Every finding on record at All Care Hospice

Based on review of hospice policy/procedure, documentation, clinical records and Pennsylvania (PA) controlled substance classification information, and based on interview with the hospice coordinator (Employee #2) and the administrator (Employee #7), the hospice failed to ensure that documentation of controlled substance/medication disposal was completed as per hospice policy/procedure for one (1) of three (3) hospice patients who expired in a private home. (Patient #13) --- Findings Include: On October 10, 2024 at approximately 3:29 PM, review of the hospice policy titled "Controlled Drug Disposal" revealed the following: Purpose: To promote the proper disposal of hospice medications. Objectives...To prevent use of a controlled drug by someone other than the patient. On October 10, 2024 at approximately 3:20 PM, review of PA Code, Title 28, Chapter 25. Controlled Substances, Drugs, Devices and Cosmetics ( https://www.pacodeandbulletin.gov/Display/pacode?file=/secure/pacode/data/028/chapter25/s25.72.html ) revealed the following: Lorazepam (Ativan) is classified as a Schedule IV controlled substance. On October 10, 2024 at approximately 3:22 PM, review of the PA Department of Health Questions and Answers under the Prescription Drug Monitoring Program (https://www.pa.gov/en/agencies/health/healthcare-and-public-health-professionals/pdmp/qa.html ) revealed the following: Schedule II - drugs with acceptable medical use, but with a high abuse potential that leads to dependence (morphine...). Patient #13: On October 10, 2024 at approximately 3:07 PM, review of hospice medication delivery records revealed the following medications were delivered to the patient: -Lorazepam: 30 tablets on 10/16/2023. -Morphine Sulfate: 30 milliliter bottles on 10/16/2023 and 10/23/2023. On October 10, 2024 at approximately 2:40 PM, review of the clinical record revealed the patient expired on 10/25/2023 as documented on the "Discharge-Death" skilled nursing note. "Discharge-Death" skilled nursing note documentation under "Comments/Summary" revealed the registered nurse/hospice administrator (Employee #7) documented that hospice medications were disposed as per hospice policy but there was no documentation under the section titled "Medication Disposal: Please indicate the name and quantity of all medications that were disposed" which provided evidence that Employee #7 had documented the name and quantity the remaining doses of lorazepam and morphine sulfate which were disposed on 10/25/2023. During interview conducted on 10/10/2024 at approximately 3:26 PM, the hospice coordinator and administrator confirmed the name and remaining doses/volume of controlled substances/medications supplied by the hospice are to be documented at the time of disposal. During interview on October 10, 2024 at approximately 4:00 PM, the hospice coordinator and the administrator confirmed that documentation of controlled substance/medication disposal was not completed as per hospice policy/procedure for Patient #13.

Based on a review of hospice policies/procedures, observation and clinical records, and based on interview with the administrator, the hospice failed to ensure emergency preparedness education was provided to five (5) of five (5) active patients/caregivers who resided in a private home. (Patients #3, #4, #7, #8 and #9) Findings Included: On October 15, 2021 at approximately 12:00 PM, review of the hospice emergency preparedness policies revealed the following: Public Information...2. Upon admission to the agency, every patient/patient representative/family/caregiver...will receive education that will assist them in managing emergencies... Patient #3: Between 10/14/2021 at approximately 1:50 PM and 10/15/2021 at approximately 11:46 AM, review of the clinical record revealed the start of care date was 05/28/2021, that the primary diagnosis is unspecified severe protein calorie malnutrition, that skilled nursing (SN) services are to be provided three (3) times a week and as needed and that home health aide (HHA) services are to be provided five (5) times a week as documented on the "Plan of Care Order" for the recertification period of 09/20/2021 through 11/18/2021. Review of initial skilled nursing SN assessment note dated 05/28/2021 revealed the patient's emergency preparedness classification was 3. "Emergency Plan for Active Patients" revealed the patient is bedbound that the patient requires activation of 911 to be evacuated from the home. During home visit conducted on 10/14/2021 at approximately 8:30 AM, the patient was noted to be confined to a hospital bed and the patient was unable to assist with personal care (bathing, etc.). A family member assisted with the provision of personal care services. There was no documentation in the clinical record which provided evidence that emergency preparedness education was provided to the patient's family member. Patient #4: Between 10/14/2021 at approximately 2:52 PM and 10/15/2021 at approximately 11:49 AM, review of the clinical record revealed the start of care date was 04/27/2021, that the primary diagnosis is unspecified severe protein calorie malnutrition, that SN and HHA services are to be provided two (2) times a week followed by three (3) times a week and as needed as documented on the "Plan of Care Order" for the recertification period of 07/26/2021 through 10/23/2021. Review of initial skilled nursing SN comprehensive assessment note dated 04/27/2021 revealed the patient's emergency preparedness classification was 3. "Emergency Plan for Active Patients" revealed the patient's spouse resides at the same address, that the patient is bedbound that the patient requires a transfer via litter (gurney) to be evacuated from the home. There was no documentation in the clinical record which provided evidence that emergency preparedness education was provided to the patient's spouse. Patient #7: On 10/15/2021 between the approximate times of 7:01 AM and 11:43 AM, review of the clinical record revealed the start of care date was 03/05/2021, that the primary diagnosis is COVID-19, that SN services are to be provided two (2) times a week for one (1) week followed by three (3) times a week and as needed and that HHA services were refused because 24 hour home care aides were present in the home as documented on the "Plan of Care Order" for the recertification period of 09/01/2021 through 10/30/2021. Review of initial skilled nursing SN comprehensive assessment note dated 03/05/2021 revealed the patient's emergency preparedness classification was blank. "Emergency Plan for Active Patients" revealed the patient's friend/power of attorney (POA) resides at the same address and that the patient requires a transfer via litter to be evacuated from the home. Review of the SN visit note dated 09/13/2021 revealed a PRN (as needed) SN visit was required because a power failure occurred and the caregivers did not know how to use the portable oxygen tanks. There was no documentation in the clinical record which provided evidence that emergency preparedness education was provided to the patient's POA nor the home care aides prior to 09/13/2021. Patient #8: On 10/15/2021 between the approximate times of 7:48 AM and 11:55 AM, review of the clinical record revealed the start of care date was 12/03/2020, that the primary diagnosis is Alzheimer's disease, that SN services are to be provided two (2) times a week and as needed and that HHA services are to be provided three (3) times a week as documented on the "Plan of Care Order" for the recertification period of 09/29/2021 through 11/27/2021. Review of initial skilled nursing SN comprehensive assessment note dated 12/03/2020 revealed the patient's emergency preparedness classification was 3. "Emergency Plan for Active Patients" revealed the patient's family member resides at the same address and that the patient requires a litter transport to be evacuated from the home. There was no documentation in the clinical record which provided evidence that emergency preparedness education was provided to the patient's family member. Patient #9: On 10/15/2021 between the approximate times of 07:25 AM and 11:57 AM, review of the clinical record revealed the start of care date was 08/18/2021, that the primary diagnosis is chronic obstructive lung disease (COPD) and that SN and HHA services are to be provided two (2) times a week and as needed as documented on the "Plan of Care Order" for the initial certification period (re-admission) of 08/18/2021 through 11/15/2021. Review of initial skilled nursing SN comprehensive assessment note dated 08/18/2021 revealed the patient's emergency preparedness classification was 2. "Emergency Plan for Active Patients" revealed the patient's family member resides at the same address, that the patient is oxygen dependent and that the patient's family members are responsible for evacuating the patient from the home. There was no documentation in the clinical record which provided evidence that emergency preparedness education was provided to the patient's family member. During interview conducted on 10/15/2021 at approximately 12:20 PM, the administrator confirmed there was no documentation in the clinical record which provided evidence that emergency preparedness education had been provided to the family members of patients #3, #4, #8 and #9, and that there was no documentation in the clinical record which provided evidence that emergency preparedness education had been provided to the POA/home care aides of patient #7 prior to 09/13/2021. During interview conducted on 10/15/2021 at approximately 12:20 PM, the administrator confirmed that documentation was not present in the clinical record which provided evidence that emergency preparedness education had been provided to the above referenced patients/caregivers.

Based on review of hospice policies/procedures and clinical records, and based on interview with the administrator, the hospice failed to ensure reports of missed spiritual counseling (SC) visits were reported as per hospice policies/procedures for three (3) of three (3) active patients for whom missed visits were documented by the SC. (Patients #2, #8 and #9) Findings include: On October 15, 2021 at approximately 12:10 PM, review of the hospice policy titled "Coordination of Patient Care Policy" revealed the following: Guidelines...10. Communication is maintained between those providing services regarding changes in...service or care to be provided... 11. IDG (Interdisciplinary Group) are held every 2 weeks or more often as necessary...to facilitate interdisciplinary coordination and communication of patient care with all disciplines involved. These occur spontaneously between team members and are documented in the patient's medical record... On October 15, 2021 at approximately 12:03 PM, review of the hospice policy titled "Establishment of the Plan of Care" revealed the following: Procedure...7. When a missed visit occurs, the physician/practitioner and Clinical Manager will be made aware of the missed visit and the reason why... Patient #2: Between 10/14/2021 at approximately 12:05 PM and 10/15/2021 at approximately 11:45 AM, review of the clinical record revealed the start of care date was 07/22/2021, that the primary diagnosis is severe protein calorie malnutrition and that SC services are to be provided one (1) time a week and as needed as documented on the "Plan of Care Order" for the initial certification period of 07/22/2021 through 10/19/2021. Review of SC missed visit documentation revealed SC services were not provided on 08/10/2021 because the SC was unable to reach/contact the patient's family member. There was no documentation in the clinical record which provided evidence that the SC notified the physician/practitioner and the clinical manager of the missed SC visit. Patient #8: On 10/15/2021 between the approximate times of 7:48 AM and 11:55 AM, review of the clinical record revealed the start of care date was 12/03/2020, that the primary diagnosis is Alzheimer's disease and that SC services are to be provided one (1) time a week and as needed as documented on the "Plan of Care Order" for the recertification period of 0929/2021 through 11/27/2021. Review of SC missed visit documentation revealed SC services were not provided on 09/14, 09/21 and 9/28/2021 because the SC was unable to reach/contact the patient's family member. There was no documentation in the clinical record which provided evidence that the SC notified the physician/practitioner and the clinical manager of the missed SC visits. Patient #9: On 10/15/2021 between the approximate times of 07:25 AM and 11:57 AM, review of the clinical record revealed the start of care date was 08/18/2021, that the primary diagnosis is chronic obstructive lung disease (COPD) and that SC services are to be provided one (1) time a week and as needed as documented on the "Plan of Care Order" for the initial certification period (re-admission) of 08/18/2021 through 11/15/2021. Review of SC missed visit documentation revealed SC services were not provided on 08/24, 09/21, 9/28 and 10/05/2021 because the SC was unable to reach/contact the patient's family member. There was no documentation in the clinical record which provided evidence that the SC notified the physician/practitioner and the clinical manager of the missed SC visits. During interview conducted on 10/15/2021 at approximately 12:20 PM, the administrator confirmed there was no documentation in the clinical record which provided evidence that the SC notified the physician/practitioner and the clinical manager of the missed SC visits for the above identified patients.

Based on review of hospice policies/procedures, the CMS (Centers for Medicare/Medicaid Services) COVID-19 provider guidance and clinical records, and based on interview with the administrator, the hospice failed to ensure the hospice plan of care included a provision which authorized telehealth services for eight (8) of eight (8) active patients for whom social work (MSW) and spiritual counseling (SC) services were provided via telephone contact. (Patients #1, #2, #3, #4, #5, #7, #8 and #9) Findings include: On October 15, 2021 at approximately 12:01 PM, review of the hospice policy titled "Telephone Visit Policy" revealed the following: Policy: All Care Hospice Care ensures that the care, treatment and services provided by the agency staff are consistent with those identified throughout the care planning process and are delivered in accordance with Federal regulatory requirements. Procedure...2. The spiritual counselor and medical social worker will provide care and services per the patients written plan of care... On October 14, 2021 at 5:02 PM, review of the CMS document titled COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing" revealed the following under "HH.Hospice" 1. Question: Can hospices furnish services using telecommunications technology during the PHE (Public Health Emergency) for the COVID-19 pandemic? Answer: Yes. Hospices are able to furnish services using telecommunications technology during the PHE when a patient is receiving routine home care. This can include telephone calls...two-way audio-video telecommunications technology that allow for real-time interaction between the patient and clinician (FaceTime, Skype, etc.), and remote patient monitoring. It would be up to the clinical judgment of hospice as to whether such technology can meet the patient's/caregiver's/family's needs and the use of technology should be included on the plan of care for the patient and family. Patient #1: Between 10/14/2021 at approximately 11:25 AM and 10/15/2021 at approximately 11:44 AM, review of the clinical record revealed the start of care date was 10/01/2021, that the primary diagnosis is mesothelioma (type of cancer that occurs in the thin layer of tissue that covers the majority of the internal organs), that MSW services are to be provided two (2) times a month and as needed, and that SC services are to be provided one (1) time a week and as needed as documented on the "Plan of Care Order" for the initial certification period of 10/01/2021 through 12/29/2021. Review of "MSW Assessment" and/or MSW visit/contact documentation revealed MSW services were provided via telephone contact on 10/04/2021. Review of "Chaplain/Counselor Assessment" and/or SC visit/contact documentation revealed SC services were provided via telephone contact on 10/02/2021 and 10/05/2021. There was no documentation on the "Plan of Care Order" which provided evidence that a provision for telehealth services had been included on the "Plan of Care Order" for the initial certification period of 10/01/2021 through 12/29/2021. Patient #2: Between 10/14/2021 at approximately 12:05 PM and 10/15/2021 at approximately 11:45 AM, review of the clinical record revealed the start of care date was 07/22/2021, that the primary diagnosis is severe protein calorie malnutrition, that MSW services are to be provided one (1) time a month for one (1) month followed by two (2) times a month and as needed, and that SC services are to be provided one (1) time a week and as needed as documented on the "Plan of Care Order" for the initial certification period of 07/22/2021 through 10/19/2021. Review of "MSW Assessment" and/or MSW visit/contact documentation revealed MSW services were provided via telephone contact on 07/26/2021, 08/06, 08/30, 09/10, 09/22 and 10/07/2021. Review of "Chaplain/Counselor Assessment" and/or SC visit/contact documentation revealed SC services were provided via telephone contact on 07/23, 07/27, 08/03, 08/18, 08/26, 09/01, 09/07, 09/14, 09/30, 10/05 and 10/13/2021. There was no documentation which provided evidence that a provision for telehealth services had been included on the "Plan of Care Order" for the initial certification period of 07/22/2021 through 10/19/2021. Patient #3: Between 10/14/2021 at approximately 1:50 PM and 10/15/2021 at approximately 11:46 AM, review of the clinical record revealed the start of care date was 05/28/2021, that the primary diagnosis is unspecified severe protein calorie malnutrition, that MSW services are to be provided one (1) time a month for one (1) month followed by two (2) times a month and as needed, and that SC services are to be provided one (1) time a week and as needed as documented on the "Plan of Care Order" for the recertification period of 09/20/2021 through 11/18/2021. Review of MSW visit/contact documentation revealed MSW services were provided via telephone contact on 09/28/2021 and 10/14/2021. Review of SC visit/contact documentation revealed SC services were provided via telephone contact on 09/21, 09/28, 10/05 and 10/12/2021. There was no documentation which provided evidence that a provision for telehealth services had been included on the "Plan of Care Order" for the recertification period of 09/20/2021 through 11/18/2021. Patient #4: Between 10/14/2021 at approximately 2:52 PM and 10/15/2021 at approximately 11:49 AM, review of the clinical record revealed the start of care date was 04/27/2021, that the primary diagnosis is unspecified severe protein calorie malnutrition, that MSW services are to be provided two (2) times a month and as needed, and that SC services are to be provided one (1) time a week and as needed as documented on the "Plan of Care Order" for the recertification period of 07/26/2021 through 10/23/2021. Review of MSW visit/contact documentation revealed MSW services were provided via telephone contact on 07/29, 08/12, 08/30, 09/20 and 09/29/2021. Review of SC visit/contact documentation revealed SC services were provided via telephone contact on 07/27, 08/03, 08/10, 08/17, 08/26, 09/01, 09/07, 09/14, 09/23, 09/30, 10/05 and 10/13/2021. There was no documentation which provided evidence that a provision for telehealth services had been included on the "Plan of Care Order" for the recertification period of 07/26/2021 through 10/23/2021. Patient #5: Between 10/14/2021 at approximately 5:47 PM and 10/15/2021 at approximately 11:50 AM, review of the clinical record revealed the start of care date was 09/03/2021, that the primary diagnosis is breast cancer, that MSW services are to be provided two (2) times a month and as needed, and that SC services are to be provided one (1) time a week and as needed as documented on the "Plan of Care Order" for the initial certification period of 09/03/2021 through 12/01/2021. Review of "MSW Assessment" and/or MSW visit/contact documentation revealed MSW services were provided via telephone contact on 09/05, 09/20 and 10/12/2021. Review of "Chaplain/Counselor Assessment" and/or SC visit/contact documentation revealed SC services were provided via telephone contact on 09/05, 09/16, 09/23, 09/29, 10/05 and 10/12/2021. There was no documentation which provided evidence that a provision for telehealth services had been included on the "Plan of Care Order" for the initial certification period of 09/03/2021 through 12/01/2021. Patient #7: On 10/15/2021 between the approximate times of 7:01 AM and 11:43 AM, review of the clinical record revealed the start of care date was 03/05/2021, that the primary diagnosis is COVID-19, that MSW services are to be provided one (1) time a month and as needed, and that SC services are to be provided one (1) time a week and as needed as documented on the "Plan of Care Order" for the recertification period of 09/01/2021 through 10/30/2021. Review of MSW visit/contact documentation revealed MSW services were provided via telephone contact on 09/04 and 09/24/2021. Review of SC visit/contact documentation revealed SC services were provided via telephone contact on 09/03, 09/10, 09/17, 09/24 and 10/01/2021. There was no documentation which provided evidence that a provision for telehealth services had been included on the "Plan of Care Order" for the recertification period of 09/01/2021 through 10/30/2021. Patient #8: On 10/15/2021 between the approximate times of 7:48 AM and 11:55 AM, review of the clinical record revealed the start of care date was 12/03/2020, that the primary diagnosis is Alzheimer's disease and that SC services are to be provided one (1) time a week and as needed as documented on the "Plan of Care Order" for the recertification period of 09/29/2021 through 11/27/2021. Review of SC visit/contact documentation revealed SC services were provided via telephone contact on 10/05/2021. There was no documentation which provided evidence that a provision for telehealth services had been included on the "Plan of Care Order" for the recertification period of 09/29/2021 through 11/27/2021. Patient #9: On 10/15/2021 between the approximate times of 07:25 AM and 11:57 AM, review of the clinical record revealed the start of care date was 08/18/2021, that the primary diagnosis is chronic obstructive lung disease (COPD), that MSW services are to be provided one (1) time a month for one (1) month followed by two (2) times a month and as needed, and that SC services are to be provided one (1) time a week and as needed as documented on the "Plan of Care Order" for the initial certification period (re-admission) of 08/18/2021 through 11/15/2021. Review of MSW visit/contact documentation revealed MSW services were provided via telephone contact on 09/10, 09/28 and 10/12/2021. Review of "Chaplain/Counselor Assessment" and/or SC visit/contact documentation revealed SC services were provided via telephone contact on 08/20, 08/31, 09/07, 09/14 and 10/12/2021. There was no documentation which provided evidence that a provision for telehealth services had been included on the "Plan of Care Order" for the initial certification period of 08/18/2021 through 11/15/2021. During interview conducted on 10/15/2021 at approximately 12:20 PM, the administrator confirmed there was no documentation which provided evidence that a provision for telehealth services had been included on the hospice "Plan of Care Order" forms for the above identified patients.