Aseracare Hospice

“Based on a review of agency policy/procedure, a review of employee files, and an interview with the agency Administrator, it was determined that the agency failed to ensure tuberculosis (TB) screening was conducted, per policy, for two (2) of seven (7) employee files (EF) reviewed (EF#4, EF#5). Agency policy/procedure reviewed on October 25, 2024 at approximately 11:30 p.m. Policy ‘Tuberculosis Screening and Testing’ ‘Purpose’ “To properly screen all direct patient care staff for the presence of TB at the time of employment.” ‘Procedure’ (1) Baseline screening and testing of newly hired staff’ .... (b) “Newly hired staff without a documented negative TB test in the past (12) months will .... and get tested with a 2-step TB skin test or a single TB blood test.” A review of EFs was conducted on October 22, 2024 at approximately 10:45 a.m. The employees date of hire (DOH) is included below. EF#4, DOH 04/24/23: No documentation of the agency conducting a two-step TB test or TB blood test. A single step TST (tuberculin skin test) was administered on 05/03/23. EF#5, DOH 11/14/22: No documentation of the agency conducting a two-step TB test or TB blood test. A single step TST (tuberculin skin test) was administered on 11/01/22. An interview conducted with the agency Administrator on October 25, 2024 at approximately 11:45 p.m. confirmed the above findings.”

“Based on a review of agency policy/procedure, a review of the agency volunteer utilization records, and an interview with the agency Administrator, the agency failed to ensure volunteers provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours, for one (1) of one (1) volunteer cost savings documentation (VCSD) reviewed (VD#1). Agency policy/procedure reviewed on October 25, 2024 at approximately 11:30 p.m. ‘Volunteers’ ‘Operational Guidelines’ “..... The hospice will document and maintain a volunteer staff sufficient to provide direct patient care in an amount that, at a minimum, equals five (5) percent of the total patient care hours of all paid hospice personnel.” VCSD was reviewed on October 22, 2024 at approximately 1:00 p.m. VD#1: Volunteer cost savings was requested for the past (12) months. Documentation provided of September 2023 - September 2024 (13 months). Per the agency Administrator, the average volunteer hours percentage was 1.4%. No other documentation provided. The total cost savings equated to less then five (5) percent of the total patient care hours. An interview conducted with the agency Administrator on October 25, 2024 at approximately 11:45 p.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 send the patients discharge summary to the receiving hospice agency for one (1) of one (1) clinical record (CR) patient transfer reviews (CR#18). Agency policy/procedure reviewed on October 25, 2024 at approximately 11:30 p.m. ‘Discharge’ ‘Operational Guidelines’ “.... (f) “When the patient is discharged to another organization, relevant medical information is provided to that agency and/or patient, when requested, including: .... (c) “Summary of Care provided by the hospice agency.” A review of CRs was completed on October 25, 2024 at approximately 11:30 a.m. CR#18 Start of Care 05/07/24: Patient transfer date to another Hospice was 06/14/24. No documentation provided of the discharge summary being sent to the receiving hospice agency. An interview conducted with the agency Administrator on October 25, 2024 at approximately 11:45 p.m. confirmed the above findings. Repeat deficiency.”

“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 send the patients discharge summary to the attending physician for one (1) of one (1) clinical record (CR) patient transfer reviews (CR#19). Agency policy/procedure reviewed on October 25, 2024 at approximately 11:30 p.m. ‘Discharge’ ‘Operational Guidelines’ “.... (C) “The Discharge process is as follows: ..... (j) If a patient is discharged alive, the hospice will forward to the attending physician: (i) “A copy of the hospice discharge summary.” A review of CRs was completed on October 25, 2024 at approximately 11:30 a.m. CR#19 Start of Care 01/03/24: Patient hospice revocation was 01/09/24. No documentation provided of the discharge summary being sent to the patients attending physician. An interview conducted with the agency Administrator on October 25, 2024 at approximately 11:45 p.m. confirmed the above findings.”

“Based on a 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 three (3) of three (3) skilled nursing facility contracts (SNFC) reviewed (SNFC#1 - SNFC#3). Agency policy/procedure reviewed on October 25, 2024 at approximately 11:30 p.m. Policy ‘HR-01D’ ‘Orientation-Contract Personnel’ ‘Operational Guidelines’ (6) “Orientation will be provided to contracted nursing facility staff will include: (a) hospice policies and procedures regarding pain and symptom management. (b) Principles of death and dying. (c) Individual response to death. (d) Patient rights. (e) Appropriate forms. (f) Record keeping requirements.” SNFC were reviewed on October 24, 2024 at approximately 2:00 p.m. SNFC #1: Documentation provided of a ‘Professional Service Contract’, ‘Beginning Date: November 1, 2023, Termination Date: October 31, 2027”, signed by the skilled nurse facility (county) and the hospice agency. Section E. ‘Orientation and training of staff’ (i) (Hospice) will assure orientation of (facility) staff furnishing care to hospice residents in the hospice philosophy, ....” Documentation provided of the most recent hospice patient (clinical record #21) residing at this facility 06/02/24. There are currently (0) hospice patients residing at this facility. Documentation requested of the agency assuring hospice philosophy orientation for skilled nursing facility staff was requested on October 24, 2024 at approximately 2:30 p.m. No documentation provided. Documentation provided of a ‘Sign in Sheet’ with ‘Topic’ “(Facility name listed in this section and not actual topic of inservice), Location: (blank with no entry), Instructor: (blank with no entry), Date: (blank with no entry), participant section included eight (8) names. SNFC #2: Documentation provided of a ‘Hospice Care Services Agreement’, beginning date January 3, 2019 with an automatic renew unless earlier terminated, signed by the skilled nurse facility and the hospice agency. ‘Comparison of Facility/Hospice Responsibilities’ lists the hospice agency as being responsible for ‘Orientation and training of facility staff to include: Hospice philosophy, ...” Documentation provided of two (2) hospice patients (clinical record # 22, #23) currently residing at this facility. Documentation requested of the agency assuring hospice philosophy orientation for skilled nursing facility staff was requested on October 24, 2024 at approximately 2:30 p.m. No documentation provided. SNFC #3: Documentation provided of a ‘Nursing Facility Services Agreement’ effective June 24, 2024, signed by the skilled nurse facility and the hospice agency. Section (iv) ‘Hospice Training’ “..... For personnel who have not received hospice training, Hospice shall provide training and shall document the names of the individuals who gave the training and a description of the training. ....” Documentation provided of one (1) hospice patient (clinical record #24) currently residing at this facility. Documentation requested of the agency assuring hospice philosophy orientation for skilled nursing facility staff was requested on October 24, 2024 at approximately 2:30 p.m. No documentation provided. An interview conducted with the agency Administrator on October 25, 2024 at approximately 11:45 p.m. confirmed the above findings. Repeat deficiency.”

“Based on a review of agency policy/procedure, a review of employee files, and an interview with the agency Administrator, it was determined that the agency failed to ensure a federal criminal history record was conducted, per policy, for one (1) of seven (7) employee files (EF) reviewed (EF#4). Agency policy/procedure reviewed on October 25, 2024 at approximately 11:30 p.m. Policy ‘HR-007’ ‘Criminal and Motor Vehicle Background Checks and Conviction that Bar and Employees application/Employment’ ‘Pennsylvania’ (a) (2) “Federal criminal history record. If the applicant is not and for the 2 years immediately preceding the date of application has not been a resident of this Commonwealth, the facility shall require the applicant to submit a Federal criminal history record and a full set of fingerprints to the Department which will forwarded to the Federal Bureau of Investigation.” A review of EFs was conducted on October 22, 2024 at approximately 10:45 a.m. The employees date of hire (DOH) is included below. EF#4, DOH 04/24/23: No documentation of the agency conducting a federal criminal history record check per policy. Per the agency Business Office Manager (employee #10) on 10/24/24 at approximately 2:30 p.m, employee #10 was informed by the employee that employee relocated to Pennsylvanian the day before he started working for the agency. Documentation provided of employee #4 having a State of Delaware driving license. An interview conducted with the agency Administrator on October 25, 2024 at approximately 11:45 p.m. confirmed the above findings. Repeat deficiency.”