Acts Hospice of Pennsylvania

“Based upon review of agency policy, accepted nursing practice, observation of hospice staff during home visits, and interview with hospice staff, employees failed to follow basic infection control practices for two (2) of four (4) observations (OBS). (OBS # 1 & 4). Findings included: Request for hospice policy pertaining to bag technique and infection control on December 21, 2023, at approximately 9:15 A.M. revealed that the agency did not have a policy for bag technique or infection control. According to an article in Home Healthcare Nurse 32(1):p 39-45, January 2014. | DOI: 10.1097/NHH.0000000000000003 titled “;Bag Technique: Preventing and Controlling Infections in Home Health Care and Hospice”, the nursing bag should be one that “;has an exterior surface material of a nonporous, non-cloth/canvas/fabric material (e.g., vinyl or leather) for ease in cleaning and disinfecting the bag’s exterior surfaces... It is suggested that minimally the bag be cleaned and decontaminated on a weekly basis with a maximum time frame of monthly and when visibly soiled...” The practice of bag technique often varies between home care and hospice organizations and depends on the home care or hospice organization’s policies, and the patient and home situation... The nursing bag should be placed on a visibly clean, dry surface in the patient’s environment. If there is no visibly clean, dry surface available, place a barrier under the bag or hang it on a doorknob or the back of a heavy chair.” “;In addition, a surface barrier should be used if a nursing bag is not taken into a home for any reason and items are temporarily removed from the nursing bag. These items removed from the bag should be placed on a barrier in the home.” Observations during home visits conducted on December 19, 2023, from approximately 10:30 A.M. to 12:30 P.M. revealed the following: Observation # 1 on December 19, 2023, at approximately 10:46 A.M. Employee (EMP) #5 was observed placing EMPs books on the patient (PT) #1s bedside table without the table surface being wiped or a barrier being placed. Observation # 4 on December 19, 2023, at approximately 11:10 A.M. EMP #9 was observed placing personal supplies, which were contained in a cloth tote bag, directly onto patient #8’s table without the table surface being wiped or a barrier being placed. An interview with the hospice Administrator and the Clinical Manager on December 21, 2023, at approximately 4:00 P.M confirmed the above findings.”

“Based on a review of hospice policy, clinical records (CR), and an interview with hospice staff, the hospice failed to ensure that the plan of care was developed in consultation with the Interdisciplinary Group (IDG) within five (5) days after the election of the hospice benefit for five (5) of nineteen (19) CR reviewed. (CR# 8, 9, 11, 12, and 16). Findings Included: Request for hospice policy pertaining to IDG and plan of care (POC) on December 21, 2023, at approximately 9:15 A.M. revealed that the agency did not have a policy for IDG and POC. A review of clinical records was conducted on December 19, 2023, from approximately 8:45 A.M. to 9:45 A.M., 1:45 P.M. to 4:30 P.M., December 20, 2020, from approximately 9:30 A.M. to 3:45 P.M., and December 21, 2023, from approximately 9:30 A.M. to 2:30 P.M. revealed the following: CR #8, start of care and hospice benefit election August 16, 2023. An initial assessment by the chaplain was conducted on September 6, 2023, twenty-one (21) days after hospice benefit election. There was no documentation the chaplain contacted the patient and/or family within the first five (5) days of hospice benefit election. CR #9, start of care and hospice benefit August 13, 2023. An initial assessment by the chaplain was conducted on August 20, 2023, seven (7) days after hospice benefit election. There was no documentation the chaplain contacted the patient and/or family within the first five (5) days of hospice benefit election. CR #11, start of care and hospice benefit election December 18, 2022. An initial assessment by the chaplain was conducted on December 31, 2022, thirteen (13) days after hospice benefit election. There was no documentation the chaplain contacted the patient and/or family within the first five (5) days of hospice benefit election. CR #12, start of care and hospice benefit election August 12, 2023. An initial assessment by the chaplain was conducted on August 20, 2023, seven (7) days after hospice benefit election. There was no documentation the chaplain contacted the patient and/or family within the first five (5) days of hospice benefit election. CR #16, start of care and hospice benefit election August 12, 2023. An initial assessment by the chaplain was conducted on August 24, 2023, twelve (12) days after hospice benefit election. There was no documentation the chaplain contacted the patient and/or family within the first five (5) days of hospice benefit election. An interview with the hospice Administrator and the Clinical Manager on December 21, 2023, at approximately 4:00 P.M confirmed the above findings.”

“Based on a review of agency policies, clinical records (CR), an interview with the agency staff, it was determined that the agency failed to conduct a review of all prescription and over-the-counter medications for three (3) of nineteen (19) clinical records (CR) reviewed (CR# 1, 6, and 8). Findings included: Request for hospice policy pertaining to medication reviews on December 21, 2023, at approximately 9:15 A.M. revealed that the agency did not have a policy for medication reviews. A review of clinical records was conducted on December 19, 2023, from approximately 8:45 A.M. to 9:45 A.M., 1:45 P.M. to 4:30 P.M., December 20, 2020, from approximately 9:30 A.M. to 3:45 P.M., and December 21, 2023, from approximately 9:30 A.M. to 2:30 P.M. revealed the following: CR #1, start of care October 31, 2022. Certification period reviewed, October 26, 2023, through December 24, 2023. Review of facility order summary report during a home visit on December 19, 2023, at approximately 11:00 A.M. revealed an order for Lorazepam Concentrate 2mg/ml (milligrams per milliliter), give 0.25 milliliter by mouth every 4 hours as needed for anxiety for 60 days. The medication was documented as discontinued on May 15, 2023, on the facility order summary report. The medication was still listed as active on the hospice team care plan as of December 18, 2023. There was no documentation of verbal orders to discontinue the medication. CR #6, start of care September 15, 2023. Certification period reviewed, November 14, 2023, through January 12, 2024. Review of facility order summary report during a home visit on December 19, 2023, at approximately 11:30 A.M. revealed the following orders: Lorazepam Concentrate 1mg/0.5 ml, give 0.25 ml sublingually (under tongue) every 6 hours as needed for agitation or anxiety. Boost Breeze give 120 ml by mouth two times a day for dietary supplement give 8 oz. (8 oz is 240 ml) by mouth. Lidocaine external ointment 5%, apply to sacrum and sacroiliac joint topically two times a day for pain. As of December 18, 2023, the hospice team care plan contained order as follows: Lorazepam by mouth concentrate 2MG/ML 0.25ML Q6H (every 6 hours) PRN (as needed) PO (by mouth) anxiety/agitation. Boost Breeze by mouth liquid 8 ounce (240 ml) BID (2 times per day) PO, supplement. Lidocaine external ointment 5% 1 application BID EX pain- R (right) sacroiliac joint, B/L UE (upper extremities) and LE (lower extremities). The hospice team care plan contained duplicate orders as follows: Ativan by mouth tablet 0.5 MG 1 tablet TID PO Lorazepam by mouth tablet 0.5 MG 1 tablet TID PO The duplicate medication was not listed on the facility order summary report. CR #8, start of care August 16, 2023. Certification period reviewed, November 14, 2023, through February 11, 2023. Review of patient medications in patients private residence on December 19, 2023, at approximately 11:15 A.M. revealed an order dated August 16, 2023, on the POC for Furosemide by mouth tablet 20 mg 1 tablet PRN PO Mon/Thurs- PRN. There was no Furosemide in the home. The patient stated that their “;daughter fills the medication box”. The POC contained an order dated December 13, 2023, for Loperamide HCl (anti-diarrheal) by mouth capsule 2mg 1 cap (capsule) Q6H PRN PO for diarrhea. The medication container lists the dosage as 4 mg every 6 hours as needed. An interview with the hospice Administrator and the Clinical Manager on December 21, 2023, at approximately 4:00 P.M confirmed the above findings.”

“Based on review of hospice policies, clinical records (CR), and interview with hospice staff, the hospice failed to provide services as ordered for four (4) of nineteen (19) CR reviewed. (CR #1, 2, 6, and 16) Findings included: Request for hospice policy pertaining to visit frequencies on December 21, 2023, at approximately 9:15 A.M. revealed that the agency did not have a policy for visit frequencies. A review of clinical records was conducted on December 19, 2023, from approximately 8:45 A.M. to 9:45 A.M., 1:45 P.M. to 4:30 P.M., December 20, 2020, from approximately 9:30 A.M. to 3:45 P.M., and December 21, 2023, from approximately 9:30 A.M. to 2:30 P.M. revealed the following: CR #1, start of care October 31, 2022. Certification period reviewed October 26, 2023, through December 24, 2023, contained orders for volunteer services three (3) to five (5) times per month for two (2) months and two (2) PRN (as needed) visits. Review of volunteer visit notes revealed documentation of only one (1) volunteer visit in the month of November, 2023. There was no documentation that the visit frequency had been amended or that the physician was notified that visits were not provided as ordered. CR #2, start of care November 15, 2023. Certification period reviewed, November 15, 2023, through January 13, 2024, contained an order for volunteer services beginning November 21, 2023, eight (8) to ten (10) visits per month for three (3) months and two (2) PRN visits. Review of volunteer visit notes revealed documentation of three (3) visits from November 15 to November 30, 2023. There was no documentation that the visit frequency had been amended or that the physician was notified that visits were not provided as ordered. CR #6, start of care September 15, 2023. Certification period reviewed, November 14, 2023, through January 12, 2024, contained an order for volunteer services three (3) to five (5) times per month for two (2) months and two (2) PRN visits. Review of volunteer visit notes revealed no documentation of volunteer visits from November 14 to November 30, 2023. There was no documentation that the visit frequency had been amended or that the physician was notified that visits were not provided as ordered. CR #16, start of care August 12, 2023. Certification period reviewed August 12, 2023, through November 9, 2023, contained an order for volunteer services six (6) to eight (8) times per month for three (3) months and two (2) PRN visits. Review of volunteer visit notes revealed that the patient received eleven (11) visits in September, 2023. There was no documentation that the visit frequency had been amended or that the physician was notified that additional visits were provided. An interview with the hospice Administrator and the Clinical Manager on December 21, 2023, at approximately 4:00 P.M confirmed the above findings.”

“Based on a review of hospice policy, clinical records (CRs), and staff interviews, the hospice failed to ensure that a registered nurse documented an on-site visit to the patient’s home no less frequently than every 14 days (two weeks) to assess the quality of care and services provided by the home hospice aide (HHA) for one (1) of nineteen (19) CR reviewed. (CR #8) Findings included: Request for hospice policy pertaining to supervision of hospice aides on December 21, 2023, at approximately 9:15 A.M. revealed that the agency did not have a policy for supervision of hospice aides. A review of clinical records was conducted on December 19, 2023, from approximately 8:45 A.M. to 9:45 A.M., 1:45 P.M. to 4:30 P.M., December 20, 2020, from approximately 9:30 A.M. to 3:45 P.M., and December 21, 2023, from approximately 9:30 A.M. to 2:30 P.M. revealed the following: CR #8, start of care August 16, 2023, certification period reviewed - November 14, 2023, through February 11, 2024. The registered nurse conducted skilled nursing visits on November 15, 2023, November 22, 2023, and November 29, 2023, December 6, 2023, and December 13, 2023. There was no documentation of a hospice aide supervision from November 15, 2023, through December 13, 2023. An interview with the hospice Administrator and the Clinical Manager on December 21, 2023, at approximately 4:00 P.M confirmed the above findings.”

“Based on a review of the hospice policies, clinical records, and staff interviews, the governing body and the administrator failed to ensure that the hospice maintained policies for nursing bag technique, wound care practices, hospice aide supervisions, medication monitoring, clinical documentation, and interdisciplinary team functions. Findings included: Request for hospice policies pertaining to nursing bag technique, wound care practices, hospice aide supervisions, medication monitoring, clinical documentation, and interdisciplinary team functions on December 21, 2023, at approximately 9:15 A.M. revealed that the agency did not have any of the requested policies. An interview was conducted with the agency administrator on December 21, 2023, at approximately 1:00 P.M. The administrator stated that the agency has procedures in place for the policies requested. The administrator stated that the hospice is working on writing new policies, which have not been approved by the governing body yet. An interview with the Administrator and the Clinical Manager on December 21, 2023, at approximately 4:00 P.M. confirmed the above findings.”

“Based on review of hospice policies, clinical records (CR), and interview with hospice staff, the hospice registered nurse (RN) failed to document detailed description of wounds and wound measurements for six (6) of nineteen (19) CR reviewed. (CR #2, 3, 10, 15, 18, and 19) Findings included: Request for hospice policy pertaining to wound care on December 21, 2023, at approximately 9:15 A.M. revealed that the agency did not have a policy for wound care. A review of clinical records was conducted on December 19, 2023, from approximately 8:45 A.M. to 9:45 A.M., 1:45 P.M. to 4:30 P.M., December 20, 2020, from approximately 9:30 A.M. to 3:45 P.M., and December 21, 2023, from approximately 9:30 A.M. to 2:30 P.M. revealed the following: CR #2, start of care November 15, 2023. Certification period reviewed, November 15, 2023, through January 13, 2024. The Plan of Care (POC) contained orders for wound care as follows: “;Wound care: Right heel: Polymem Pink (wound dressing), gauze, kling (gauze wrap). Keep heel off loaded per community staff nurse daily. Wound Care: Cleanse B/L (bilateral- both sides) buttocks with soap and water. Pat dry. Apply A & D ointment (vitamin ointment) to open areas and apply anti-fungal cream to B/L buttock Q shift (each shift) and PRN (as needed) per community staff.” The initial assessment by the registered nurse (RN) noted a wound on the right heel and a wound on the gluteal fold (buttock). with no documentation of description of the wounds or wound measurements. Subsequent visits on November 16, 2023, or November 22, 2023, contained no documentation of wound assessments or measurements. On November 30, 2023, the RN documented that they assisted the facility wound care nurse with the right heel wound dressing change and included a wound assessment and measurements. The RN documented that the gluteal fold wound was not observed or measured. On December 8, 2023, and December 12, 2023, the RN documented that both wounds were not observed. The gluteal fold wound was documented as healed on December 12, 2023. On December 19, 2023, the RN documented, “;Dressing changed as described: SN assisted FSN (facility skilled nurse) with dressing change this morning...” The wound was noted as “;necrotic (dead tissue), foul smelling and is now draining small amount of serous drainage.” No wound measurements were documented. CR #3, start of care December 1, 2023. Certification period reviewed, December 1, 2023, through January 29, 2024. The POC contained the following wound care orders, “;Wound care: cleanse skin tear to posterior LUE with NSS (normal saline solution), apply Adaptic (wound dressing) and CDD (clean dry dressing) per community staff nurse. Trt d/c 12/3.; Wound care: triple antibiotic (ointment) to LUE scratch daily, d/c 12/4/23; Wound care: Cleanse right lower leg with NSS, then apply adaptic with dry dressing daily per community staff nurse; change to protective tegaderm (wound dressing) til 12/10.” The initial assessment by the RN on December 1, 2023, contained documentation of a scratch on the left upper extremity (LUE) that was “;Present on SOC (start of care), not addressed”, a skin tear on the posterior (back) LUE that was “;Present on SOC, not addressed”, and a skin tear on the right lower extremity (RLE) that was “;present on SOC, not addressed.” There was no wound assessment or wound care documented for any of the wounds. The same documentation was noted on December 2, 2023, with no wound assessment or wound care documented. On subsequent SN visits on December 6, 2023, December 12, 2023, December 13, 2023, and December 18, 2023, the RN documented that all three (3) wounds were healed. The posterior LUE skin tear contained the following documentation, “;Per pcc (patient community chart) notes trt (treatment) d/c (discontinued) 12/3, healed.” CR #10, start of care November 16, 2023. Certification period reviewed, November 16, 2023, through February 13, 2024. The POC contained orders for “;Wound care: Right thumb skin tear: cleanse w/NSS, apply medihoney (wound dressing) and change daily per community staff.” The initial assessment by the RN on November 16, 2023, contained documentation of a skin tear on the right thumb that was “;Present on SOC, not addressed.” There was no documentation of a wound assessment or measurements. A subsequent SN visit note on November 17, 2023, contained no documentation of a wound assessment or measurements. On November 20, 2023, the RN documented that the right thumb skin tear was “;healing by secondary intent, scabbed and OTA (open to air).” There was no documentation of wound measurements. On November 27, 2023, the RN documented that the right thumb wound was healed. CR #15, start of care November 10, 2023, discharged November 20, 2023. Certification period reviewed, November 10, 2023, through February 7, 2023. The POC contained the following orders, “;Wound Care: Calmoseptine (moisture barrier cream) buttocks QS (quantity sufficient) for redness, community staff will apply. Wound care: Aquaphor (skin barrier cream) left shin, community staff will apply.” The initial assessment by the RN on November 10, 2023, contained documentation of a surgical wound on the left shin which was “;Present on SOC, not addressed.” There was no documentation of wound assessment or wound measurements. Subsequent documentation on November 11, 2023, contained the same information. On November 13, 2023, the RN documented, “;healing by secondary intent, not measured, not evaluated, covered with dressing CDI (clean, dry and intact).” CR #18, start of care May 14, 2023, discharged November 9, 2023. Certification period reviewed, August 12, 2023, through November 9, 2023. The initial POC contained the following orders for wound care, “;Betadine (iodine) external solution 10% (Povidone-iodine) Apply to right chest wall topically one time a day for wound. Lightly pack betadine soaked gauze into wound, cover with foam dsg (dressing). Performed by FSN.” There were no orders for wound care to the left lower leg skin tear that was documented as present on SOC. POC orders as of August 2, 2023, contained the previous orders for the chest all wound. Additional orders were as follows, “;Wound care: Hydrogel Gel (Carbomer Gel Base) Apply to coccyx wound topically one time a day for wound. Cleanse wound with NSS, apply hydrogel, cover with foam, change OD (once daily), performed by FSN.” There were no orders for wound care to the left lower leg wound. POC orders as of September 13, 2023, contained the same orders for wound care to the right chest wall as previously ordered. New orders were written for wound care to a new wound, which was not documented on the RN assessment. “;Wound Care: right medial chest wall cleanse with NSS, apply calc (calcium) alginate silver (wound dressing) and cover with foam dressing BID (two (2) times per day).” Additional orders were documented for the coccyx wound as follows, “;Wound care: Antifungal Clotrimazole External Cream 1% (Clotrimazole (Topical)) to coccyx.” The initial assessment by the RN on May 14, 2023, contained documentation of a skin tear on the left lower leg that was “;Present on SOC, not addressed, leave OTA (open to air)” and an “;unknown wound type on the right chest wall, not addressed, dressing CDI”. There was no documentation of a wound assessment or wound measurements for either wound. During the certification period reviewed, the RN documented on August 16, 2023, skin tear on the left lower leg “;Present on SOC, healing by secondary intent, not measured, not evaluated”, an unknown type of wound on the right chest wall “;Present on SOC, not healing, no measured, not evaluated”, and a pressure ulcer on the coccyx (tail bone) “;Stage 3 (wound through the skin and into the underlying tissue), healing by secondary intent, not measured, not evaluated”. Subsequent weekly visits from August 25, 2023, through September 15, 2023, contained no documentation of wound assessments or wound measurements. On September 20, 2023, the RN documented, “;Left lower leg, present on SOC, skin tear, healing by secondary intent, not measured, not evaluated”, “;right chest wall, present on SOC, unknown type, healing by secondary intent, not measured, not evaluated”, “;Coccyx pressure ulcer, healing by secondary intent, not measured, not evaluated”, and a new wound on the left lateral (side) leg “;type unknown, healing by secondary intent, not measured, not evaluated”. Subsequent documentation from September 26, 2023, through November 9, 2023, contained not documentation of wound assessments or wound measurements. CR #19, start of care July 21, 2023, discharged October 18, 2023. Certification period reviewed, July 21, 2023, through October 8, 2023. The initial assessment by the RN on July 21, 2023, noted that the skin was intact, no wounds noted. On July 25, 2023, the RN documented a LLE skin tear that was “;healing by secondary intent, not measured, dressing in place.” On August 1, 2023, the RN documented a LLE medial (inner leg area) skin tear, no measurements, on wound assessment, and a LLE anterior (front of leg) skin tear which was not measured and not observed. On August 4, 2023, the RN documented an additional “;quarter sized blood blister on the medial aspect of the left shin area next to the skin tear. There was no documentation of a measurement of the blister or a wound assessment due to the wound being covered. On August 15, 2023, the RN documented wound assessment and measurements for the blood blister on the left medial aspect of the left shin. An additional skin tear was documented on the RLE. No wound assessment or wound measurements were documented. No wound measurements or wound assessments were documented for the LLE medial skin tear and the LLE anterior skin tear. The RN did not document wound assessments or wound measurements for any of the wounds on July 22, and 27, 2023, August 3, 8, 22, 24, 25, and 29, 2023, September 6, 8, 9, 10, 12, 14, 15, 17, 19, and 26, 2023, and October 5 and 7, 2023. An interview with the hospice Administrator and the Clinical Manager on December 21, 2023, at approximately 4:00 P.M confirmed the above findings.”