Every finding on record at Hospice of Central Pennsylvania

Based on review of agency documents and interview with agency Director of Quality, the agency failed to complete documentation of agency staff fire drills in two (2) of two (2) reviewed events (#1-2 fire drills). --- Review conducted on August 22, 2024, at approximatley12:00 PM, of agency Emergency Preparedness binder documents revealed: -Hazard Vulnerability – Risk Assessment document listed ";Fire: Offices and Carolyns House, Risk of Occurrence Low, Category 1, HCP Readiness Fair." -Emergency Management Plan Policy No. 7-002.1: Page 2 ";Testing: 1. HCP will test the emergency management plan annually, either in response to an actual emergency or in a planned exercise.; ... page 3, item 4. All actual responses and exercises will be documented and evaluated. Documentation will be used to identify deficiencies and opportunities for improvement based on monitoring activities and observations during the exercise or actual emergency.; ... page 5, Fire Evacuation Procedures – Drills In preparation for an actual fire event, Hospice staff in the office buildings participates in fire drills conducted and documented twice a year by the Safety Committee." -Safety Committee Meeting Minutes Jule 19, 2023: ";Fire Drill at 1:20 PM on June 5, 2023 – a Fire drill did occur but it was reported to not have gone well. Many staff were slow to respond." -Safety Committee Meeting Minutes April 14, 2024: ";Fire Drill on 4/15/24, (1 minute 59 seconds to clear building." -No completed documentation with evaluation, plans from improvement, and participant staff signatures for agency fire drills of July 19, 2023 and April 14, 2024 are found. Interview conducted on August 22, 2024, at approximately 12:30 PM, with agency Director of Quality confirmed no separate/additional documentation of agency fire drills (other than the Safety Committee Meeting Minutes) were completed.

Based on a review of clinical records, agency policies and tool, and interview with agency staff (EF#8 and #9), the agency failed to complete the plan of care orders for scope and frequency of necessary services to meet specific patient needs in two (2) out of three (3) clinical records reviewed (CR#1-2). --- Review conducted on 7/27/23, at approximately 11 AM to 3:30 PM of comparative selected clinical records (CR #1-3) revealed: -CR#1, start of care (soc) 4/26/23, certification period 4/26/23-7/24/23, hospice calendar worksheet noted missing home health aide (HHA) care visit on week 2 (4/30/23-5/6/23) with agency notification of physician for missing HHA visit on 5/10/23 – late notification to physician, no rescheduled HHA visit for week 2; no reason documented by agency for missed visit. -CR#2, soc 1/9/23, certification period 4/9/23-6/29/23, hospice calendar worksheet noted one missing home health aide (HHA) care visit on: Week 3 (4/23/23-4/29/23) with agency notification of physician for missing HHA visit on 5/3/23 - a late notification to physician, no rescheduled HHA visit for week 3, and no reason documented by agency for missed visit; Week 6 missing SN care visit, no agency notification of physician of missing visit found, no rescheduled SN visits for week 6; Week 8 (5/28/23-6/3/23) missed two HHA care visits, with agency notifications of physician of missing 2 HHA visits on 6/7/23 – a late notification to physician, no rescheduled HHA visits for week 8, and no reasons documented by agency for missed visits; and Week 11 (5/18/23-5/24/23) missed one HHA care visit, no agency notification of physician of missing visit found, no rescheduled HHA visits for week 11. -CR#3 soc 3/28/23, certification period 3/28/23-5/26/23, no missed care visits. Review conducted on 7/27/23, at approximately 12:00 – 12:10 PM of three agency policies revealed: ";Provision of Care" policy 2-035 ";Monitoring Patients Response/Reporting to Physician" states: ";Procedure Item 3. The patients physician and/or the hospice medical director or designee will be contacted on the same day when any of the following occur: E. There is any problem implementing the plan of care or inability to achieve goals within specific time." ";Missed Visits Policy No. 2-034 revealed under ";Procedure ... #2. If a visit is missed and not rescheduled the clinician will: A. Notify Interdisciplinary Team (IDT) and Team Manager of the missed visit and reason for missed visit. B. Document in the patients clinical record the following information: 1. Patient name, 2. Date and type of visit that was missed, 3. Reason for the missed visit, 4. Any follow-up needs 5 other person(s) that were notified of the missed visit, if any ... ." ";Hospice Aide Needs Assessment" revealed an assessment tool used by the registered nurse (RN) or case manager to review patient acuity for ordered HHA care visits during time periods of low HHA staffing availability. Review conducted on 7/27/23, at approximately 12:15 PM, email communication dated 6/6/23 from hospice agency scheduling coordinator to agency team leaders and EF#8, revealed significant missed care visits week of 5/28 -6/2/23 [total 71]. Cited reasons for missing or cancelled patient care visits are due to occurrence of holiday (5/29/2023), lack of HHA staff availability, and family preference. Interview conducted on 7/27/23, at approximately 12:15 PM, with EF#8 and #9 revealed: A Hospice Aide Needs Assessment tool is frequently used by team schedulers to prioritize which patients received care visits from available HHAs; priority decisions are/were made based on specific patient factors (level of consciousness, ADL abilities, anxiety or safety awareness, caregiver/family input), patient locations, availability of home caregivers, physical care needs, HHA frequency request, and total tool patient need score; team schedulers attempt to reschedule missed visits in the same calendar week; and due to lack of unfilled HHA positions and US holiday occurrences, agency has difficulty fully staffing HHA care visits. EF#8 and #9 confirmed the above information.

Based on review of clinical records, agency internal complaint investigation, and interviews with staff, it was determined that the agency did not provide a patient with appropriate medical supplies (gloves, incontinence wipes, and adult briefs) when changes in patient's physical condition occurred in one (1) of one clinical review (CR#3). --- Review conducted on 7/27/23, at approximately 1:30 PM, of clinical record CR#3 revealed: 3/28/23 - SN Admission assessment documents: Patient is alert and oriented to person/place/time, 0/10 pain complaints, able to ambulate to first floor bathroom and care for self with minimal caregiver assistance, no complaints of urine or stool incontinence reported or observed. No gloves, incontinence wipes or adult briefs are needed by patient. 3/29/23 - SN Comprehensive assessment documents: Patient is alert and oriented to person/place/time, 0/10 pain complaints, able to ambulate to first floor bathroom and care for self with minimal caregiver assistance, no complaints of urine or stool incontinence reported or observed. 3/30/23 - no hospice interventions required on this date. 3/31/23 - Two SN PRN home visits provided due to increased pain levels. #1 SN PRN visit occurred 12:35 PM to 3:20 PM with documentation describing "patient trying to have a bowel movement (without his oxygen on) in the bathroom and patient was found unresponsive, bilateral toes cyanotic and body feels cold to the tough, Pt having periods of long apnea, applied oxygen, and assisted patient with additional help of neighbors from bathroom to couch (preferred resting/sleeping location), elevated Pt's head with pillows, VS 97.3 F, RR 28, HR 98, BP 90/60, and oxygen saturation level not reading. No documentation of bowel incontinency recorded. No patient care supplies given at this time. #2 SN PRN visit occurred 5:35 – 9:20 PM documentation revealed patient in his hospital bed with some restlessness and agitation observed. Medication adjustments performed. No documentation of bowel or bladder incontinence documented. No patient care supplies given at this visit. 3/31/23 17:03 PM Agency Triage RN received telephone message from caregiver informing her ";Patient very agitated, confused. Had to be lowered to the floor (from couch). Needs help cleaning pt up (bowel incontinence), does not have gloves or wipes." Triage RN called provider (NP) for a new medication order and SN to return to patients home for additional home visit. Caregiver/daughter aware of SN returning. Interview conducted on 7/27/2023, at approximately 3 PM, with EF#8 and #9 revealed hospice basic patient care supplies are only distributed to patients and their caregivers based on initial and ongoing patient assessments and confirmed that CR#3 and caregiver did not receive theses patient care supplies. Review conducted on 7/27/23, at approximately 4:30 pm, of agency internal complaint investigation revealed during 3/31/23 #2 SN PRN visit that the "SN remembered assisting with CR#3s bowel incontinence care/change of incontinent brief when patient was in the electronic hospital bed." No documentation of agency provided incontinence supplies (gloves, personal hygiene wipes, or incontinent briefs) after change of patient condition are assessed.