Penn Hospice, Inc.

“Based on a review of agency policy, medical record (MR), and staff (EMP) interview the hospice failed to ensure that the plan of care was developed in consultation within five (5) days after the election of the hospice benefit for two (2) of nineteen (19) MR reviewed. (MR7 and MR15). Findings Included: Review of the policy and procedures was conducted on 4/1/2025 at approximately 9:00 AM which revealed, “COMPREHENSIVE ASSESSMENT…POLICY A comprehensive patient assessment will be performed by the interdisciplinary group no later that 5 calendar days after the election of hospice care in consultation with attending physician. PROCEDURE 1. During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient’s clinical record, including at least the following information, as relevant…2. The assessment should determine…C. Patient goals related to the terminal illness D. Type of services, frequency, and duration needed to meet patient care needs…” Review of the policy and procedures was conducted on 4/1/2025 at approximately 9:00 PM which revealed, “ONGOING COMPREHENSIVE ASSESSMENTS…POLICY The scope and intensity of ongoing hospice patient assessments will be determined by the patient’s prognosis, diagnoses, condition, desire for care, response to previous care, and the care setting. PROCEDURE 1. During each home visit, the Case Manager or other discipline will evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment. 2. The nurse will assess each patient on each visit, for…4. Based on the assessments, the plan of care-including problems, needs, goals, and outcomes-will be reviewed and updated by the interdisciplinary group members responsible for the case. 5. Based upon the findings of the assessment, change/verbal orders will be generated and forwarded to the physician (or other authorized independent practitioner) as needed. 6. The physician will be notified to verify any changes in medications, including over-the-counter medications, and treatment/interventions that require physician approval…”A review of MR #7 was conducted on 3/25/2025 at approximately 12:12 PM, with a start of care of 1/23/2025, and hospice benefit election of 1/23/2025 to 4/22/2025. The facility did not provide documentation to confirm an assessment was completed by the chaplain or social worker within the first five (5) days of hospice benefit election. No documentation was available to confirm the patients or patients’ representatives declined Chaplain and/or social worker services. A review of MR#15 was conducted on 3/27/2025 at approximately 3:42 PM, with a start of care of 3/19/2025, and hospice benefit election 3/19/2025 to 6/16/2025. The facility did not provide documentation to confirm an assessment was completed by the chaplain or social worker within the first five (5) days of hospice benefit election. No documentation was available to confirm the patients or patients’ representatives declined Chaplain and/or social worker services.An exit interview was conducted with the executive director and clinical director on 3/27/2025 at approximately 4:30 PM which confirmed the above findings.”

“Based on a review of agency policy, medical record (MR) and staff (EMP) interview, it was determined that the agency failed to maintain an accurate medication profile to ensure review of all medications the patient was taking in order to identify and address potential adverse effects, drug reactions for three (3) of nineteen (19) MR’s reviewed (MR3, MR4 and MR16).Findings included:Review of the policy and procedures was conducted on 3/28/2025 at approximately 2:00 PM which revealed, “Reconciliation at admission and resumption of care: a. On accepting a patient referral, obtain the patient’s list of active/current medications from the referring facility or from the primary care provider. b. Call the patient/caregiver before making the visit to perform the initial comprehensive medication assessment. c. Ask patient/caregiver to collect all medications 1) Prescribed and over-the-counter meds 2) Vitamins and nutritional Supplements 3) Meds taken routinely or as needed 4) By any route, including inhaled, injected, applied to skin, eyes, etc. 2. During the visit, record all medicines the patient has collected on the Medication Profile (or Reconciliation Form). a. Include the name, dose, route, and how frequently the patient takes each one…3. Carefully compare the Medication List you have created from the drugs in the patient’s home to the medication list supplied by the discharging facility or by the primary care provider. a. Identify any discrepancies cannot be resolved by the nurse, report and resolve the discrepancies with the primary care provider within one day. c. Amend the Medication Profile as per the primary care provider’s orders…”A review of (MR3 OBV1) was conducted on 3/31/2025 at approximately 2:00 PM with a start of care date of 2/19/2025 for a certification period starting 2/19/2025 and ending 5/19/2025. The primary diagnosis was other Alzheimer’s disease. The facility physicians orders was compared to the agency medication profile. The following three (3) medications were not listed on the on the facility physicians order report compared to the agency medication profile: “7/26/2024 Carboxymethylcellulose 0.5% liquid…7/26/2024 levocetirizine 5 mg oral tablet…7/26/2024 tamsulosin 0.4 mg oral capsule…” The following three (3) medications were not listed on the on the agency medication profile report compared to the facilities physicians orders:“Lubiprostone 24mcg Caps…Orig Date: 20-jan-2025…BENZONATATE CAP 100 MG…Orig Date 10-Oct-2024Guaif-Codeine 100-10/5mL…Orig Date 31-Oct-2024…”A review of (MR4 OBV3) was conducted on 3/31/2025 at approximately 2:15 PM with a start of care date of 3/8/2024 for a certification period starting 3/3/2025 and ending 5/1/2025. The primary diagnosis was heart failure unspecified. The facility active medication profile was compared to the agency medication profile. The following three (3) medications were not listed on the on the facility active medication profile compared to the agency medication profile: “3/8/2024 Daily vite/iron 1 dose tablet…3/8/2024 Calprotect 0.44%-20.6% topical ointment…3/8/2024 Remedy phytoplex Z-Guard topical paste…”A review of MR16 on 3/25/2025 at approximately 1:07 PM with a start of care date of 12/4/2024 for a certification period starting 3/4/2025 and ending 6/1/2025. Review of the plan of care revealed under “Safety Measures…Oxygen Precaution…Supplies…Oxygen…Orders/Treatments…SN: Teach patient/caregiver regarding oxygen therapy…” The primary diagnosis was Chronic obstructive pulmonary disease with acute exacerbation. The following medication was not listed on the on the medication profile:OxygenAn exit interview was conducted with the executive director and clinical director on 3/27/2025 at approximately 4:30 PM which confirmed the above findings.”

“Based on review of the agency policies/procedures, medical record (MR), and staff (EMP) interview the hospice failed to ensure that goals and interventions were documented on the plan of care relating to the management of the terminal illness and related conditions for four (4) of nineteen (19) MR reviewed (MR7, MR10, MR12, MR15).Findings included:Review of the policy and procedures was conducted on 3/28/2025 at approximately 2:00 PM which revealed, “THE PLAN OF CARE, PURPOSE To ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues…PROCEDURE…3. Orders for the start of care will be verbally received by the Case Manager (or hospice registered nurse) from the attending physician (or other authorized independent practitioner) and documented on the plan of care/physician order form. 4. The plan of care will identify the patient’s needs and services to meet those needs including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs. 5. The individualized plan of care will be reviewed by the rest of the interdisciplinary group within two (2) days of start of care. 6. The plan of care will be provided to both the attending physician and the hospice Medical Director for approval of verbal orders and certification of the terminal illness signatures…7. Each patient will be monitored for his/her response to care or services provided against established patient goals and patient outcomes to evaluate progress toward goals…12. The written plan of care will contain, but will not be limited to, the following…N. Statement of treatment goals…T. Measurable outcomes anticipated from implementing and coordinating the plan of care. 13. All appropriate hospice staff will have access to the plan of care. 14. Care provided to the patient will be in accordance with the plan of care…”Review of the policy and procedures was conducted on 4/1/2025 at approximately 9:00 PM which revealed, “ONGOING COMPREHENSIVE ASSESSMENTS…POLICY The scope and intensity of ongoing hospice patient assessments will be determined by the patient’s prognosis, diagnoses, condition, desire for care, response to previous care, and the care setting. PROCEDURE 1. During each home visit, the Case Manager or other discipline will evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment. 2. The nurse will assess each patient on each visit, for…4. Based on the assessments, the plan of care-including problems, needs, goals, and outcomes-will be reviewed and updated by the interdisciplinary group members responsible for the case. 5. Based upon the findings of the assessment, change/verbal orders will be generated and forwarded to the physician (or other authorized independent practitioner) as needed. 6. The physician will be notified to verify any changes in medications, including over-the-counter medications, and treatment/interventions that require physician approval…”A review of MR7 was conducted on 3/26/2025 at approximately 2:15 PM with a start of care date of 1/23/2025 for a current certification period starting 1/23/2025 and ending 4/22/2025. The primary diagnosis is melanoma of right lower limb including hip. Review of the plain of care revealed “Orders/Treatments: Discipline Orders…Skilled Nursing; 1-2 wk 14wk 28 PRN…Aide; 1-2wk 14 wk; 12 PRN…Medical Social Worker to Assess and Evaluate…” Under the interventions section only intervention for aide was listed. No Goals were listed for any discipline on the plan of care.A review of MR10 was conducted on 3/26/2025 at approximately 2:40 PM with a start of care date of 8/19/2024 for a current certification period starting 2/15/2025 and ending 4/15/2025. The primary diagnosis is Alzheimer’s disease unspecified. Review of the plan of care revealed “Orders/Treatments: Discipline Orders…Aide; 4-5 wk 9 wk; 12 PRN…” Under the interventions and goals section only intervention and goals for aide was listed. The orders were reviewed on 3/27/2025 at approximately 2:00 PM which revealed “Orders…From Date 2/15/2025 To Date 4/15/2025…Medical Social Worker; 1 m, 3m 1PRN…Chaplain; 1-2 m 3 m 3 PRN…Skilled Nursing 1-2 d 13 wk 30 PRN…” No orders, interventions or Goals were listed for skilled nursing on the plan of care.A review of MR12 was conducted on 3/25/2025 at approximately 12:38 PM with a start of care date of 2/13/2025, for a current certification period starting 2/13/205 and ending 5/13/2025. The primary diagnosis is end stage heart failure. Review of the plain of care revealed “Orders/Treatments: Discipline Orders…Skilled Nursing; 1-2 wk 14wk 15 PRN…Aide; 1-2wk 13 wk; 12 PRN…Chaplain to Assess and Evaluate…Medical Social Worker to Assess and Evaluate…” Under the interventions and goals section only intervention and goals for skilled nursing were listed. No interventions or goals were listed for disciplines: aide, Chaplain and social worker were on the plan of care.A review of MR15 was conducted on 3/27/2025 at approximately 3:42 PM with a start of care date of 3/19/2025 for a current certification period starting 3/19/2025 and ending 6/16/2025. The primary diagnosis is heart failure unspecified. Review of the plain of care revealed “Orders/Treatments: Discipline Orders…Skilled Nursing; 1-2 wk 14wk 15 PRN…” Under the interventions and goals section no interventions or goals were listed for any disciplines on the plan of care. An exit interview was conducted with the executive director and clinical director on 3/27/2025 at approximately 4:30 PM which confirmed the above findings.”

“Based on review of agency policy and procedure, observation (OBV), and staff (EMP) interviews, the agency failed to ensure employees followed infection control policy and procedure during observations for one (1) of four (4) observations (OBV1).Findings included:Review of the policy and procedures was conducted on 3/28/2025 at approximately 2:00 PM which revealed, “BAG TECHNIQUE, PURPOSE To describe the procedure for maintaining a clen nursing bag/computer bag and preventing cross-contamination. PROCEDURE…Bag Technique 1. The bag will be placed on a clean surface (i.e., a surface that can be easily disinfected) in the car and in the home…”Observations (OBV1), during a visit to MR3 residence on 3/27/2025 at 9:02 AM revealed, EMP3 provided direct patient care. EMP3 placed the bag on clean towels located on a table. A strap from the nursing/supply bag and a cleaning towel connected to the nursing/supply bag was lying off the towels on the tablecloth. An exit interview was conducted with the executive director and clinical director on 3/27/2025 at approximately 4:30 PM which confirmed the above findings.”