Every finding on record at Good Samaritan Hospice of Pittsburgh

Based on review of agency policy, clinical records (CR), and staff (EMP) interview, the hospice interdisciplinary group, in collaboration with the patient's attending physician, failed to ensure the comprehensive assessment was updated to consider changes in the patient's condition since the initial comprehensive assessment to include the patient's progress toward goals for one (1) of three (3) clinical records (CR1) residing in a skilled nursing facility (SNF). --- Findings include: Review of agency policy on September 12, 2024, at 12 p.m. showed, "Initial and Comprehensive Assessment ... The comprehensive assessment takes into consideration the following: ... Severity of symptoms ... Drug profile including: effectiveness of drug therapy ... Comprehensive Assessment Updates a. The hospice interdisciplinary group is responsible for updating the comprehensive assessment (in collaboration with the hospice medical director/associate medical director and/or patient's attending physician, if any). b. Considerations for updating the comprehensive assessment include: Changes that have taken place since the initial assessment ... Patient's progress toward desired outcomes ... c. The update is required as frequently as the patient requires." Review of CR1 on September 11, 2024, at 1 p.m. showed patient was admitted to hospice on 6/23/2024 with an initial certification period ending 9/20/2024. The admitting diagnosis was hypertensive heart disease with heart failure. Orders included skilled nursing to see the patient once a week routinely with additional visits for symptom control as needed (PRN). Nursing was to assess and monitor effectiveness of cardiopulmonary symptom relief measures including oxygen treatment at 2 liters continuous. The patient's goal was for respiratory comfort, "[Patient] will verbalize/demonstrate reduction or relief of cardiopulmonary symptoms by end of each SN [skilled nursing] visit over the next two weeks AEB [as evidenced by] respiratory rate of 22 breaths/minute or less and unlabored breathing." The initial comprehensive assessment was completed 6/23/2024, and subsequent skilled nursing (SN) visits occurred on 6/25, 6/28, and 7/2/2024. During this time the patient was using 2 liters of oxygen continuous. Per the IDG "Plan of Care Update" from 7/9/2024, the patient's goal had changed, "Goals: ... [Patient] will verbalize/demonstrate reduction or relief of cardiopulmonary symptoms by end of SN visit." On 7/13/2024, the facility (SNF) called the hospice to report the patient (CR1) was having a hard time breathing and his/her oxygen levels were low. Upon return call by the hospice to the facility, the patient had received Morphine (comfort medication that can help ease breathlessness) and the agency instructed the facility to increase the dose from 5 to 10 mg and to give PRN Ativan (comfort medication that can help ease breathlessness and anxiety) as needed. A PRN LPN (licensed practical nurse) visit was made the same day (7/13/2024) related to aforementioned phone call from facility staff, "SN visit made for CIC [change in condition]." During the visit, the LPN noted the patient was on 4L of continuous oxygen, but the order was for 2L of continuous oxygen. The LPN noted the patient was SOB (short of breath) with the use of accessory muscles needed for conversation. Per the IDG "Plan of Care Update" from 7/16/2024, "Goals: ... [Patient] will verbalize/demonstrate reduction or relief of cardiopulmonary symptoms by end of SN visit." There was no update to patient's goals related to increased use of oxygen as noted during 7/13/2024 LPN visit. A review of "HOSPICE CASE COMMUNICATION" dated 7/21/2024 showed, "Received call from facility nurse [...] to report pt is having increased SOB while talking, resting in bed. Receiving PRN Morphine ... Family requested GSH [Good Samaritan Hospice] nursing visit." The RN made a PRN visit the same day (7/21/2024) and noted patient was on 4L of oxygen but still only 2L of oxygen was ordered. On 7/23/2024, the RN saw the patient for a routine visit and noted the patient's respirations were labored and the patient was on 3.5L of oxygen but the order was still only for 2L of oxygen. Per the IDG "Plan of Care Update" from 7/23/2024, "Goals: ... [Patient] will verbalize/demonstrate reduction or relief of cardiopulmonary symptoms by end of SN visit." There was no update to patient's goals related to increased use of oxygen and episodes of breathlessness as notedwi during SN visits on 7/21, and 7/23/2024. On 7/25/2024, the family called the hospice to report patient could not breathe. The family had the patient transported to the hospital and removed the patient from GSH services. Interviews with EMP1 (administrator) and EMP2 (clinical manager) on September 12, 2024, at 10:45 a.m. confirmed above findings.

Based on review of agency policy, clinical records (CR), and staff (EMP) interview, the hospice interdisciplinary group (IDG) and the attending physician failed to review and revise the plan as frequently as the patient's condition required for one (1) of three (3) clinical records (CR1) residing in a skilled nursing facility (SNF). --- Findings include: Review of agency policy on September 12, 2024, at 12 p.m. showed: "Initial and Comprehensive Assessment ... The comprehensive assessment takes into consideration the following: ... Severity of symptoms ... Drug profile including: effectiveness of drug therapy ... Comprehensive Assessment Updates a. The hospice interdisciplinary group is responsible for updating the comprehensive assessment (in collaboration with the hospice medical director/associate medical director and/or patient's attending physician, if any). b. Considerations for updating the comprehensive assessment include: Changes that have taken place since the initial assessment ... Patient's progress toward desired outcomes ... c. The update is required as frequently as the patient requires." "Interdisciplinary Group ... Purpose: The interdisciplinary group (IDG) works together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. ... a. the IDG is responsible for: ... updating the comprehensive assessment as the patient's condition requires ... Working to develop and update an individualized plan of care for each patient based on the assessment in order to meet patient/family needs and goals ... Directing, coordinating, and supervising the care and services offered by the hospice." Review of CR1 on September 11, 2024, at 1 p.m. showed the patient was admitted to hospice on 6/23/2024 with an initial certification period ending 9/20/2024. The admitting diagnosis was hypertensive heart disease with heart failure. Orders included skilled nursing to see the patient once a week routinely with additional visits for symptom control as needed (PRN). Nursing was to assess and monitor effectiveness of cardiopulmonary symptom relief measures including oxygen treatment at 2 liters continuous. The patient signed his/her own benefit on 6/23/2024 and chose the SNF's medical director to be his/her attending physician (PCP). On 7/13/2024, the facility (SNF) called the hospice to report the patient (CR1) was having a hard time breathing and his/her oxygen levels were low. A PRN LPN (licensed practical nurse) visit was made the same day related to aforementioned phone call from facility staff. The LPN noted the patient was on 4L of continuous oxygen, but the hospice order was for 2L of continuous oxygen. The patient was SOB (short of breath) with use of accessory muscles needed for conversation. On 7/16/2024, the RN saw the patient during a routine visit (not PRN). The RN noted that patient was scared by last breathless episode over the weekend (7/13). The patient's family was present and requested Morphine be given on a routine instead of as needed. A review of "HOSPICE CASE COMMUNICATION" dated 7/21/2024 showed, "Received call from facility nurse [...] to report pt is having increased SOB while talking, resting in bed. Receiving PRN Morphine ... Family requested GSH [Good Samaritan Hospice] nursing visit. Would like Morphine scheduled and some routine medications discontinued." The RN made a PRN visit the same day (7/21/2024) and spoke to the patient's family. At this time, the family was "not happy" that some non-comfort medications had not yet been discontinued. The family voiced their wish that the patient only receive comfort medications so that he/she could pass peacefully. The RN documented, "Left recommendations with [SNF Staff] per [Hospice medical director], to discontinue ... decrease [non-comfort medications]. Roxanol [Morphine/comfort medication] 5mg ... [every 6 hours] scheduled. ... Explained again to family that attending [SNF medical director] has the final decision on recommendations left." Patient on 4L of oxygen but 2L of oxygen was the current order. On 7/23/2024, the RN saw patient for a routine visit, "This SN [skilled nurse] explained attending physician [SNF medical director] and recommendations by hospice physician." Family questioning policy of giving Morphine for SOB. Asking why GSH has to be called and come out each time pt needs something." The RN noted the patient's respirations were labored and the patient was on 3.5L of oxygen, however 2L of oxygen was ordered. A review of the IDG "Plan of Care Update" from 7/23/2024 did not show that the IDG reviewed and revised the plan to ensure the patient's and family's needs were met concerning comfort medications, and the patient's increased use of oxygen and breathlessness. Interviews with EMP1 (administrator) and EMP2 (clinical manager) on September 12, 2024, at 10:45 a.m. confirmed above findings.

Based on review of agency policy, clinical records (CR), documentation, and staff (EMP) interviews, the agency failed to provide care that was consistent with patient and family needs for one (1) of three (3) clinical records (CR1) residing in a skilled nursing facility (SNF). --- Findings include: Review of agency policy on September 12, 2024, at 1 p.m., "Interdisciplinary Group ... Purpose: The interdisciplinary group (IDG) works together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement." Review of CR1 on September 11, 2024, at 1 p.m. showed patient was admitted to hospice on 6/23/2024 with an initial certification period ending 9/20/2024. The admitting diagnosis was hypertensive heart disease with heart failure. Orders included skilled nursing to see the patient once a week routinely with additional visits for symptom control as needed (PRN). Nursing was to assess and monitor effectiveness of cardiopulmonary symptom relief measures including oxygen treatment at 2 liters continuous. Nursing was to also coordinate the plan of care with SNF staff. The initial comprehensive assessment was completed on 6/23/2024, and a subsequent skilled nursing (SN) visit occurred on 6/25/2025. On 6/28/2024, the patient's family called the hospice to report the patient was declining, "Received call from [Family] to report pt [patient] is declining. Congested with cough, requested nursing visit today and [routine/scheduled] increase in nursing visit frequency." The Skilled nurse saw the patient on 6/28/2024 (PRN visit) and made medication changes to address patient's congestion but there was no change to the patient's SN visit frequency of once per week. The patient was on 2L (liters) of oxygen during these SN visits. On 7/2/2024, the RN made a routine visit patient and noted the patient's lips were dusky, and was on 2L of oxygen. Vital signs were within normal limits with oxygen saturation (SPO2) at 95% (above 90% is acceptable). The RN left a message with patient's son with an update. On 7/9/2024, the RN made a routine visit. The patient's family was present. The patient's lips were blue, but vital signs were normal and SPO2 was 97% on 2L of oxygen. The patient's SN visit frequency remained once a week. On 7/11/2024, the patient's family called the agency to report the patient was up all night and requested SN see patient tomorrow (7/12/2024). On 7/12/2024, the LPN (licensed practical nurse) saw the patient (PRN visit) and noted the patient was pale but alert and orientated and pleasant. The patient's vital signs were WNL with SPO2 at 95 on 2L of oxygen. On 7/13/2024, the facility (SNF) called the hospice to report the patient (CR1) was having a hard time breathing and his/her oxygen levels were low. Upon return call by the hospice to the facility, the patient had received Morphine (comfort medication that can help ease breathlessness) and instructed the facility to increase the dose from 5 to 10 mg and to give PRN Ativan (comfort medication that can help ease breathlessness and anxiety) as needed. A PRN LPN visit was made the same day related to aforementioned phone call from facility staff. The LPN noted the patient was on 4L of continuous oxygen, but the order was for 2L of continuous oxygen. The patient was SOB (short of breath) with use of accessory muscles needed for conversation. On 7/16/2024, the RN saw the patient during a routine visit (not PRN). The RN noted that patient was scared by last breathless episode over the weekend (7/13). The patient's family was present and requested Morphine be given on routine basis instead of as needed. A review of "HOSPICE CASE COMMUNICATION" dated 7/21/2024 showed, "Received call from facility nurse [...] to report pt is having increased SOB while talking, resting in bed. Receiving PRN Morphine ... Family requested GSH [Good Samaritan Hospice] nursing visit. [Family] Would like Morphine scheduled and some routine medications discontinued." The RN made a PRN visit the same day (7/21/2024) and spoke to the patient's family. At this time, they are "not happy" that some non-comfort medications have not been discontinued. The family voiced its wish that the patient only receive comfort medications so that he/she could pass peacefully. And once again the family requested scheduled Morphine. Patient on 4L of oxygen but 2L of oxygen was ordered. 7/23/2024, RN saw patient for routine visit, "[Family] had most [non-comfort] medications discontinued by facility [SNF] CRNP [nurse practitioner]. Family questioning policy of giving Morphine for SOB. Asking why GSH has to be called and come out each time pt needs something." The RN noted the patient's respirations were labored and the patient was on 3.5L of oxygen. On 7/25/2024, the family called the hospice to report patient could not breathe. The family had the patient transported to the hospital and removed the patient from GSH services. A review of " Hospice IDG [interdisciplinary group] Comprehensive Assessment and Plan of Care Update Report[s]" for the above episode was reviewed on 9/12/2024 at 9:40 a.m. and included IDG meetings from 6/26, 7/9, and 7/23/2024. The review showed that the IDG did not address/mention family's concerns for an increase in routine skilled nursing visits, a change to patient's Morphine from PRN to routine so that patient did not have to ask for it (patient was 92 years old and sometimes forgetful), the patient's increased need for supplementary oxygen of 2L, or the family's desire to have the patient's non-comfort medications discontinued. Interviews with EMP1 (administrator) and EMP2 (clinical manager) on September 12, 2024, at 10:45 a.m. confirmed above findings.

Based on review of agency policy, clinical records (CR), and staff (EMP) interview, the agency failed to ensure the clinical record was provided to the patient's power of attorney (POA) upon request for one (1) of three (3) clinical records (CR1) who resided in a skilled nursing facility (SNF). --- Findings include: Review of agency policy on September 12, 2024, at 12 p.m. showed: "Policy Title: Request To Access Own PHI ... Policy Statement: Concordia will provide persons served access to their protected health information in a designated record set for the purpose of inspecting and/or obtaining a copy, ... Purpose: To comply with the individual's right to access their PHI ... a person served or legal representative may upon verbal or written request have access to all records ... Concordia will arrange with the individual a convenient time and place to inspect or obtain a copy of the protected health information, or mailing a copy of the protected health information at the individual's request." "Policy Title: Disclosures of PHI to Friends and Family ... Concordia may disclose a person's served PHI to friends and family members involved in their care if: 1. The amount of PHI disclosed is directly relevant to their involvement in the person's served care." Review of CR1 on September 11, 2024, at 1 p.m. showed patient was admitted to hospice on 6/23/2024 with an initial certification period ending 9/20/2024. Review of "Client Coordination Note Report" from dated 7/23/2024 showed, "Care conference with family ... [Family] would like a copy of care plan sent to them. Message sent in [secure system] to have this sent by email to [POA]." During interview with EMP1 (administrator) on September 12, 2024, at 11 a.m. surveyor requested confirmation that the POA had received requested clinical record information, but EMP1 unable to locate confirmation to show that the POA was sent the plan of care as requested on 7/23/2024.

Based on review of agency policy, the contract between the hospice and the skilled nursing facility (SNF), clinical records (CR), and staff (EMP) interview, the hospice failed to assume full responsibility for professional management of the resident's hospice services for one (1) of three (3) records (CR1) who resided in a SNF. The hospice failed to ensure the hospice medical director's medication orders were coordinated with and implemented by the SNF. --- Findings include: Review of agency policy on September 12, 2024, at 12 p.m., "Plan of Care ... a. the individualized plan of care is established by the interdisciplinary group in collaboration with the attending physician ... the patient representative, and the primary caregiver in accordance with the patient's wishes. ... 3. Plan of Care Reviews a. the interdisciplinary group reviews, revises, and documents the individualized plan of care as frequently as the patient's condition requires. ... Coordination of Services ... There are several systems in place to facilitate exchange of information and coordination of services among hospice staff and other healthcare providers including: ... Interdisciplinary group notes- added to Vision EMR system (Concordia SNFs and PCHs) and communicated to the attending physician." Review of CR1 on September 11, 2024, at 1 p.m. showed the patient was admitted to hospice on 6/23/2024 with an initial certification period ending 9/20/2024. The admitting diagnosis was hypertensive heart disease with heart failure. Orders included skilled nursing to see the patient once a week routinely with additional visits for symptom control as needed (PRN). Nursing was to assess and monitor effectiveness of cardiopulmonary symptom relief measures including oxygen treatment at 2 liters continuous. The patient lived in a SNF, and the hospice was to coordinate the plan of care with the SNF, "Hospice nurse to coordinate plan of care with facility staff at [SNF]." The episode lasted approximately 5 weeks and included 10 nursing visits. The patient signed his/her own benefit on 6/23/2024 and chose the SNF's medical director to be his/her attending physician (PCP). On 7/13/2024, the facility (SNF) called the hospice to report the patient (CR1) was having a hard time breathing and his/her oxygen levels were low. A PRN LPN (licensed practical nurse) visit was made the same day related to aforementioned phone call from facility staff. The LPN noted the patient was on 4L of continuous oxygen, but the hospice order was for 2L of continuous oxygen. The patient was SOB (short of breath) with use of accessory muscles needed for conversation. On 7/16/2024, the RN saw the patient during a routine visit (not PRN). The RN noted that patient was scared by last breathless episode over the weekend (7/13). The patient's family was present and requested Morphine be given on a routine instead of as needed. A review of "HOSPICE CASE COMMUNICATION" dated 7/21/2024 showed, "Received call from facility nurse [...] to report pt is having increased SOB while talking, resting in bed. Receiving PRN Morphine ... Family requested GSH [Good Samaritan Hospice] nursing visit. Would like Morphine scheduled and some routine medications discontinued." The RN made a PRN visit the same day (7/21/2024) and spoke to the patient's family. At this time, the family was "not happy" that some non-comfort medications had not yet been discontinued. The family voiced their wish that the patient only receive comfort medications so that he/she could pass peacefully. The RN documented, "Left recommendations with [SNF Staff] per [Hospice medical director], to discontinue ... decrease [non-comfort medications]. Roxanol [Morphine/comfort medication] 5mg ... [every 6 hours] scheduled. ... Explained again to family that attending [SNF medical director] has the final decision on recommendations left." Patient was on 4L of oxygen but 2L of oxygen was ordered. On 7/23/2024, the RN saw patient for a routine visit, "[Family] had most [non-comfort] medications discontinued by facility [SNF] CRNP [nurse practitioner]. "This SN [skilled nurse] explained attending physician [SNF medical director] and recommendations by hospice physician." Family questioning policy of giving Morphine for SOB. Asking why GSH has to be called and come out each time pt needs something." The RN noted the patient's respirations were labored and the patient was on 3.5L of oxygen, however 2L was ordered. On 7/25/2024, the family called the hospice to report patient could not breathe. Per "Hospice Case Communication" note from 7/25/2024, "Received call from [Family] who is there at the facility [SNF], states patient called [him/her] in a panic at 3:30AM, ... [patient] is saying [he/she] cant [sic] breathe, the staff [SNF] are confused on Morphine and Ativan thats [sic] ordered, won't give Ativan when asked by family." The family had the patient transported from the SNF to the hospital and removed the patient from GSH services. Another "Hospice Case Communication" note from 7/25/2024 showed, "To [hospital] to see [Patient] and family. ... Per [Family], ... [he/she] asked for [patient's] Ativan to be given and the nurse [SNF] stated that Ativan is for behavior only not respiratory distress. [Family] states that the nurse refused to give the Ativan until 6AM." Review of CR1's medication record from the SNF showed the patient's Ativan was ordered 0.5 milligrams every 4 hours as needed for "mild anxiety/restlessness, shortness of breath." Per the medication, record the patient was administered Ativan on 7/21/2024 at 2:19 a.m. and again 7/25/2024 at 6:14 a.m. During interview with EMP2 on September 11, 2024, at approximately 12 p.m. he/she was asked how hospice medication orders are incorporated into the SNF's medical record so that SNF staff can administer them. EMP2 noted that the hospice leaves medication orders at the SNF on a "recommendation" form and that the SNF's medical director, and in this case CR1's attending, has the final say whether to approve these orders so that patient can receive them. Review of contract between the SNF and the hospice on September 12, 2024, at 12 p.m. showed, "FACILITY PROVIDER AGREEMENT WITH GOOD SAMARITAN HOSPICE ... I. DEFINITIONS ... 1.8 Hospice Medical Director shall mean a duly licensed doctor ... employed by Hospice who assumes overall responsibility for the medical component of the Hospice Patient's care program and acts as a consultant to the Hospice Patient's Attending Physician when requested. ... II. COOPERATION IN PROFESSIONAL MANAGEMENT 2.1 Joint Responsibility: As required by Medicare and Medicaid, Hospice assumes full responsibility for the professional management of the Residential Hospice Patient's care and the facility agrees to provide room and board services to the Hospice Patient. ... 3.3 Professional Responsibility: Hospice shall retain professional management responsibility for the assessment and admission of Hospice patients and their families to the Hospice and for the services furnished by the Facility pursuant to this agreement in accordance with the respective coordinated Plan of Care for each Hospice patient. ... 4.10 Hospice Physicians: The facility shall grant full staff privileges to the Hospice Medical Director and to other Hospice physicians upon application and qualification for such privileges to the Hospice Medical Director." Interviews with EMP1 (administrator) and EMP2 (clinical manager) on September 12, 2024, at 10:45 a.m. confirmed above findings. During another interview with EMP1 on September 12, 2024, at 12:30 p.m., after he/she had reviewed the above contract, confirmed that a recommendation for hospice orders for SNF medical director approval is not needed. The hospice medical director has privileges at the SNF and the ability to write hospice orders for hospice patients who reside at the SNF without utilizing a "recommendation" form left at the SNF by hospice nurses for subsequent SNF medical director approval and before the hospice patient can receive those orders.

Based on review of agency policy and a clinical record (CR), and staff (EMP) interview, the agency failed to protect and promote the rights of the patient and family for one (1) of one (1) clinical record reviewed with an advance directive and discharged (revoked) from the Beaver inpatient unit (CR1). --- Review of agency policy on February 2, 2024, at 12 p.m. showed: "Subject: Patient Rights and Responsibilities Policy 11.1 Policy Statement: ... the hospice must protect and promote the exercise of these rights. ... Procedures: 1. Patient Rights The following rights are to be respected by all Good Samaritan employees and integrated into all hospice agency functions. ... Have your family or guardian exercise your rights when or if you may be judged incompetent ... Be involved in ... developing and participating in your hospice plan of care; including transfer to another hospice, and changes in level of care as condition warrants ... Be informed of anticipated discharge or transfer of care/service, continuing care requirements and other available services." "Subject: Advance Directives Policy 11.5 ... Definition ... Advance health care directive-The term as defined in 20 Pa.C.S. § 5422 (relating to definitions). An advance health care directive is a signed and witnessed document which directs health care in the event that the individual (the principal) is incompetent and has an end-stage medical condition or is permanently unconscious. It also may designate a person to carry out the individuals wishes regarding health care at the end of life. ... Purpose: To provide an opportunity to educate patients/family about their right to be involved in decisions regarding their care including documentation of advance directives and allowance of the patients representative to facilitate care or make treatment decisions when the patient is unable to do so." A review of CR1 on January 31, 2024, at 8 a.m. showed a physician ordered plan of care with an initial certification period from 12/12/2023 to 3/10/2024. The patient was admitted to the agency's Beaver Valley inpatient unit (IPU) on 12/12/2023 with sepsis and altered mental status. According to the "RN HOSPICE IPU ADMISSION VISIT" completed on 12/12/2023, the patient had a "POA [power of attorney] AND LIVING WILL," and "WILL OPEN EYES, BUT IS MINIMALLY RESPONSIVE." On 12/13/2023, the patient was unresponsive. A review of patient's "DURABLE HEALTH CARE POWER OF ATTORNEY" showed the patient had appointed his/her granddaughter (DTR1) to server as his/her successor. The POA also indicated that if DTR1 was not readily available, then his/her other granddaughter (DTR2) would serve as his/her successor. Review of "Patient Contacts" contained within CR1 showed DTR1 was listed as the patient's power of attorney. A review of CR1's hospice "Election of Benefit" showed that DTR1 elected the hospice benefit on 12/12/2023 due to pt's mental incapacitation. Review of registered nurse note from 12/12/2023 showed, "Spoke with both granddaughters ([DTR1] first POA [DTR2] second). ... [DTR1] resides in South Carolina and is available by phone 24/7." Review of "Client Coordination Note Report" from 12/15/2023 showed the social worker documented, "Pt's granddaughter [DTR2] wants to take pt back to [personal care home] to pass there on [another hospice agency]. ... [DTR2] understands all of the risk and everything discussed if transport can accommodate today SW [social worker] will make arrangements to send back to [personal care home] tonight." Review of "Hospice Revocation Statement Form" showed that DTR2 revoked CR1's hospice benefit on 12/16/2023. Further review of CR1 did not show that DTR1 wished to revoke CR1's hospice benefit or that DTR1 was notified that DTR2 wanted to revoke the patient's hospice benefit. There was nothing in CR1 to show that DTR1 was not readily available. Interviews with EMP1 (administrator) and EMP2 (director of compliance) on February 5, 2024, at 12 p.m. confirmed above findings.

Based on review of agency policy and clinical records (CR), and staff (EMP), the agency failed to implement a plan of care with measurable outcomes for four (4) of 21 records with goals for pain (CR19, CR20, CR21, & CR25). --- Review of agency policy on February 2, 2024, at 12 p.m. showed, "Subject: Plan of Care Policy 9.4 ... Policy Statement: All hospice care and services provided to patients/families must follow an individualized written plan of care. Purpose: To include and address all services necessary for the palliation and management of the terminal illness and related conditions. Procedures: ... 2. Content Plan of Care a. The plan of care must include documentation of the following: ... Measurable outcomes anticipated from implementing and coordinating the plan of care." Review of CR19 on 1/31/2024 at 2 p.m. showed a plan of care for an initial certification period from 12/20/2023 to 3/18/2024. Goals included, "Pain will be managed at a level acceptable to [CR19] while on hospice services." A review of the start of care and subsequent visit notes showed that on 12/20/2023 CR19 was "nonresponsive" and on 12/21/2023 CR1 was "unable to respond." Patient was not able to state his/her acceptable level of pain. Review of CR20 on 1/31/2024 at 2:30 p.m. showed a plan of care for an initial certification period from 10/18/2023 to 1/15/2024. Goals included, "Pain will be managed at a level acceptable to [CR20]." A review of the start of care visit note by registered nurse from 10/18/2022 did not show that the patient stated what his/her acceptable level of pain was. On 10/21/2023, the registered nurse documented patient was, "Lethargic" with "no verbal communication." Review of CR21 on 1/31/2024 at 3 p.m. showed a plan of care for an initial certification period from 11/3/2023 to 1/31/2024. Goals included, "Pain will be managed at a level acceptable to [CR21]." A review of the start of care visit note from 11/3/2023 did not show that the patient rated his/her acceptable level of pain. On 11/4/2023, the licensed practical nurse documented that the patient was "bedbound" and "unresponsive." The patient expired on 11/5/2023 and according to the "Hospice POC Report," the goal of "Pain will be managed at a level acceptable to [CR21]" was "MET." Patient was not able to state his/her acceptable level of pain. Review of CR25 on 2/2/204 at 1:30 p.m. showed a plan of care for an initial certification period from 1/21/2024 to 4/19/2024. Goals included, "Pain will be managed at a level acceptable to [CR25] while on IPU [inpatient unit]." Review of start of care visit note by the registered nurse from 1/21/2024 showed patient as oriented to self only and minimally verbal. There was no documentation from this visit to show what patient's acceptable level of pain was. Subsequent nursing visit note from 1/22/2024 showed patient was "Unable to respond." Interviews with EMP1 (administrator) and EMP2 (director of compliance) on February 5, 2024, at 12 p.m. confirmed above findings.

Based on review of agency policy, infection logs, meeting minutes, quality assessment and performance improvement (QAPI) data, and staff (EMP) interview, the agency failed to measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the hospice to assess processes of care, hospice services and operations for 17 patients and 18 employees diagnosed with covid-19 since August 1, 2023. --- Review of agency policy on February 2, 2024, at 12 p.m. showed, "Subject: Infection Control Program Policy 7.11 Policy Statement: Good Samaritan Hospice maintains and documents an infection control program. Purpose: An effective infection control program protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases. Procedures: ... 3. Reporting a. The identifying clinician or agency representative is responsible for completing a QI report. b. The QI reports are reviewed and processed by the agency designee. 4. Tracking/Trending a. The agencys Quality and/or Compliance representative is responsible for tracking and trending all reported infections. Some of the information tracked includes: Type of infection ... Branch location ... Interventions ... Contributing factors ... Number of infections per 1000 patient days b. Infections are aggregated quarterly and reported to the Compliance Committee as part of the QAPI program." A review of "QI Event Report" infection logs was conducted February 2, 2024, at 1:30 p.m. The logs listed patient infections since 8/1/2023. There were no covid-19 infections listed. Review of QAPI meeting minutes on February 2, 2024, at 2 p.m. showed, "Good Samaritan Hospice Compliance Committee Date: August 4, 2023 ... Education & Training The following education had been provided for staff: Effective June 2023, COVID is No longer reportable to Department of Health for 'Reportable Diseases'." The "Good Samaritan Hospice Compliance Committee Date: November 3, 2023" minutes were also reviewed. There was nothing contained in the QAPI documentation to show that the agency measured, analyzed, and tracked patient and employee covid-19 infections. During interview with EMP2 (compliance director) on February 5, 2024, at 11:50 a.m. he/she confirmed that the agency has not been tracking or analyzing covid-19 positives since 8/1/2023, "No longer a health department reportable disease." He/she noted that he/she kept employee covid-19 positives in a small notebook but that they weren't counted. EMP1 (administrator), EMP2, and EMP8 (IT) took several minutes to review several different systems within their EMR (electronic medical record), patient infection logs, and EMP2's handwritten notebook before a covid-19 positive count was obtained for 18 employees and 17 patients.

Based on review of agency policy, manufacturer's directions for use, standards of practice, observations, and staff (EMP) interview, the agency failed maintain a sanitary environment and follow accepted standards of practice for one (1) of two (2) inpatient units (Beaver Valley). --- Review of agency policy on February 2, 2024, at 12 p.m. showed, "Subject: Infection Control Program Policy 7.11 Policy Statement: Good Samaritan Hospice maintains and documents an infection control program. Purpose: An effective infection control program protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases. Procedures: 1. Responsibility The agencys Quality and/or Compliance representative is responsible for the Infection Control Program. ... 5. Accepted Standards of Practice ... Examples of best practice standards used to prevent the transmission of infections and communicable diseases include: ... Standard Precautions are indicated for all patients. Standard precautions are based on the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. Standard Precautions include a group of infection prevention practices that apply to all patients such as hand hygiene, use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure and safe injection practices. Contact precautions, droplet precautions, or airborne precautions may be added to standard precautions, if indicated." Review of International Health Facility Guidelines (iHFG) on February 2, 2024, at 2 p.m. showed, "2.3 Handwash Basins [sinks] Handwash basins should be provided in rooms where procedures are likely to occur, including inpatient rooms, ICU bed bays, treatment and procedure rooms. ... 2 Hand Hygiene ... Handwash basins should be provided with the following: Paper towel dispenser and waste receptacle." Retrieved from https://www.healthfacilityguidelines.com/ViewPDF/ViewIndexPDF/iHFG_part_d_hand_hygiene Observations at the Beaver Valley inpatient unit on February 1, 2024, at 9:30 a.m. were conducted in rooms 2, 3, 7, and 9. After observation of care in room 9 the registered nurse (RN) washed his/her hands using the room's sink. After RN finished washing his/her hands and while hands were dripping wet, he/she took some paper towels from a stack located directly on top of sink. As a result of no paper towel dispenser in room 9, unused paper towels in the stack were left wet from when RN washed his/her hands. Observation in the IPU's medication room revelaed it's sink also had no paper towel dispenser and only a stack of paper towels sitting directly on the counter. Continued observations in the IPU's medication room and the patient isolation room 7 revealed agency had expired containers of disinfectant wipes that were available for use, "PDI Sani-Cloth Germicidal Disposable Wipe[s] [Expired] 9/2023." Interview with EMP3 (clinical manager) and EMP4 (clinical supervisor) on February 2, 2024, at the time of observations and again at 10 a.m., confirmed findings and that none of the sinks at the Beaver Valley IPU have paper towel dispensers to protect them from contamination. Review of "PDI Sani-Cloth" manufacturer's website on February 5, 2024, at 3:45 p.m. showed, "August 27, 2018 ... Please NOTE: Product can be used until the expiration date, even after being opened." Retrieved from https://pdihc.com/faq/where-can-i-find-the-expiration-date-on-sani-cloth-and-sani-prime-products-2/