Every finding on record at Constellation Hospice PA, LLC

Based upon review of agency policy, clinical records, and interview with the director of nursing, the agency failed to protect the patient's rights to receive effective pain management and symptom control. --- Findings included: This CONDITION (418.52 Condition of Participation: Patients rights) was not met due to the failure: -Receive effective pain management and symptom control from the hospice for conditions related to the terminal illness, §418.52(c)(1)

Based on review of policies and procedures, Clinical records (CR), and an interview with the agency's director of nursing, the agency failed to ensure the patients received effective pain management and symptom control in one (1) of three (3) files reviewed. (CR#1). --- Findings Include: Review of agency's policies and procedures on 11/29/23 at approximately 1:00PM revealed the following: Policy titled, "Pain Assessment" states, " All patients will receive pain assessments. When pain is identified a more comprehensive pain assessment will be completed when warranted by the patient's condition. Pain Assessments will be appropriate to the patient's age/capacities and will be documented to facilitate regular reassessments and follow-up by the clinicians... Pain Management: The patient's preferences for pain management will be reflected in the pain control measures selected..." Documentation titled, "Hospice Patient's Bill of Rights/Responsibilities" states, "Patients have the right to be free from mistreatment and mental, physical, sexual and verbal abuse, neglect and exploitation...receive effective pain management and symptom control for conditions related to terminal illness..." Clinical records were reviewed on 11/29/23 at approximately 10:30 AM and revealed the following: CR #1: Start of Care (SOC): 11/15/23. Patient date of death: 11/19/23. Patient resided in a skilled nursing facility. A review of certification period 11/15/23-2/12/24 revealed order for Skilled nursing once weekly for one week, two times weekly for twelve weeks and six as needed, Home Health Aides for one-two visits weekly for one week then four-five times weekly for twelve weeks then once weekly for one-week, Social Worker starting on 11/17/23 for once monthly for one month and Chaplain evaluation only. Patient did not receive pain medication (morphine) until sometime between the evening on 11/17/23 and the morning of 11/18/23. (2-3 days post admission). Prior to receiving pain medication patient was assessed by the nurse and the patients family to be visually in pain (patient nonverbal). See documentation below. The initial RN assessment for pain stated patient is not comfortable with current pain treatment and stated a medication regimen change was implemented. RN assessed the patient through non-verbal means as a 3/10 (10 being the highest pain). Medication profile included Morphine 20mg/ml solution: take 5mg orally or under the tongue every three hours as needed for shortness of breath or moderate to severe pain that was listed with a start date of 11/15/23. Nursing visit on 11/16/23 conducted and the narrative stated, ";Visit made to assess pts status. Pt (patient) received in bed at the facility. Pt was nonverbal and sleeping continuously since her daughter left per supervisor...Supervisor could not confirm whether pts meds arrived from their pharmacy since pts charge nurse was on break. Supervisor promised to follow up since pt needs the medicine to control her symptoms especially pain management. Spoke to daughter after the visit. She stated she was with pt all day but was worried about medication not arriving on time since she saw patient grimacing in pain." In addition, the RN assessed the patients pain during visit to be 5/10 (10 being the highest pain). Service Comment Report Form stated 11/17/23 at 2:00 PM states patients family member called stating, ";pain meds still not arrived at facility...I spoke with (Facility staff nurse) who stated meds were due to arrive that evening. Recommendation made to remove IV line since arm was swollen. (Facility staff nurse) noted pt was comfortable...updated (patients family member) at 8:30 PM. F/U (follow-up) next morning 11/18/23, meds arrived." Skilled nursing visit conducted on 11/18/23 stated, ";FSN (facility staff nurse) also reported the pt has been getting the Morphine and Ativan as ordered. Pt was totally unresponsive with a flat affect. The pt was peaceful and not showing s/s (signs and symptoms) of distress or pain...I discussed the pts status with the family and the pts death was probably imminent. The family stated they understood and just wanted (patients name) to be comfortable..." An interview with the director of nursing was conducted on 11/29/23 at approximately 10:15 AM and stated that the facility where CR#1 resided at would only allow their specific pharmacy to order and deliver the medications. The hospice failed to follow-up on the delivery on the medication in a timely matter. Medications were delivered sometime between the evening on 11/17/23 and the morning of 11/18/23. (2-3 days post admission). In addition, the director of nursing stated the RN made an additional visit to the patient on 11/16/23 due to the patient's family "calling about pain meds." After a review of the nursing visit conducted on 11/16/23 the RN failed to effectively follow-up on the delivery of the patient's medication during their visit and that the RN spoke to the family after this visit, and they stated they were "worried about medication not arriving on time since she saw patient grimacing in pain." An additional interview conducted with agency's director of nursing on 11/29/23 at approximately 2:30 PM confirmed the above findings.

Based on review of agency policy, clinical records (CR) interview with the Director of Nursing, the hospice failed to follow the Hospice Plan of Care and/or Physician orders for one (1) of three (3) clinical records (CR #1). --- Findings include: A review of the agency policy occurred on 11/29/23 at approximately 1:00 PM and revealed the following: Policy titled "Wound Assessment, Documentation, Treatment, and Clinical Oversight" stated, "All patients with wounds will receive a comprehensive wound assessment at time of admission or upon first report of wound. Wounds will be documented in detail. Wound assessments will allow through documentation and will prompt and facilitate regular reassessment and follow-up of wounds by clinicians...The Registered Nurse performs the initial assessment for open wounds and surgical incisions upon admission and as ordered by the physician...Assessment of wound should include the following: location, wound condition, condition of surrounding skin, pain...Wound measurement techniques: stage...size..." A review of Clinical Records was conducted on 11/29/23 at approximately 10:30 am and revealed the following: CR #1: Start of Care (SOC): 11/15/23. Date of Death: 11/19/23. Patient resided in a skilled nursing facility. A review of certification period 11/15/23-2/12/24 revealed order for Skilled nursing once weekly for one week, two times weekly for twelve weeks and six as needed, Home Health Aides for one-two visits weekly for one week then four-five times weekly for twelve weeks then once weekly for one-week, Social Worker starting on 11/17/23 for once monthly for one month and Chaplain evaluation only. The Hospice Plan of Care listed pressure ulcer on sacral region, stage 4 on patient when they were admitted to services on 11/15/23. The wound treatment listed stated Cleanse Sacrum with Normal Saline Solution, pack with 4X4 gauze soaked with 1/4 Dakins Solution (germicidal/bacteriostatic topical agent used in wound cleansing) and cover with foam border gauze two times a week." The file did not contain any documentation of wound measurements or assessment. In addition, initial RN assessment and Hospice plan of care did provide any assessment on the patient's IV lines but did state, "She is currently on two IV antibiotics Vancomycin and Zosyn...daughter prefers to allow it to finish. (Hospice Medical Director) agreed to allow it complete." An interview with the agency's director of nursing on 11/29/23 at approximately 2:00 pm confirmed the above findings. ***This is a repeat deficiency (wound assessment). It was also cited during a re-licensure survey conducted on 7/21/23

Based on review of agency policy, clinical records (CR), observed home visit, and interview with the Administrator and Director of Nursing, the hospice failed to follow the Hospice Plan of Care and/or Physician orders for six (6) of fourteen (14) clinical records (CR #2, 3, 4, 9, 13 & 14) --- Findings include: A review of the agency policy occurred on 7/20/23 at approximately 11:00 am and revealed the following: Policy titled, "Physician Orders" stated, "The IDG Plan of Care is established in consultation with the physician, medical director, hospice staff, the patient and members of the patient's family.... Hospice professional staff with promptly alert the physician to any changes that suggest a need to alter the plan of care...Care and services will be provided according to physician orders. Orders are current and updated. Drugs and treatments are administered by staff only as ordered by physician. Oral orders are put in writing, signed and dated with the date of receipt by a RN (or therapist) responsible for furnishing or supervising ordered services..." Policy titled, "Communication with Office and Physician" stated, "If this is a significant change of status or change in the Plan of Care, the on-call nurse is notified, and immediate measures are determined. If client is not home for scheduled visit, MD or agent will be notified of missed visit." Policy titled, "IDG Care Planning Process" stated, "All Care and services furnished to patients and their families follows an individualized written plan of care established by the IDG in collaboration with the attending physician (if any), the patient or representative and the primary caregiver in accordance with the patient's needs... The plan of care included all services necessary for the palliation and management of the terminal illness and related conditions... a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs..." A wound assessment policy was requested on 7/21/23 at approximately 10:30AM and the administrator stated the agency does not have one. A review of the "Organization of Wound Care Nurses & Allied Health professionals" on 7/21/23 at approximately 12:00 PM states "Wound Care management" stated that "It is extremely important to measure the wound periodically since it shows the actual progress of the wound...Weekly wound imaging is the recommended best practice..." A review of Clinical Records was conducted on 7/19/23 and 7/20/23 at approximately 9:45 am and revealed the following: CR#2. Start of Care: 6/1/23. Certification period reviewed: 6/1/23-8/29/23. File contained Hospice aide orders for 1-2 week for 11 weeks. There is a missed visit documented on 6/27/23 and 6/29/23. There was no documentation that the Physician was notified about the missed visit and there were no verbal orders to update the frequency. CR#3. Start of Care: 6/28/23. Certification period reviewed: 6/28/23-8/26/23. File contained Chaplain and MSW orders for evaluation. There were missed visits for both Chaplain and MSW on 6/30/23. There was no chaplain or MSW visits conducted. There was no documentation that the Physician was notified about the missed visits and there were no verbal orders to update or discontinue the original evaluation orders. CR#4. Start of Care: 6/6/23. Certification period reviewed: 6/6/23-9/3/23. File contained chaplain order for evaluation. There was no Chaplain evaluation visit conducted. There was a scheduled chaplain visit that was missed on 6/9/23. There was no documentation that the Physician was notified about the missed visit and there was no verbal order to update or discontinue the original evaluation order. In addition, The Hospice Plan of Care listed multiple pressure ulcers on patient when they were admitted to services on 6/6/23. The wound treatment listed stated "cleanse wounds with 1/4 Dakins Solution (antiseptic to cleanse wounds), apply calcium alginate, and dry sterile dressing." The file did not contain any documentation of wound measurements, assessment or documentation that the wound treatment was conducted. CR#9. Start of Care: 5/26/22. Certification period reviewed: 5/21/23-7/19/23. Contained verbal order that stated "1 PRN visit. Received call from office that patient had one new small wound to sacral. Made visit to assess" that was written on 6/10/23. Nursing documentation of wound management revealed wound was only measured/assessed on 6/8/23. There was no additional documentation that contained any wound measurements/assessments in the clinical record. CR#13. Start of Care: 6/30/22. Certification period reviewed: 5/26/23-7/24/23. Contained Hospice Aide orders for once per week for one week, then 4-5 times per week for 8 weeks then once weekly for one week. And an additional order from 6/25/23 stating Hospice aides 1-2 times per week for 4 weeks. There were missed hospice aide visits on 6/13/23, 6/14/23, 6/15/23, 6/16/23, 6/22/23, and 7/6/23. There was no documentation that the Physician was notified about the missed visits and there was no verbal order to update the order frequency. CR#14. Start of Care: 2/9/23. Certification period reviewed: 5/10/23-8/7/23. IDG meeting conducted on 6/15/23 contained documentation from the RN on 6/7/23 that stated, "Pt (patient) is being treated for a sacral wound with medi-honey (antibacterial wound gel) and calcium alginate (wound dressing). Wound care completed earlier this AM, dressing clean, dry and intact." Medication profile for patient does not any orders for medi-honey or calcium alginate. An interview with the agency's administrator and director of nursing on 7/21/23 at approximately 2:30 pm confirmed the above findings.

Based on review of agency policy, clinical records (CR), and interview with the Administrator and Director of Nursing, the hospice failed to provide a plan of care that includes all services necessary for the palliation and management of the terminal illness and related conditions for twelve (12) of fourteen (14) clinical records (CR # 1, 2, 3, 4, 6, 8, 9, 10, 11, 12, 13 & 14). --- Findings include: A review of the agency policy occurred on 7/20/23 at approximately 11:00 am and revealed the following: Policy titled, "Physician Orders" stated, "The IDG Plan of Care is established in consultation with the physician, medical director, hospice staff, the patient and members of the patient's family.... Hospice professional staff with promptly alert the physician to any changes that suggest a need to alter the plan of care...Care and services will be provided according to physician orders. Orders are current and updated. Drugs and treatments are administered by staff only as ordered by physician. Oral orders are put in writing, signed and dated with the date of receipt by a RN (or therapist) responsible for furnishing or supervising ordered services..." Policy titled, "Communication with Office and Physician" stated, "If this is a significant change of status or change in the Plan of Care, the on-call nurse is notified, and immediate measures are determined. If client is not home for scheduled visit, MD or agent will be notified of missed visit." Policy titled, "IDG Care Planning Process" stated, "All Care and services furnished to patients and their families follows an individualized written plan of care established by the IDG in collaboration with the attending physician (if any), the patient or representative and the primary caregiver in accordance with the patient's needs... The plan of care included all services necessary for the palliation and management of the terminal illness and related conditions... a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs..." A review of Clinical Records was conducted on 7/19/23 and 7/20/23 at approximately 9:45 am and revealed the following: CR#1. Start of Care: 2/11/23. Certification period reviewed: 5/12/23-8/9/23. The Hospice Plan of Care did not contain any skilled nursing orders. There was a skilled nursing visit conducted on 5/15/25. There was no documentation of any verbal orders for skilled nursing. There were no skilled nursing orders listed until the Interdisciplinary Group Meeting (IDG) was conducted on 5/25/23 which stated Skilled Nursing once weekly for 13 weeks and 4 PRN (as needed). CR#2. Start of Care: 6/1/23. Certification period reviewed: 6/1/23-8/29/23. There was a Hospice Aide visit conducted on 6/20/23. There was documentation of hospice aide order written during the IDG meeting conducted on 6/22/23 which stated Hospice aides 1-2 per week for 11 weeks. There was no documentation of a verbal order for the hospice aide visit conducted on 6/20/23. CR#3. Start of Care: 6/28/23. Certification period reviewed: 6/28/23-8/26/23. The Hospice Plan of Care contained a skilled nursing order that stated skilled nursing to assess and evaluate. There was an additional skilled nursing visit conducted on 6/29/23 and no additional orders for this visit. There were verbal orders that stated Skilled Nursing 4 PRN (as needed) that was not written until 7/5/23 and there was an additional verbal order that stated skilled nursing once weekly for 9 weeks that was not written until 7/12/23. CR#4. Start of Care: 6/6/23. Certification period reviewed: 6/6/23-9/3/23. The Hospice Plan of Care did not contain any MSW (social workers) orders. There was a MSW visit conducted on 6/6/23. There was no documentation of any verbal orders for MSW There were no MSW orders listed until the Interdisciplinary Group Meeting (IDG) was conducted on 6/8/23 which stated MSW once monthly for 2 months. CR#6. Start of Care: 12/15/22. Certification period reviewed: 6/13/23-8/11/23. The Hospice Plan of Care did not contain any Chaplain or Hospice Aide orders. There was an observed home visit conducted by surveyor on 7/19/23 at approximately 12:00PM that was a chaplain visit. There were hospice aide visits conducted on 6/13/23 and 6/14/23. There were no Verbal orders for Chaplain or Hospice Aide services and in reviewing IDG meetings there were no orders for chaplain services. There was documentation of a hospice aide order written during the IDG meeting conducted on 6/15/23 which stated Hospice aides 4-5 times per week for 9 weeks. CR#8. Start of Care: 4/27/23. Certification period reviewed: 6/26/23-8/4/23. The Hospice Plan of Care did not contain any skilled nursing orders. There was a skilled nursing visit conducted on 6/26/23. There were no skilled nursing orders listed on the IDG conducted on 6/28/23. There was a verbal order for skilled nursing once weekly for one week that was not written until 7/5/23. An additional verbal order stated skilled nursing once per week for 6 weeks and 4 PRN (as needed) that was written on 7/11/23 The IDG that was conducted on 7/13/23 stated Skilled Nursing once weekly for one week and 6 PRN (as needed) visits and there was a verbal order stating the same frequency written also on 7/13/23. There were no additional skilled nursing orders. CR#9. Start of Care: 5/26/22. Certification period reviewed: 5/21/23-7/19/23. The Hospice Plan of Care did not contain any Hospice aide orders. There were hospice aide visits conducted on 5/22/23, 5/23/23, 5/24/23, 5/25/23, 5/26/23, 5/29/23, 5/30/23, 5/31/23. There was no documentation of any verbal orders for hospice aides. There were no hospice aide orders listed until the Interdisciplinary Group Meeting (IDG) was conducted on 6/1/23 which stated hospice aide 4-5 times per week for 8 weeks, then 2-3 per week for one week. CR#10. Start of Care: 5/25/23. Certification period reviewed: 5/25/23-8/22/23. The Hospice Plan of Care did not contain any Hospice aides or MSW orders. There was a MSW visit conducted on 5/26/23. There were hospice aide visits conducted on 6/8/23 and 6/13/23. The IDG meeting conducted on 6/1/23 stated MSW once per month for 3 months and 3 PRN (as needed). There were hospice aides ordered on the IDG meeting conducted on 6/15/23 that stated hospice aides 1-2 per week for one week, then 2-3 per week for 10 weeks, then 1-2 per week for one week. There were no verbal orders for Hospice aide or MSW. CR#11. Start of Care: 4/19/23. Certification period reviewed: 6/18/23-8/16/23. The Hospice Plan of Care did not contain any Skilled Nursing or Chaplain orders. There was a skilled nursing visit conducted on 6/21/23. There was Chaplain visit conducted on 6/20/23. There was no documentation of any verbal orders for skilled nursing or chaplain services. There were no skilled nursing orders listed until the Interdisciplinary Group Meeting (IDG) was conducted on 6/28/23 which stated Skilled Nursing once weekly for 8 weeks and 6 PRN (as needed) and Chaplain once monthly for one month. CR#12. Start of Care: 6/10/22. Certification period reviewed: 6/5/23-8/3/23. The Hospice Plan of Care did not contain any skilled nursing orders. There was a skilled nursing visit conducted on 6/7/23. There was no documentation of any verbal orders for skilled nursing. There were no skilled nursing orders listed until the Interdisciplinary Group Meeting (IDG) was conducted on 6/8/23 which stated Skilled Nursing once weekly for 9 weeks and 4 PRN (as needed). CR#13. Start of Care: 6/30/22. Certification period reviewed: 5/26/23-7/24/23. The Hospice Plan of Care did not contain any Chaplain orders. There were chaplain visits conducted on 5/26/23 and 6/23/23. There was no documentation of any verbal orders for chaplain. There were no chaplain orders listed on any of the IDG meeting conducted during the certification period. There was a "written" order that was attached to the patient's electronic record that was entered by the chaplain who is not a nurse, physician or mid-level practitioner that stated, "Chaplain once per month for one month." Agency unable to find any attached written orders for the chaplain. CR#14. Start of Care: 2/9/23. Certification period reviewed: 5/10/23-8/7/23. The Hospice Plan of Care did not contain any Skilled Nursing, Hospice aides or Chaplain orders. There were skilled nursing visits conducted on 5/10/23 and 5/17/23. There were hospice aide visits conducted on 5/10/23, 5/11/23, 5/12/23, 5/16/23 and 5/17/23. There was a Chaplain visit conducted on 5/17/23. There were no verbal orders for Skilled nursing, Hospice aides or Chaplain. The IDG meeting conducted on 5/18/23 stated orders for skilled nursing once weekly for 12 weeks and 4 PRN (as needed), Hospice aides for 3-4 visits per week for one week, then 4-5 visits per week for 12 weeks, then one visit per week for one week, and Chaplain one visit monthly for 3 months. An interview was conducted with the Administrator and Director of Nursing on 7/21/23 at approximately 2:30pm who confirmed the above findings.

Based upon review of agency policy, personnel files (PF), interview with the director of nursing and the administrator, the agency failed to show documentation of a completed initial competency checklist when hired for two (2) of ten (10) PFs reviewed (PF #2 & 3) and the agency failed to have documentation of annual competency completed for three (3) of ten (1) PFs reviewed (PF #5, 6, & 8) and the failed to obtain Pennsylvania State Police Background check (PATCH) at the time of hire for six (6) of ten (10) PF reviewed (PF #1, 2, 3, 4, 7 & 9). --- Findings included: Review of agency agency policy on 7/21/23 at approximately 11:00 AM revealed the following: Policy titled, "Selection/Hiring of Personnel" stated, "Hiring: An individual seeking employment will complete an application...A criminal background check and national sex offender check, if not part of criminal background check, will be obtained for positions as required by law and regulations..." Policy titled, "Competency Program" stated, "Personnel will demonstrate knowledge and proficiency of skills to their assigned responsibilities...Skill proficiency can be determined by verbal or written examination; skills demonstration in a lib setting or patient's home; or by completion of a specialized training course specific to a clinical procedure...Procedure...A supervisor or designee will be assigned to each new clinical staff member as part of the orientation process. The supervisor or designee will observe and deem proficient the indicated skills and core competencies. After the completion of orientation, competency will be monitored annually thereafter as part of the annual performance evaluation process..." PF reviewed on 7/20/23 at approximately 11:30 AM and revealed the following: PF#1, Date of Hire: 3/3/23. File reviewed revealed Pennsylvania State Police Background Check (PATCH) completed on 7/21/23 which is after the date of hire. PF # 2, Date of Hire: 1/19/22. File reviewed revealed job description for Director of Clinical Services. There was no documentation of initial competency checklist completed at the time of hire. In addition, File reviewed revealed Pennsylvania State Police Background Check (PATCH) completed on 7/20/23 which is after the date of hire. PF # 3, Date of Hire: 9/21/22. File reviewed revealed job description for Registered Nurse. There was no documentation of initial competency checklist completed at the time of hire. In addition, File reviewed revealed Pennsylvania State Police Background Check (PATCH) completed on 7/20/23 which is after the date of hire. PF#4, Date of Hire: 3/6/23. File reviewed revealed Pennsylvania State Police Background Check (PATCH) completed on 7/20/23 which is after the date of hire. PF # 5, Date of Hire: 9/21/22. There was no documentation of annual competency review completed in 2022. PF # 6, Date of Hire: 6/18/16. There was no documentation of annual competency review completed in 2021 and 2022. PF#7, Date of Hire: 8/22/22. File reviewed revealed Pennsylvania State Police Background Check (PATCH) completed on 7/20/23 which is after the date of hire. PF # 8, Date of Hire: 10/11/19. There was no documentation of annual competency review completed in 2020, 2021 and 2022. PF#9, Date of Hire: 2/20/23. File reviewed revealed Pennsylvania State Police Background Check (PATCH) completed on 7/21/23 which is after the date of hire. Interview with administrator and director of nursing on 7/21/23 at approximately 2:00 PM confirmed the above findings.