Every finding on record at Albright Hospice Inc

It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. The hospice did not ensure the emergency preparedness (EP) plan was updated at least every two years. The agency policy titled "Emergency Plan" included documentation that stated in part, "Risk Assessment and Planning (HSP7-4B (418.113 (a)(1), E-0008) [hospice agency name], has developed an Emergency Preparedness Plan that outlines the process for meeting patient and personnel needs in a disaster or crisis situation. Part of this process includes conducting a community-based risk assessment and the development of strategies and collaboration with other health organizations in the same geographic area. This emergency preparedness plan shall be reviewed and updated at least annually..." Review of the agency’s EP plan revealed no documented evidence that the emergency plan was reviewed for the years of 2021, 2022, and 2023. During document review and interview on 11/21/2024, the Administrator and the Director of Patient Care Services confirmed that the agency’s emergency preparedness plan was not reviewed and updated at least every two years. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence of the emergency plan reviewed for 2021, 2022, and 2023.

It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. The plan is based on and includes a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. This standard was not met as evidenced by document review and interview. The hospice did not ensure the emergency preparedness (EP) plan included documentation of a hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. The agency policy titled "Emergency Plan" included documentation that stated in part, "Risk Assessment and Planning (HSP7-4B (418.113 (a)(1), E-0008) [hospice agency name], has developed an Emergency Preparedness Plan that outlines the process for meeting patient and personnel needs in a disaster or crisis situation. Part of this process includes conducting a community-based risk assessment and the development of strategies and collaboration with other health organizations in the same geographic area. This emergency preparedness plan shall be reviewed and updated at least annually... Procedure 1. Hazard Vulnerability Analysis (HVA) will be conducted and evaluated annually. The Hazard Vulnerability Analysis is an "all hazards" integrated approach to planning the focuses on Hospice capacities and capabilities that are critical to preparedness planning for a full spectrum of emergencies or disasters in Hospice's location, considering the particular types of hazards which may most likely occur in Hospice's area..." Review of the agency’s EP plan revealed no documented evidence that the emergency plan included documentation of a hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served for the years 2021, 2022, and 2023. During document review and interview on 11/21/2024, the Administrator and the Director of Patient Care Services confirmed that a documented hospice-based and community-based risk assessment was not completed every two years using an “all-hazards” approach specific to the geography and population served. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence of a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served for the years 2021, 2022, and 2023.

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. The hospice did not ensure the emergency preparedness (EP) plan included documentation of a training program based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan and did not ensure documentation that the training program was reviewed and revised at least every two years. The agency policy titled "Emergency Plan" included documentation that stated in part, "Risk Assessment and Planning (HSP7-4B (418.113 (a)(1), E-0008) [hospice agency name], has developed an Emergency Preparedness Plan that outlines the process for meeting patient and personnel needs in a disaster or crisis situation. Part of this process includes conducting a community-based risk assessment and the development of strategies and collaboration with other health organizations in the same geographic area. This emergency preparedness plan shall be reviewed and updated at least annually... Procedure 1. Hazard Vulnerability Analysis (HVA) will be conducted and evaluated annually. The Hazard Vulnerability Analysis is an "all hazards" integrated approach to planning the focuses on Hospice capacities and capabilities that are critical to preparedness planning for a full spectrum of emergencies or disasters in Hospice's location, considering the particular types of hazards which may most likely occur in Hospice's area... 17. All new staff will be oriented and trained to the emergency operations plan. Ongoing staff education and training will occur annually as part of an exercise or in response to an actual emergency." Review of the agency’s EP plan revealed no documented evidence that the emergency plan was reviewed and included documentation of a hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served for the years 2021, 2022, and 2023. There was no documented evidence that the agency’s EP training program was based on a hospice-based and community-based risk assessment and updated for the years of 2021, 2022, and 2023. During document review and interview on 11/21/2024, the Administrator and the Director of Patient Care Services confirmed that the EP training program was not based on the emergency preparedness plan, risk assessment, policies and procedures, and communication plan. They also confirmed the EP training program had not been reviewed and/or revised at least every 2 years. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the training program was based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The document lacked evidence of a risk assessment for the years 2021, 2022, 2023, and 2024. The documentation lacked evidence that the training program was updated for 2021, 2022, and 2023.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over the counter (OTC) drugs, supplements, herbal remedies, other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following, the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 3 (33%) clinical records reviewed, the organization did not ensure the medication review included the patient’s current prescription and OTC drugs, supplements, herbal remedies, other alternative treatments that could affect drug therapy. Home Visit 2: The patient elected the hospice benefit on 01/12/2024. During the home visit observation on 11/20/2024 with the Registered Nurse (RN) (Personnel Record 2), a medication review was completed by comparing the patient’s home medications to the hospice medication profile. The hospice medication profile printed on 11/20/2024 included Senna 8.6mg by mouth daily started on 01/12/2024 and Nystatin 100,000 units/g topical powder daily as needed started on 06/12/2024. The patient’s home medications did not include Senna and Nystatin. Home Visit 3: The patient elected the hospice benefit on 04/13/2024 and resided in a group home. During the home visit observation on 11/20/2024 with the Registered Nurse (RN) (Personnel Record 2), a medication review was completed by comparing the patient’s home medications to the hospice medication profile. The hospice medication profile printed on 11/20/2024 included documentation that Ipratropium Bromide/Albuterol Sulfate was discontinued on 11/07/2024. The patient’s home medications included Ipratropium Bromide/Albuterol Sulfate 0.5mg-3mg/3ml by SVN [single volume nebulizer] every four hours as needed for shortness of breath/wheezing. The Group Home caregiver stated that the patient has been using this for around two months, but the dates were unsure. During a joint record review and interview on 11/21/2024, the Director of Patient Care Services confirmed that the medication review process and the medication profile did not include the patient’s current medications.

It is required that nursing care and services are provided by or under the supervision of a Registered Nurse (RN) and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that nursing care and services were provided per the patient plan of care. Clinical Record 2: The patient elected the hospice benefit on 08/22/2024. The initial nursing assessment was completed on 08/22/2024. Clinical record review revealed there was a nursing visit scheduled on 08/27/2024 per the plan of care, but the visit note was not completed. The clinical record contained no documented evidence that a nursing visit was provided for the week of 08/25/2024 to 08/31/2024. During a joint record review and interview on 11/20/2024, the Director of Patient Care Services confirmed that the nursing care and services were not provided per the patient plan of care.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed with aide services provided, the agency did not ensure the Registered Nurse made an on-site aide supervisory visit to the patient’s home no less frequently than every 14 days. Clinical Record 2: The patient elected the hospice benefit on 08/22/2024. Clinical record review revealed Hospice Aide services were ordered twice a week and the first aide visit was completed on 08/27/2024. The Registered Nurse (RN) completed an aide supervisory visit on 10/22/2024 and the next aide supervisory visit was dated 11/06/2024, a total of 15 days and one day outstanding. Clinical Record 3: The patient elected the hospice benefit on 06/11/2024. Clinical record review revealed Hospice Aide services were ordered twice a week and the first aide visit was completed on 06/17/2024. The Registered Nurse (RN) completed an aide supervisory visit on 11/02/2024 and the next aide supervisory visit was dated 11/19/2024, a total of 17 days and 3 days outstanding. Clinical Record 14: The patient elected the hospice benefit on 04/07/202 and the date of death 02/23/2024. Clinical record review revealed Hospice Aide services were ordered twice a week and the first aide visit was completed on 06/17/2023. The RN documented aide supervisory visits on 09/08/2023, 11/14/2023, and 01/30/2024. There was no documented evidence that the RN completed aide supervisory visits from 09/22/2023 through 11/14/2023 a total of 53 days, 11/28/2023 through 01/30/2024 a total of 63 days, and 01/30/2024 through 02/23/2024, a total of 24 days. During a joint clinical record review and interview on 11/20/2024, the Director of Patient Care Services confirmed the Registered Nurse did not document on-site aide supervisory visits no less frequently than every 14 days.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum, signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient's start of care/effective date of election was dated on or after the signed consent. Review of agency document titled "Admission Consents," without a date, included Release of Information and Consent for Patient, Consents for Hospice Care, Patient Acknowledgement, Hospice Election Statement, Hospice Philosophy and Coverage of Hospice Care, Rights to Request 'Patient Notification of Hospice Non-Covered Items, Services, and Drugs.'" The Hospice Election Statement on page 6 of 9 stated in part, "Note: The start of care date, also known as the effective date of the election, may be the first day of hospice care or a later date, but may be no earlier than the date of the election statement. An individual may not designate an effective date that is retroactive." Clinical Record 5: The Consents for Hospice Care and the Hospice Election Statement were completed, signed by the patient's daughter, and dated 03/23/2024. The start of care date on the Hospice Election Statement was 03/23/2024. The Plan of Care/Interdisciplinary Group Review, the Physician's Certification for Hospice Benefit, and the Initial Assessment were dated 03/22/2024, the day before the patient signed the election of benefit. During a joint clinical record review and interview on 11/21/2024, the Administrator confirmed that the record lacked evidence that the patient's start of care/effective date of election was dated on or after the signed consent.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. Criminal background checks are obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three (3) months of the date of employment for all states in which the individual has lived or worked during the past three (3) years. This standard was not met as evidenced by personnel record review and interview. In 1 of 11 (9%) personnel records reviewed, the agency did not ensure a criminal background check was obtained within three months of the date of employment. Personnel Record 11: Volunteer Coordinator date of hire 02/01/2023. Review of the personnel record revealed the National Criminal and Offense Report for the criminal background check was dated 09/04/2023. There was no documented evidence in the personnel record that a criminal background check was completed within three months of the date of hire. During an interview and joint personnel record review on 11/21/2024, the Administrator confirmed the personnel record did not include verification that a criminal background check was completed within three months of the date of employment.