Karen Ann Quinlan Hospice

“Based on a review of the hospice policies and procedures and documentation, and based on interview with the Clinical Director (Employee #8), Quality Improvement Reviewer (QIR-Employee #11) and the Associate Administrator (Employee #12), the hospice failed to ensure a transfer agreement was established with one (1) of one (1) hospices to allow for patient transfer when limitation or cessation of hospice services occurs during an emergency event. Findings Include: On March 26, 2024 at approximately 1:14 PM, review of the “Emergency Operations Plan” revealed the following under “Procedure”: 12. Activity Managment...Patient-care related activities...and patient transfer or referral will be managed by the Chief Operating Officer and/or Administrators. Between March 26, 2024 at approximately 1:14 PM and March 28, 2024 at approximately 11:01 AM, review of the emergency preparedness binder failed to reveal that a transfer agreement was established an alternate hospice to allow for patient transfer when limitation or cessation of hospice services occurs during an emergency event. During Webex interview conducted on April 2, 2024 at approximately 9:31 AM, the Clinical Director, QIR and Associate Administrator confirmed a transfer agreement was not established with an alternate hospice to allow for patient transfer when limitation or cessation of hospice services occurs during an emergency event.”

“Based on a review of the hospice policies and procedures and documentation, and based on interview with the Clinical Director (Employee #8), Quality Improvement Reviewer (QIR-Employee #11) and the Associate Administrator (Employee #12), the hospice failed to the contact information for three (3) of four (4) emergency management agencies had been included in the hospice emergency management plan. (Federal Emergency Management Agency (FEMA), Pennsylvania Emergency Management Agency (PEMA) and the Pennsylvania Department of Health (PA DOH)/Division of Home Health (DHH)) Findings Include: On March 26, 2024 at approximately 1:14 PM, review of the “Emergency Operations Plan” revealed the following under “Procedure”: 2. Coordinate...Hospice will coordinate efforts with the area emergency agencies to mitigate, prepare, respond and recover from high priority emergencies that impact the community... Between March 26, 2024 at approximately 1:14 PM and March 28, 2024 at approximately 11:01 AM, review of the emergency preparedness binder failed to reveal the contact information for FEMA, PEMA) and the PA DOH/DHH had been included in emergency management plan. During Webex interview conducted on April 2, 2024 at approximately 9:31 AM, the Clinical Director, QIR and Associate Administrator confirmed the contact information for FEMA, PEMA and the PA DOH/DHH was not included in the emergency management plan.”

“Based on a review of the hospice policies and procedures and documentation, and based on interview with the Clinical Director (Employee #8), Quality Improvement Reviewer (QIR Employee #11) and Associate Administrator (Employee #12), the hospice failed to ensure emergency preparedness exercises were conducted for one (1) of three (3) years beginning 2021. (2023) Findings Include: On March 26, 2024 at approximately 1:14 PM, review of the “Emergency Operations Plan” revealed the following under “Procedure”: 15. Testing and Training...The plan will be tested and evaluated annually at each site... Between March 26, 2024 at approximately 1:14 PM and March 28, 2024 at approximately 11:01 AM, review of the emergency preparedness binder failed to reveal that an emergency preparedness exercise (full-scale community-based, facility-based functional, mock disaster drill or tabletop exercise) had been conducted in 2023. During Webex interview conducted on April 2, 2024 at approximately 9:31 AM, the Clinical Director, QIR and Associate Administrator confirmed an emergency preparedness exercise was not conducted in 2023.”

“Based on a review of the hospice policies and procedures and clinical records, and based on interview with the primary caregiver of Patient #2, the Clinical Director (Employee #8), Quality Improvement Reviewer (QIR-Employee #11) and Associate Administrator (Employee #12), the hospice failed to ensure hospice aide services were provided in accordance with the ordered frequency for three (3) of six (6) active patients for whom orders for hospice aide services were included on the hospice plan of care or interim verbal order. (Patients #2, #9 and #10) Findings include: On March 29, 2024 at approximately 2:47 PM, review of the hospice policy titled “Hospice Interdisciplinary Team & Care Plan” revealed the following under “Purpose”: Hospice services are provided and documented in a manner consistent with accepted standards of practice to all patients by members of this interdisciplinary team and as ordered by a physician. Patient #2: On March 29, 2024 at approximately 9:51AM, review of the clinical record revealed hospice aide services were to be provided one (1) time a week for one (1) week as ordered on the hospice “Plan of Care” for the recertification period of March 4 through May 2, 2024. There was no documentation in the clinical record which provided evidence the hospice aide visit was provided nor refused between 03/04/2024 and 03/29/2024. During home visit conducted on March 27, 2024 at approximately 12:00 PM, the patient’s primary caregiver reported hospice aide services are no longer being provided due to the hospice aide suffering an injury. Patient #9: On March 29, 2024 at approximately 12:05 PM, review of the clinical record revealed hospice aide services are to be provided one (1) time a week for 13 weeks as ordered on the hospice interim verbal plan of care order dated 01/10/2024. There was no documentation in the clinical record which provided evidence the hospice aide service were provided nor refused during the week of 01/28/2024 through 02/03/2024. Patient #10: On March 29, 2024 at approximately 12:35 PM, review of the clinical record revealed hospice aide services are to be provided five (5) times a week for 13 weeks as ordered on the hospice “Plan of Care” for the recertification period of 01/01/2024 through 03/30/2024. Review of hospice aide visit documentation revealed 4 hospice aide visits were provided during the weeks beginning 01/14/2024, 01/28, 02/11 and 02/25/2024. There was no documentation in the clinical record which provided evidence the fifth hospice aide visit was provided nor refused during the aforementioned weeks. During Webex interview conducted on April 2, 2024 at approximately 9:31 AM, the Clinical Director, QIR and Associate Administrator confirmed hospice aide services were not provided as per the frequency ordered on the hospice plan of care or interim verbal order for the above identified patients.”

“Based on review of hospice policies and procedures and clinical records, the Pennsylvania Department of Health (DOH) “Health Care Facilities Act of 1979” and Medicare (CGS) guidelines, and based on interview with the Clinical Director (Employee #8), Quality Improvement Reviewer (QIR-Employee #11) and Associate Administrator (Employee #12), the hospice failed to ensure verbal orders for the initial certification of the terminal illness were provided by a physician licensed to practice medicine in Pennsylvania (PA) for one (1) of two (2) active patients who selected an attending physician other than the Medical Director. (Patient #1) Findings include: On March 29, 2024 at approximately 2:47 PM, review of the hospice policy titled “Hospice Interdisciplinary Team & Care Plan” revealed the following under “Purpose”: The team is comprised of the Medical Director...May include...any other individuals involved in the Plan of Care. On April 2, 2024 at approximately 2:09 PM, review of the Pennsylvania Health Care Facilities Act of 1979 revealed the following under “Definitions”: Health care practitioner.: An individual who is authorized to practice some component of the healing arts by a license, permit, certificate or registration issued by a Commonwealth (of Pennsylvania) licensing agency or board. Health care facility: For purposes of Chapter 8, a health care facility includes...a hospice... On April 2, 2024 at approximately 2:37 PM, review of the Medicare guidelines for certification of terminal illness revealed the following as documented on the webpage https://www.cgsmedicare.com/hhh/coverage/coverage_guidelines/cert_recert_requirements.html : Content of the Certification...The certification should be based on the clinical judgment of the hospice medical director (or physician member of the interdisciplinary group (IDG), and the patient’s attending physician...Nurse practitioners and physician assistants cannot certify or recertify an individual is terminally ill. If the patient’s attending physician is a nurse practitioner or a physician assistant, the hospice medical director or the physician member of the hospice IDG certifies the individual as terminally ill. Patient #1: On March 28, 2024 at approximately 2:38 PM and March 29, 2024 at approximately 9:20 AM, review of the clinical record revealed the patient selected a physician other than the hospice Medical Director to act as the attending physician as evidenced by documentation included on the hospice benefit “Statement of Election” form. Review of the hospice “Plan of Care” for the initial certification period of February 9 through May 8, 2024 revealed the attending physician who provided the verbal order for the certification of terminal illness was based in New Jersey (NJ). The provider who counter-signed the hospice “Plan of Care”/certification of terminal illness form was a physician assistant. On March 28, 2024 at approximately 5:20 PM, review of the PA Department of State licensure verification site failed to reveal the NJ attending physician who provided the verbal order for certification of the terminal illness was licensed to practice medicine in PA. There was no documentation in the clinical record which provided evidence the hospice obtained a verbal order for the initial certification of the terminal illness from an attending physician licensed to practice medicine in PA. During Webex interview conducted on April 2, 2024 at approximately 9:31 AM, the Clinical Director, QIR and Associate Administrator confirmed a verbal order for the certification of terminal illness for patient #1 was not obtained from an attending physician licensed to practice medicine in PA.”

“Based on review of hospice policies and procedures and clinical records and Pennsylvania Department of Health (DOH) “Out-of-Hospital Do-Not-Resuscitate Order” (DNR) order documentation standards, and based on interview with the Clinical Director (Employee #8), Quality Improvement Reviewer (QIR-Employee #11) and Associate Administrator (Employee #12), the hospice failed to ensure do-not-resuscitate orders were completed as per hospice policies/procedures and/or PA DOH DNR order documentation standards for four (4) of seven (7) active patients for whom a DNR order form was present in the clinical record. (Patients #2, #5, #7 and #8) Findings include: On March 29, 2024 at approximately 2:41 PM, review of the hospice policy titled “Do Not Resuscitate Policy” revealed the following: A DNR will be considered when a competent person request that cardiopulmonary resuscitation not be provided...A DNR will then be obtained from the attending physician or Medical Director, the patient or surrogate utilizing...The “Out-of-Hospital Do-Not-Resuscitate” orders form (Pennsylvania). On March 26, 2024 at approximately 10:43 AM, review of the PA DOH Out-of-Hospital Do-Not-Resuscitate Order” form revealed the following: When Order Is Effective: An out-of-hospital DNR order is effective when it is signed by the attending physician. The attending physician signs last. On March 26, 2024 at approximately 11:13 AM, review of the PA DOH Out-of-Hospital Do-Not-Resuscitate Orders frequently asked questions revealed the following: How does a person, the persons surrogate, or other authorized representative of the person obtain an out-of-hospital DNR order? The person, the persons surrogate, or other authorized representative of the person must contact the persons attending physician and request an out-of-hospital DNR order. The attending physician will determine if the person for whom the order is sought qualifies for an out-of-hospital DNR order and, if the person does qualify, the attending physician may issue the order for the person. An attending physician may only issue an out-of-hospital DNR order on a form that is available from the Departments vendor. Before completing, signing and dating an out-of-hospital DNR order, the attending physician will ensure that the person for whom it is issued is identified in the order, that all other provisions of the order have been completed, and that the person, surrogate, or other authorized representative of the person, as applicable, has signed the order. On March 29, 2024 at approximately 2:41 PM, review of the hospice policy titled “Do Not Resuscitate Policy” revealed the following: A DNR will be considered when a competent person request that cardiopulmonary resuscitation not be provided...A DNR will then be obtained from the attending physician or Medical Director, the patient or surrogate utilizing...The “Out-of-Hospital Do-Not-Resuscitate” orders form (Pennsylvania). On March 26, 2024 at approximately 10:43 AM, review of the hospice patient admission packet revealed the PA DOH “Out-of-Hospital Do-Not-Resuscitate” order form was pre-signed as evidenced by the signature entered on the “Signature of Physician” line. Patient #1: On March 28, 2024 at approximately 2:38 PM and March 29, 2024 at approximately 9:20 AM, review of the clinical record revealed the physician signature pre-entered on the PA DOH “Out-of-Hospital Do-Not-Resuscitate” form was that of the hospice Medical Director (Employee #10). Patient #2: On March 29, 2024 at approximately 9:51AM, review of the clinical record revealed the start of care date was 01/14/2022 as documented on the “Plan of Care”. Review of the PA DOH “Out-of-Hospital Do-Not-Resuscitate” form revealed the hospice Medical Director (MD-Employee #10) failed to enter the date the MD signed the DNR order form. Patient #5: On March 29, 2024 at approximately 11:01 AM, review of the clinical record revealed the start of care date was 05/06/2023 as documented on the “Plan of Care”. Review of the PA DOH “Out-of-Hospital Do-Not-Resuscitate” form revealed the hospice Medical Director (MD-Employee #10) failed to enter the date the MD signed the DNR order form. Patient #7: On March 29, 2024 at approximately 11:32 AM, review of the clinical record revealed the start of care date was 03/09/2024 as documented on the “Plan of Care”. Review of the PA DOH “Out-of-Hospital Do-Not-Resuscitate” form revealed the hospice Medical Director (MD-Employee #10) failed to enter the date the MD signed the DNR order form. Patient #8: On March 29, 2024 at approximately 11:54 AM, review of the clinical record revealed the start of care date was 12/22/2023 as documented on the “Plan of Care”. Review of the PA DOH “Out-of-Hospital Do-Not-Resuscitate” form revealed the hospice Medical Director (MD-Employee #10) failed to enter the date the MD signed the DNR order form. During Webex interview conducted on April 2, 2024 at approximately 9:31 AM, the Clinical Director, QIR and Associate Administrator confirmed DNR orders were not completed as per the above referenced hospice policy/procedure nor the PA DOH DNR order documentation standards for the above identified patients.”

“Based on review of hospice policy/procedure, the Pennsylvania Older Adult Protective Services Act (OAPSA), observation, clinical records, and personnel files, and based on interview with the Clinical Director (Employee #8), the Quality Improvement Reviewer (QIR-Employee #11) and the Associate Administrator (Employee #12), the hospice failed to ensure a Pennsylvania State Police (PSP) criminal history report and/or Federal Bureau of Investigation (FBI) criminal history record was obtained for five (5) of eight (8) hospice employees and volunteers who provided hospice services in Pennsylvania. (Employees #5, #6, and #9, Volunteers #2 and #3) Findings include: On March 29, 2024 at approximately 3:05 PM, review of the hospice policy titled “Employee Records” revealed the following: Procedure: Criminal background checks are required...Employment record may include, but is not limited to the following: 5. Criminal Background Check Results... On March 29, 2024 at approximately 4:55 PM, review of the Older Adult Protective Services Act (Pennsylvania Act 169 of 1996 as amended by Act 13 of 1997) revealed the following as documented on the Pennsylvania Department of Aging website: The Act 169-1996 Amendment to OAPSA requires a criminal background check for all employees and administrators of a facility...In addition, the Pennsylvania Department of Health has defined home health care organization or agency to include: hospices...”; and The criminal background check requirement is that all facility applicants must submit with their employment application a criminal history report from the Pennsylvania State Police... If the applicant is not a resident of Pennsylvania, or has not been a resident of Pennsylvania for the entire two years immediately preceding employment application, then in addition to the report from the PA State Police, a report of Federal (FBI) criminal history record information must be obtained from the Federal Bureau of Investigation through the PA Department of Aging which has been designated by statute as the intermediary... Notwithstanding section 502, administrators may employ applicants on a provisional basis for a single period not to exceed 30 days or, for applicants under section 502(a)(2), a period of 90 days... Patient #2: On March 29, 2024 at approximately 9:51AM, review of the clinical record revealed the social worker (SW-Employee #9) provide social work services in February and March 2024 as documented on the SW visit notes. Patient #3: During home visit conducted on March 28, 2024 at approximately 9:30 AM, observation of the residence revealed the patient resided in an assisted living facility (ALF). Review of SW visit note documentation revealed the SW (Employee #9) provided hospice services in March 2024. Patient #8: On March 29, 2024 at approximately 11:54 AM, review of the clinical record revealed the registered nurse (RN-Employee #6) provided hospice services in March 2024 as documented on the skilled nursing (SN) visit notes. Review of the 03/26/2024 interdisciplinary group meeting minutes revealed the volunteer coordinator documented the following: Volunteer #3 has been assigned to volunteer. Volunteer visits two (2) to three (3) times a month for socialization. Patient #9: On March 29, 2024 at approximately 12:05 PM, review of the clinical record revealed the RN (Employee #6) provided hospice services in January and March 2024 as documented on the SN visit notes. Review of SW visit note documentation revealed the SW (Employee #9) provided hospice services in January, February and March 2024. Patient #10: On March 29, 2024 at approximately 12:35 PM, review of the clinical record revealed the RN (Employee #6) provided hospice services in January 2024 as documented on the SN visit notes. Review of SW visit note documentation revealed the SW (Employee #9) provided hospice services in January, February and March 2024. Review of the hospice “Plan of Care” revealed the patient resided in an ALF. During observation on March 26, 2024 at approximately 10:30 AM, it was noted that a bereavement group meeting was conducted at the hospice office. Between 03/27/2024 at approximately 1:33 PM and 03/29/2024 at approximately 9:42 AM, review of personnel files for employees and volunteers revealed the following: Employee 5: The date of hire of the Bereavement Coordinator was 09/28/2020 and that the place of residence was New Jersey. There was no documentation in the personnel file which provided evidence a PSP and FBI criminal history report was obtained prior to 03/27/2024. Employee 6: The date of hire of the per-diem (as needed) RN was 03/27/2023. There was no documentation in the personnel file which provided evidence a PSP criminal history report was obtained prior to 03/27/2024. Employee 9: The date of hire of the per-diem social worker was 08/28/2023. There was no documentation in the personnel file which provided evidence a PSP criminal history report was obtained prior to 03/27/2024. Volunteer #2: The volunteer completed the volunteer orientation program on 06/30/2022. Review of volunteer coordinator documentation revealed the volunteer attended hospice holiday programs at the assisted living facilities in which hospice patients reside. There was no documentation in the personnel file which provided evidence a PSP criminal history report was obtained prior to 03/27/2024. Volunteer #3: The volunteer completed the volunteer orientation program on 06/30/2022. There was no documentation in the personnel file which provided evidence a PSP criminal history report was obtained prior to 03/27/2024. During Webex interview conducted on April 2, 2024 at approximately 9:31 AM, the Clinical Director, QIR and Associate Administrator confirmed PSP and/or FBI clearances had been obtained prior to 03/7/2024 for the above referenced hospice employees and volunteers.”