) of eight (8) employee files (EF) reviewed (EF#1). Findings: The Pennsylvania (Pa.) ‘Health and Safety (Title 35)’ ‘Older Adults protective Services Act’ §10225.502 Information relating to prospective facility personnel. (a) General rule, -- A facility shall require all applicants to submit with their applications, ............, who have or may have direct contact with a recipient to submit, there following information obtained within the preceding one-year period: (1) pursuant to 18 Pa. C.S. Ch. 91 (relating to criminal history record information), a report of criminal history record information from the state police or a statement from the State Police that their central repository contains no such information relating to that person”.Agency policy was reviewed January 11, 2024 at approximately 11:00 am. Agency policy ‘HRS 04-09, Criminal History Reports’ ‘Policy’ (1) states “As part of the application process, utilizing the Conditional Employment form, the applicant will; (a) provide information necessary to obtain a criminal history background check. (c) affirm in writing if a resident in the State of PA for 2 or more years, which if less than two years would warrant a federal criminal record (FBI clearance). (2) New hires will be considered provisional hires for 30 calendar days for individuals who need a Pennsylvania State Police Background Check and 90 days for individuals who need the FBI Background check. A copy of the Background Check will be maintained in the personnel file. A review of EFs completed on January 11, 2024 at approximately 11:00 am. revealed the following: EF#1, date of hire 10/21/21: No documentation of the agency conducting a Pennsylvania State Police criminal background check. Documentation provided of a Federal Background Check dated 02/26/2019. An interview conducted with the agency Administrator on January 11, 2024, at approximately 11:45 a.m. confirmed the above findings”