The Care Team Hospice

“Based on a review of agency policy/procedure, clinical record review, an interview with the agency Administrator, it was determined that the agency failed to conduct a patient drug profile, reviewing all of the patient’s prescription and over-the-counter drugs, for six (6) of fourteen (14) clinical records (CR) reviewed (CR#2, CR#4, CR#9, CR#10, CR#13, CR#14). Findings: Agency policy was reviewed December 15, 2023 at approximately 1:30 p.m. Agency policy ‘PC.85, Medication List and Monitoring’ ‘Procedure’ (I) states “The hospice will maintain a current, accurate list of all prescription and over the counter medications taken by the patient (Medication Profile). (II) All medications will be documented on the medication profile. (IV) This medication profile will also include, but is not limited to: ..... (C) Dosage, frequency, route; ....’ (IX) (A) The medication profile will be updated as frequently as necessary to reflect changes in the medication regimen, keeping the profile accurate.” A review of CRs completed on December 13, 2023 at approximately 2:45 p.m. revealed the following: CR#2, Start of Care 05/17/23: This patient was selected for a home visit while at the agency on Friday, 12/8/23, at approximately 2:00 p.m. The agency was provided the list with the selected home visit patients. The patients ‘General Details’ form, dated 05/17/23, ‘Medications’ included ......’Haldol, 0.5 Concentrate Intragastric every 4 hours as needed for agitation/restlessness and nausea/vomiting (2mg/ml concentrate). During a home visit on Monday, 12/11/23 at approximately 11:00 a.m. the agency nurse (employee #10) was asked to review the patient’s medications. The medications reviewed included ‘Haldol, 2mg/ml, oral, every 4 hours as needed for ....’ The agency ‘Medications’ list was revise/updated on Sunday, 12/10/23, the day before the patients scheduled home visit. Two revisions/updates were made the day prior to the home visit: ‘Robitussin DM 100; 10mg/5ml, 10 ml intragastric every 6 hours as need for cough .......’ ‘Deleted Date:12/10/23’ and changed to ‘Robitussin DM 10;100;5mg; mg; ml, 10 ml oral every 6 hours as need for congestion and cough .....). ‘Haldol, 0.5 Concentrate Intragastric every 4 hours as needed for agitation/restlessness and nausea/vomiting .....’ Deleted Date:12/10/23’ and changed to ‘Haldol2.1 mg/ml, 0.5 ml oral every 6 hours as needed ......’ An interview was conducted with employee #10 on Tuesday 12/12/23 at approximately 12:15 p.m. Employee #10 was asked about the discrepancy of the Haldol order (Robitussin discrepancy at a discovered later time). Employee #10 stated she was reviewing the patient medication on Sunday, 12/10/23 (the day prior to the patients scheduled home visit) and discovered the medication route discrepancy and updated the medication list from intragastric to oral. Employee #10 stated this discrepancy (from patients admit date to current date) was not discovered by the agency until 12/10/23 (the day prior to the patients scheduled home visit).No documentation provided of the ordering physician being notified of the medication route revision. CR#4, Start of Care 08/08/23: No documentation provided of the comprehensive assessment including a drug profile, reviewing all of the patient’s prescription and over-the-counter drugs. CR#9, Start of Care 08/28/23: No documentation provided of the comprehensive assessment including a drug profile, reviewing all of the patient’s prescription and over-the-counter drugs. CR#10, Start of Care 11/21/23: No documentation provided of the comprehensive assessment including a drug profile, reviewing all of the patient’s prescription and over-the-counter drugs. CR#13, Start of Care 09/07/23: No documentation provided of the comprehensive assessment including a drug profile, reviewing all of the patient’s prescription and over-the-counter drugs. CR#14, Start of Care 08/21/23: No documentation provided of the comprehensive assessment including a drug profile, reviewing all of the patient’s prescription and over-the-counter drugs. An interview conducted with the agency Administrator on December 13, 2023 at approximately 3:45 p.m. confirmed the above findings.”

“Based on a review of clinical records, agency policy/procedure, and an interview with the agency Administrator, it was determined that the agency failed to ensure an update of the comprehensive assessment was accomplished by the hospice interdisciplinary group no less frequently than every 15 days for three (3) of fourteen (14) clinical records (CR) reviewed (CR#3, CR#4, CR#6). Findings: Agency policy was reviewed December 15, 2023 at approximately 1:30 p.m. Agency policy ‘PC.30’, Plan of Care Process’ ‘Procedure’ (VII) “The Hospice IDG/IDT (in collaboration with the individuals attending physician, if any) will review, revise, and document the individualized plan as frequently as the patien’ts condition requires, but no less frequently than every 15 calendar days.” ‘PC.45, Review and Revision of Patient Care’ ‘Procedure’ (III) Upon identifying that patient care needs have changed (according to hospice policy), adjustments to the care planning documents will be made as follows: ...IDG/IDT POC (RN, PT, OT, ST, MSW, Counselor/Chaplain). A review of CRs completed on December 13, 2023 at approximately 2:45 p.m. revealed the following: CR#3 Start of Care 12/24/22: No documentation provided of the agency social worker and no documentation of a registered nurse participating in the patients plan of care update during the November 8, 2023 and the November 22, 2023 IDG (interdisciplinary group) plan of care review. Documentation was provided of the IDG meetings conducted on 11/08/23 and 11/22/23. CR#4 Start of Care 08/08/23: No documentation provided of the agency social worker participating in the patients plan of care update during the December 6, 2023 IDG (interdisciplinary group) plan of care review. Documentation was provided of the IDG meetings conducted on 11/08/23, 11/22/23, and 12/06/23. CR#6 Start of Care 06/24/23: No documentation provided of the agency social worker participating in the patients plan of care update during the November 15, 2023 IDG (interdisciplinary group) plan of care review. Documentation was provided of the IDG meetings conducted on 11/01/23, 11/15/23, and 11/29/23. An interview conducted with the agency Administrator on December 13, 2023 at approximately 3:45 p.m. confirmed the above findings.”

“Based on a review of clinical records, agency policy/procedure, and an interview with the agency Administrator, it was determined that the agency failed to establish and/or follow an individualized written plan of care established by the hospice interdisciplinary group for eight (8) of fourteen (14) clinical records (CR) reviewed (CR#4- CR#9, CR#12, CR#14). Findings: Agency policy was reviewed December 15, 2023 at approximately 1:30 p.m. Agency policy ‘PC.35’ ‘Implementing Physician Orders’ ‘Procedure’ section (VI) states “When the provision of care/treatment cannot be implemented as established on the care planning document/s, the patients physician will be notified. The appropriate documentation will be completed and submitted by the assigned discipline or Clinical Manager.” A review of CRs completed on December 13, 2023 at approximately 2:45 p.m. revealed the following: CR#4 Start of Care 08/08/23: ‘Plan of Care General Details’ dated 08/08/23 state “MSW (masters of social work): 1x to assess and determine frequency.” Documentation provided of social worker visits on 08/11/23, 09/12/23, 09/20/23, 10/09/23, 10/25/23, 11/07/23, 12/08/23.No documentation provided of obtaining physician order for additional visit/s. ‘Plan of Care General Details’ dated 08/08/23 state “SC (spiritual counselor) 1x to assess and determine frequency.” Documentation provided of chaplain visits on 08/11/23, 10/27/23, 11/30/23.No documentation provided of obtaining physician order for additional visit/s. CR#5 Start of Care 04/05/23: ‘Plan of Care General Details’ dated 04/05/23 state “MSW (masters of social work): 1x to assess and determine frequency.” Documentation provided of social worker visits on 05/04/23, 06/09/23, 07/05/23, 08/23/23, 09/13/23, 10/25/23, 11/29/23, 12/06/23. No documentation provided of obtaining physician order for additional visit/s. ‘Plan of Care General Details’ dated 04/05/23 state “SC (spiritual counselor) 1x to assess and determine frequency.” Documentation provided of chaplain visits on 05/17/23, 08/07/23, 09/28/23, 10/19/23, 11/13/23.No documentation provided of obtaining physician order for additional visit/s. CR#6 Start of Care 06/24/23: ‘Plan of Care General Details’ dated 06/24/23 state “MSW (masters of social work): 1x to assess and determine frequency.” Documentation provided of social worker visits on 06/27/23, 07/09/23, 07/10/23, 07/12/23, 07/28/23, 08/03/23, 08/10/23, 08/17/23, 08/24/23, 08/31/23, 09/06/23, 09/07/23, 09/21/23, 09/28/23, 10/05/23, 10/12/23, 10/16/23, 10/17/23, 10/23/23, 10/31/23, 11/08/23, 11/14/23, 11/20/23, 11/21/23, 11/24/23, 11/27/23, 11/29/23, 12/01/23, 12/04/23, 12/09/23. No documentation provided of obtaining physician order for additional visit/s. ‘Plan of Care General Details’ dated 06/24/23 state “SC (spiritual counselor) 1x to assess and determine frequency.” Documentation provided of chaplain visits on 06/28/23, 07/28/23, 08/11/23, 08/25/23, 09/15/23, 09/29/23, 10/23/23, 11/06/23, 11/20/23, 11/28/23, 12/04/23.No documentation provided of obtaining physician order for additional visit/s. CR#7 Start of Care 08/2/23: ‘Plan of Care General Details’ dated 08/02/23 state “MSW (masters of social work): 1x to assess and determine frequency.” Documentation provided of social worker visits on 08/04/23, 09/11/23, 10/30/23, 10/25/23, 11/01/23, 12/02/23.No documentation provided of obtaining physician order for additional visit/s. ‘Plan of Care General Details’ dated 08/02/23 state “SC (spiritual counselor) 1x to assess and determine frequency.” Documentation provided of chaplain visits on 08/04/23, 09/11/23, 10/30/23, 11/27/23.No documentation provided of obtaining physician order for additional visit/s. CR#8 Start of Care 08/12/23: ‘Plan of Care General Details’ dated 08/12/23 state “MSW (masters of social work): 1x to assess and determine frequency.” Documentation provided of social worker visits on 08/15/23, 08/29/23, 09/13/23, 09/20/23, 09/27/23, 10/13/23, 10/25/23, 11/13/23, 11/29/23, 12/05/23.No documentation provided of obtaining physician order for additional visit/s. ‘Plan of Care General Details’ dated 08/12/23 state “SC (spiritual counselor) 1x to assess and determine frequency.” Documentation provided of chaplain visits on 08/12/23, 09/14/23, 10/04/23, 10/10/23, 10/24/23, 11/07/23, 11/21/23, 12/05/23.No documentation provided of obtaining physician order for additional visit/s. CR#9 Start of Care 08/28/23: ‘Plan of Care General Details’ dated 08/28/23 state “MSW (masters of social work): 1x to assess and determine frequency.” Documentation provided of social worker visits on 08/31/23, 11/16/23.No documentation provided of obtaining physician order for additional visit/s. ‘Plan of Care General Details’ dated 08/28/23 state “SC (spiritual counselor) 1x to assess and determine frequency.” Documentation provided of chaplain visits on 09/1/23 and 11/28/23. No documentation provided of obtaining physician order for additional visit/s. CR#12 Start of Care 10/25/22: ‘Plan of Care General Details’ dated 08/20/23 state ‘Hospice Aide’ ‘Start Date: 10/12/23’’End Date: 12/16/23’ ‘Visit Frequency: 2 visits weekly.’ Week of 07/23/23-07/29/23: 1/2 vists.Week of 07/30/23-08/05/23: 1/2 vists.Week of 08/06/23-08/12/23: 1/2 vists.Week of 08/13/23-08/19/23: 0/2 vists.No documentation provided of notifying the physician when the provision of care/treatment was not implemented per the plan of care. CR#14 Start of Care 08/21/23: ‘Plan of Care General Details’ with physician ordered frequencies was requested for review. No documentation provided of an individual written plan of care. Patient was discharged from the agency due to death on 08/24/23. An interview conducted with the agency Administrator on December 13, 2023 at approximately 3:45 p.m. confirmed the above findings.”

“Based on a review of clinical records, agency policy & procedure, and an interview with the agency Administrator, it was determined that the agency failed to include a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs for two (2) of fourteen (14) clinical records (CR) reviewed (CR#10, CR#13). Findings: Agency policy was reviewed December 15, 2023 at approximately 1:30 p.m. Agency policy ‘PC.35’ ‘Implementing Physician Orders’ ‘Procedure’ section (VI) states “When the provision of care/treatment cannot be implemented as established on the care planning document/s, the patients physician will be notified. The appropriate documentation will be completed and submitted by the assigned discipline or Clinical Manager.” A review of CRs completed on December 13, 2023 at approximately 2:45 p.m. revealed the following: CR#10 Start of Care 11/21/23: Plan of Care General Details dated 11/21/23 state ‘SN (skilled nurse): Weekly.’ No range of visits identified in the skilled nursing frequency order. CR#13 Start of Care 09/07/23: Plan of Care General Details dated 09/07/23 state ‘SN (skilled nurse): Weekly and PRN.’ No range of visits identified in the skilled nursing frequency order. An interview conducted with the agency Administrator on December 13, 2023 at approximately 3:45 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 forward to the patient’s attending physician a copy of the hospice discharge summary for two (2) of two (2) live discharge clinical records (CR) reviewed (CR#11, CR#12). Findings: Agency policy was reviewed December 15, 2023 at approximately 1:30 p.m. Agency policy ‘PE.35, Patient Revocation’ ‘Procedure’ section (VI) states “The hospice will forward copies of the following information to the patients attending physician: (A) The hospice discharge summary which includes but is not limited to .....”Agency policy ‘PE.20, Patient Discharge’ ‘Procedure’ section (IV) states “The discharge summary will include ....” Section (IX) states “The hospice will forward copies of the following to the patients attending physician upon discharge from the hospices service: (A) The hospice discharge summary which includes but is not limited to .....” A review of CRs completed on December 13, 2023 at approximately 2:45 p.m. revealed the following: CR#11 Start of Care 04/07/23: Patient revoked hospice care on August 9, 2023. 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. CR#12 Start of Care 10/25/22: Patient discharged from the hospice agency on August 20, 2023due to no longer being eligible for receiving hospice services. 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 December 13, 2023 at approximately 3:45 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 provide the most recent hospice plan of care specific to each patient to the skilled nursing facility for one (1) of one (1) skilled nursing facility home visits (HV) conducted (HV#1). Findings include: Agency policy was reviewed December 15, 2023 at approximately 1:30 p.m. Policy ‘PC.125, Hospice Care in a SNF/NF or ICF/IID’ section (VIII) states “The Hospice will provide the facility with the following hospice information/documentation on admission and on-going: (A) The most recent hospice plan of care specific to each patient;.......” HV#1: This patient is a resident of Skilled Nursing Facility #1. The patients hospice chart was reviewed on 12/11/23 at approximately 12:00 p.m. Agency Employee #1 was present. No documentation of the hospice agency providing the facility the residents (Clinical Record #3) most recent hospice plan of care (to include the IDG (interdisciplinary group) plan of care reviews and updated assessments). An interview conducted with the agency Administrator on December 13, 2023 at approximately 3:45 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 one (1) of one (1) skilled nursing facility contracts (SNFC) reviewed (SNFC#1). Findings include: Agency policy was reviewed December 15, 2023 at approximately 1:30 p.m. Policy ‘PC.125, Hospice Care in a SNF/NF or ICF/IID’ ‘Procedure’ section (IX) “Coordination /Continuity of Care’ (A) The hospice will: ......section (3) states “Assure the orientation of staff who provides that care, in the hospice philosophy, including hospice polices/procedures regarding methods of comfort, pain control, symptom management, as well as principles about death and dying, ....”Agency ‘Nursing Facility Services Agreement’ signed by the hospice agency and the skilled nursing facility (SNF#1) on 03/28/22 and 03/29/22 section ‘2.3, Orientation and Education’ states “Both parties agree to provide sufficient orientation and in-service education to personnel to acquaint them with the hospice or facility philosophy of care, services and, as necessary, with hospices symptom control practices. both parties agree to provide orientation of the other party’s employees, contractors, agents and volunteers to their policies and procedures, which will be provided to the other party. ....” 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 #3 currently resides at this facility). An interview conducted with the agency Administrator on December 13, 2023 at approximately 3:45 p.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 nine (9) of nine (9) employee files (EF) reviewed (EF#1 - EF#9). 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 December 15, 2023 at approximately 1:30 p.m. Agency policy ‘HR.55, Personnel Records’ ‘Policy’ (I) states “The hospice will adhere to federal and state laws and regulations when establishing and maintaining personnel records .....” A review of EFs completed on December 11, 2023 at approximately 2:50 p.m. revealed the following: EF#1, date of hire 06/19/23: No documentation of the agency conducting a Pennsylvania State Police criminal background check. Documentation provided of a third party ‘Background Screening Report’ conducted on 06/11/23. EF#2, date of hire 07/03/23: No documentation of the agency conducting a Pennsylvania State Police criminal background check. Documentation provided of a third party ‘Background Screening Report’ conducted on 06/19/23. EF#3, date of hire 09/26/22: No documentation of the agency conducting a Pennsylvania State Police criminal background check. Documentation provided of a third party ‘Background Screening Report’ conducted on 08/30/22. EF#4, date of hire 03/27/23: No documentation of the agency conducting a Pennsylvania State Police criminal background check. Documentation provided of a third party ‘Background Screening Report’ conducted on 03/11/23. EF#5, date of hire 07/09/23: No documentation of the agency conducting a Pennsylvania State Police criminal background check. EF#6, date of hire 07/03/23: No documentation of the agency conducting a Pennsylvania State Police criminal background check. Documentation provided of a third party ‘Background Screening Report’ conducted on 06/19/23. EF#7, date of hire 09/06/22: No documentation of the agency conducting a Pennsylvania State Police criminal background check. Documentation provided of a third party ‘Background Screening Report’ conducted on 09/01/22. EF#8, date of hire 06/05/23: No documentation of the agency conducting a Pennsylvania State Police criminal background check. Documentation provided of a third party ‘Background Screening Report’ conducted on 06/02/23. EF#9, date of hire 10/09/23: No documentation of the agency conducting a Pennsylvania State Police criminal background check. An interview conducted with the agency Administrator on December 13, 2023 at approximately 3:45 p.m. confirmed the above findings.”