Foulkeways Hospice

“Based on a review of patient admission packet, clinical files (CF), and an interview with the agency administrator, the agency failed to obtain the patient’s or representative’s signature confirming that he or she has received a copy of the notice of rights and responsibilities for seven (7) out of seven (7) clinical files (CF#1, CF#2, CF#3, CF#4, CF#5, CF#6, and CF7) Findings include: Review of patient admission packet on 1/17/2024, at approximately 11:00 A.M. stated the following, “;Hospice Admission Consent Form (NOE): As required by Medicare Hospice guidelines, once a patient has been deemed eligible to receive Medicare hospice benefits, a consent form (NOE) must be completed. The form clearly states the following: patient’s name, hospice admission date, patient rights and responsibilities, consent for care, release of information, financial responsibility, authorization for payment, and patient specific health care decisions...”Review of CF on 1/17/2024, from approximately 11:30 A.M. to 2:15 P.M. and 1/18/2024, from approximately 9:30 A.M. to 1:30 P.M revealed the following: CF #1 Start of care (SOC) 01/23/2024 - No documentation or evidence of the patient’s or representative’s signature confirming receipt of the notice of patient’s rights and responsibilities. CF#2 SOC 12/07/2023, No documentation or evidence of the patient’s or representative’s signature confirming receipt of the notice of patient’s rights and responsibilities. CF#3 SOC 08/28/2023, No documentation or evidence of the patient’s or representative’s signature confirming receipt of the notice of patient’s rights and responsibilities. CF#4 SOC 12/04/2023, No documentation or evidence of the patient’s or representative’s signature confirming receipt of the notice of patient’s rights and responsibilities. CF#5 SOC 01/03/2024, No documentation or evidence of the patient’s or representative’s signature confirming receipt of the notice of patient’s rights and responsibilities. CF#6 SOC 01/16/2024, No documentation or evidence of the patient’s or representative’s signature confirming receipt of the notice of patient’s rights and responsibilities. CF#7 SOC 01/16/2024, No documentation or evidence of the patient’s or representative’s signature confirming receipt of the notice of patient’s rights and responsibilities. An interview with the hospice administrator and the hospice nurse on 1/18/2024, at approximately 4:30 P.M. confirmed the above findings.”

“Based on review of clinical files (CF) and interview with agency staff, the hospice agency failed to provide services in accordance with the plan of care for four (4) of seven (7) CF reviewed. (CF # 1, 2, 3, and 5). Findings include: Review of CF on 1/17/2024, from approximately 11:30 A.M. to 2:15 P.M. and 1/18/2024, from approximately 9:30 A.M. to 1:30 P.M revealed the following: CF #1, Start of Care (SOC) 1/3/2024 - Certification period reviewed 1/3/2024 through 4/24/2024. The plan of care (POC) contained orders for chaplain services one (1) visit per week. There was documentation of visits conducted by the chaplain on 1/4/2024 and 1/5/2024. There were no physician orders amending the chaplain visit frequency. CF #2, SOC 12/7/2023 - Certification period reviewed 12/7/2023 through 3/6/2024. The POC contained orders for chaplain visits one (1) per week. There was documentation of chaplain visits conducted on 12/11/2023, 12/12/2023, 12/13/2023, 12/15/2023, 12/18/2023, 12/19/2023, 12/20/2023, 12/21/2023, and 12/22/2023. There were no physician orders amending the chaplain visit frequency. CF #3, SOC 8/28/2023 – Certification period reviewed 10/26/2023 through 12/24/2023. The POC contained orders for skilled nursing (SN) visits one (1) visit per week effective 10/26/2023 for the remainder of the certification period. The week of 11/19/2023 there were two (2) SN visits completed and the week of 12/3/2023 there were no SN visits completed. There were no physician orders amending the SN visit frequency. Hospice aide (HA) visits were ordered five (5) visits per week effective 10/26/2023. There was only documentation for four (4) HA visits the week of 10/29/2023 and 11/19/2023. There were no physician orders amending the HA visit frequency for those weeks. The POC amended the HA visit frequency to three (3) to five (5) HA visits per week effective 12/7/2023. Chaplain visits were ordered effective 10/26/2023, one (1) visit per week. The documentation by the chaplain on 10/26/2023, 11/2/2023, 11/15/2023, 11/22/2023, 11/28/2023, and 12/11/2023 documented that the chaplain visited CF #1, but the patient was asleep. The documentation on 11/7/2023 and 12/4/2023 the chaplain documented that a visit was made but the patient was receiving care. There was no documentation of any visits made with the patient for any of the dates documented. CF #5, SOC 1/3/2024 – certification period reviewed 1/3/2024 through 3/4/2024. The POC contained orders for HA visits three (3) to five (5) visits per week. There was no documentation of HA visits completed from 1/3/2024 through 1/18/2024. An interview with the hospice administrator and the hospice nurse on 1/18/2024 at approximately 4:30 P.M. confirmed the above findings.”

“Based on review of clinical files (CF), agency policy, and interview with staff, the hospice failed to ensure that all entries must be legible, clear, complete, and appropriately authenticated and dated in accordance with Foulkeways Hospice policy and currently accepted standards of practice for six (6) of (7) CF reviewed. (CF # 1, 2, 3, 5, 6, and 7) Findings include: Review of Hospice policy on January 17, 2024, at approximately 11:00 A.M stated the following, “Policy # CR-I .0 Clinical Records PROCEDURES: 4. All documentation is to be done in legible handwriting using black ink or documented in the computer. All entries must be signed and dated by the clinician making the entry........ “ Review of CF on January 17, 2024, from approximately 11:30 A.M. to 2:15 P.M. and January 18, 2024, from approximately 9:30 A.M. to 1:30 P.M revealed the following: CF #1 Start of care (SOC) 01/23/2024 - Chaplin notes observed to have two (2) entries from 01/04/2024 to 01/05/2024 with date, no time and no signature on any of the entries. The document did not have patient identifiers. CF#2 SOC 12/07/2023, Chaplin notes observed to have seven (7) entries from 12/13/2023 to 12/22/2023 with date, no time and no signature on any of the entries. The document did not have patient identifiers. CF#3 SOC 08/28/2023, Chaplin notes observed to have twenty-one (21) entries from 08/30/2023 to 12/11/2023 with date, no time and no signature on any of the entries. The document did not have patient identifiers. CF#5 SOC 01/03/2024,Chaplin notes observed to have seven (7) entries from 01/04/2043 to 01/18/2024 with date, no time and no signature on any of the entries. The document did not have patient identifiers. CF#6 SOC 01/16/2024, Chaplin notes observed to have three (3) entries from 01/16/2024 to 01/19/2024 with date, no time and no signature on any of the entries. The document did not have patient identifiers. CF#7 SOC 01/16/2024, Chaplin notes observed to have three (3) entries from 01/16/2024 to 01/19/2024 with date, no time and no signature on any of the entries. The document did not have patient identifiers. An interview with the hospice administrator and the hospice nurse on January 18, 2024, at approximately 4:30 P.M. confirmed the above findings.”

“Based on review of agency policy, personnel files (PF), and interview with the hospice administrator, the hospice failed to ensure that criminal background checks were completed in accordance with hospice policy for one (1) of ten (10) PF reviewed. (PF #1). Findings include: Review of hospice policy #HR311 titled “Employee Background Checks” on 1/18/2024, at approximately 11:00 A.M. stated, “Procedure: ... 2. The background check must be completed and results verified before any employee begins work... 6. Foulkeways requires all contractors to comply with this policy...” Review of PF on 1/18/2024 from approximately 11:30 A.M. to 2:00 P.M. and 1/19/2024 from approximately 11:00 A.M. to 11:30 A.M. revealed the following: PF #1, date of hire 11/4/2019, contained a Pennsylvania State Police criminal background check dated 8/11/2006 and a Federal Bureau of Investigation background check dated 6/9/2021. There was no documentation of a background check completed at the time of hire. An interview with the administrator on 1/18/2024 at approximately 4:30 P.M. confirmed the above findings.”

“Based on review of the hospice policies, personnel files (PF) and interview with the hospice administrator, the hospice failed to ensure staff and/or contractors were screened for Tuberculosis in accordance with Centers for Disease Control and Prevention (CDC) guideline for one (1) of ten (10) PF reviewed. (PF #1) Findings include: The CDC guidelines state baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or tuberculin skin test (TST), shall include a symptom screen questionnaire and an individual tuberculosis (TB) risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19). A review of the PF on 01/18/2024, from approximately 11:30 A.M. and 2:00 P.M. revealed the following: PF#1 Date of hire 01/14/2019, PF revealed no documentation of Tuberculosis testing or screening were conducted on hire. An interview with the administrator on 1/18/2024 at approximately 4:30 P.M. confirmed the above findings.”