Aseracare Hospice

“Based on review of facility policy and procedure, documentation, and staff (EMP) interview, the facility failed to establish and maintain a comprehensive emergency preparedness program to include delegations of authority. Findings included: Review of the agency policy and procedures was conducted on 10/24/2024 at approximately 3:40 PM which revealed, “;AGENCY SPECIFIC EMERGENCY MANAGENT PLAN-COMMUNICATION...COMMUNICATION POLICY * The agency administrator, Director of Operations, or designee will act as the emergency Disaster coordinator and will determine the activation of the emergency management plan with collaboration from the AVP and VP Operations. *The agency will determine key personnel who will act as the Emergency Disaster Coordinator if the Administrator/Director is not available...The agency will maintain a current and accurate Organizational Chart that will be used to define lines of authority, identify reporting mechanisms at all levels and will serve as the basis for the Staff Notification Tree. *The agency will define predetermined roles, in the event of an emergency/disaster. *Emergency Disaster Coordinator will ensure the existence of an emergency response team to respond to an emergency. (Care Center Task List for Emergency Management Plan Activation)...” Review of the agency documentation was conducted on 10/24/2024 at approximately 3:40 PM which revealed, Exercises conducted under the branch site location located in Johnstown, PA on 7/19/2022, 05/07/2023 and 6/25/2024. Exercises were conducted under the main site located in Altoona, PA on 9/6/2022, 2/23/2024 and 5/14/2024. Review of the main location was conducted “;Care Center Name : Altoona Location Code: 2674 date: 5/14/2024. Emergency Preparedness Planning-Care Center Tasks, CARE CENTER TASKS FOR EMERGENCY MANAGEMENT PLAN ACTIVATION The Administrator of the home health provider or Director of Operations who serves as the Emergency Disaster Coordinator, has the authority to activate the Emergency Management Plan after collaboration with the AVP and SVP of Operations...Position EMERGENCY DISASTER COORDINATOR, Care Center Role Administrator/Director of Operations, Responsibilities Establish and maintain overall response strategy and coordination as the care center level at all times. Assigned to (EMP7), Date Reviewed 4.9.2024...” Review of the Branch location was conducted “;Care Center Name : Johnstown, PA Location Code: 2672 date: 6/25/2024. Emergency Preparedness Planning-Care Center Tasks, CARE CENTER TASKS FOR EMERGENCY MANAGEMENT PLAN ACTIVATION The Administrator of the home health provider or Director of Operations who serves as the Emergency Disaster Coordinator, has the authority to activate the Emergency Management Plan after collaboration with the AVP and SVP of Operations...Position EMERGENCY DISASTER COORDINATOR, Care Center Role Administrator/Director of Operations, Responsibilities Establish and maintain overall response strategy and coordination as the care center level at all times. Assigned to (EMP5), Date Reviewed 6/25/2024...” Upon review of the agency comprehensive emergency preparedness program the surveyor could not distinguish the delegations of authority for the agency. An exit interview was conducted via teleconference on 10/25/2024 at approximately 3:00 PM with the five (4) vice presidents, two (2) directors of operations, two (2) business office managers, regional business office manager, clinical regulatory operations coordinator, clinical regulatory RN specialist, regional volunteer coordinator, director of clinical resource, regional bereavement coordinator and regional manager of bereavement services which confirmed the above information.”

“Based on review of hospice policies, medical records (MR), and interview with hospice staff, the hospice failed to provide services as ordered for two (2) of twenty-three (23) MR reviewed. (MR4 and MR20). Findings included: Review of the agency policy on 11/13/2024 at approximately 12:40 PM revealed, “;Clinical Records Maintenance and Confidentiality...7.Missed Visits – A missed visit is defined as a visit that is not made as scheduled and cannot be rescheduled within the patients Medicare treatment week. If an ordered visit cannot be made, the clinician will first determine whether the visit is appropriate to be made up in the current Medicare treatment week. If this is possible, the clinician will reschedule the visits within Medicare treatment week. Typically, a new order is not required in these situations unless the visit was ordered to take place on a specific day. If the clinician is unable to make up the visit during the Medicare week and the frequency of made visits will be lower than that ordered, a Hospice Missed Visit Note would need to be completed in the tablet and syncd in with other visit documentation. Although a verbal order for this missed visit is not required, the physician must be notified of the missed visit. Other documentation that may be submitted to document less than ordered visits includes: Supplemental orders to decrease a frequency (note: Follow Medicare guidelines for completing the HHABN when appropriate) *Discipline or care center discharge summary...” Review of the agency policy on 11/13/2024 at approximately 12:40 PM revealed, “;Topic: Hospice Plan of Care...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 patients needs if any of them so desire. The hospice must ensure that each patient and the primary care giver(s) receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care. (c) Standard: Content of the Plan of Care: The hospice must develop an individualized written plan of care for each patient. The plan of care must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: 1. Interventions to manage pain and symptoms. 2. A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs...” A review of MR4 was conducted on 10/23/2024 at approximately 11:25 AM review of the medical record revealed a hospice recertification plan of care update dated 9/24/2024. With a start of care 4/13/2022 with a certification period of 9/29/2024 to 11/27/2024. Hospice aide services were to be provided three (3) time a week for eight (8) weeks then two (2) times a week for one (1) week. The surveyor requested the home health aide calendar for October of 2024. The dates of 10/7/2024, 10/11/2024 and 10/16/2024 were listed as missed visits. No documentation was provided by the agency to confirm the reason or refusal for the dates services were not provided. During a complaint survey a review of MR20 was conducted on 10/30/2024 at approximately 12:30 PM review of the medical record revealed a hospice recertification plan of care update dated 8/20/2024. With a start of care 8/20/2024 with a certification period of 8/20/2024 to 11/17/2024. Hospice aide services were to be provided two (2) times a week for twelve (12) weeks. The surveyor requested the home health aide calendar for October of 2024. The dates of 10/10/2024 and 10/17/2024 were listed as missed visits. No documentation was provided by the agency to confirm the reason or refusal for the dates services were not provided. An exit interview was conducted via teleconference on 10/25/2024 at approximately 3:00 PM with the five (4) vice presidents, two (2) directors of operations, two (2) business office managers, regional business office manager, clinical regulatory operations coordinator, clinical regulatory RN specialist, regional volunteer coordinator, director of clinical resource, regional bereavement coordinator and regional manager of bereavement services which confirmed the above information.”

“Based on review of agency policy and procedure, observation (OBV), and staff (EMP) interviews, the agency failed to ensure one (1) of four (4) employees followed infection control policy and procedure during observations for bag technique conducted during (OBV#4 MR3). Findings included: Review of the agency policy and procedures was conducted on 10/24/2024 at approximately 3:40 PM which revealed, “;Bag Technique... Home Health and Hospice...GUIDELINES...Supply bags are cleaned when visibly soiled and at least monthly. Surface barrier materials should be a water-resistant material, should protect the full bottom surface of the supply bag, used on a one-time basis and discard as household waste. PROCEDURE: 1. Bags are placed on a barrier in the patients home. Bags should be placed on padded furniture, such as sofas or beds without a barrier. Bags should not be placed on the floor in the patients home The bag may be hung on a doorknob or the back of a heavy chair...13. When visibly soiled, the supply bag should be washed with soap and water and dried thoroughly. Routinely disinfect the inside of the supply bag with a disinfectant wipe, check supply expiration dates and restock your bag...” Observations (OBV4 MR3), during a visit on 10/24/2024 at 2:14 PM revealed, EMP6 provided direct patient care. EMP6 placed the backpack on a clean chuck/barrier on a table. A strap from the backpack was lying off the left side of the chuck/barrier against the table and tablecloth. No observation of disinfectant or cleaning of the strap was observed after services were provided. An exit interview was conducted via teleconference on 10/25/2024 at approximately 3:00 PM with the five (4) vice presidents, two (2) directors of operations, two (2) business office managers, regional business office manager, clinical regulatory operations coordinator, clinical regulatory RN specialist, regional volunteer coordinator, director of clinical resource, regional bereavement coordinator and regional manager of bereavement services which confirmed the above information.”