Every finding on record at Pilgrimage Health Care, LLC

Based on review of clinical records (CR), agency policy and staff (EMP) interview, the agency failed to ensure the needs of the patients were met for two (2) of eighteen (18) CRs reviewed. (CR1 and CR9). --- Findings include: A review of agency policy "Missed Visits Policy NO.1-027" on 9/8/23 at approximately 1:30 p.m. revealed: "1. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained...2. If a visit is missed and not rescheduled the clinician will: A. Notify the IDG and clinical supervisor of the missed visit and reason for missed visit...3. If an aid visit is missed...the case manager or clinical supervisor and the manager/supervisor will take the appropriate action." A review of CR1 on 9/7/23 at approximately 10:20 a.m. revealed a "Hospice Certification and Plan of Care" with a start of care date of 4/21/23. Certification period reviewed 7/20/23 to 10/17/23. A review of the clinical record for CF1 revealed a physician order dated 7/17/23, Calendar frequency: Home Hospice Aide (HHA) effective 7/20/23 1WK1, 4WK12, 2WK1. A review of the patient visits calendar for CR1 revealed no documented evidence that an HHA provided care to CR1 four times for the week of 7/23/23 through 7/29/23. Three patient HHA visits were completed 7/24/23, 7/25/23 and 7/27/23. Further review of CR1 found no documentation as to the reason for the missed visit and found no documented evidence that the physician was notified of the HHA missed visit. A review of CR9 on 9/7/23 at approximately 2:28 p.m. revealed a "Hospice Certification and Plan of Care" with a start of care date of 7/26/23. Certification period reviewed 7/26/23 to 10/23/23. A review of the clinical record for CR9 revealed a physician order dated 7/26/23, Frequency/Duration of Visits: Home Hospice Aide (HHA) 2WK1, 5WK12, 1WK1. A review of the patient visits calendar for CR9 revealed no documented evidence that an HHA provided care to CR9 five times for the week of 8/20/23 through 8/26/23. Four patient HHA visits were completed 8/21/23, 8/22/23, 8/23/23 and 8/24/23. Further review of CR9 found no documentation as to the reason for the missed visit and found no documented evidence that the physician was notified of the HHA missed visit. An exit conference conducted on 9/8/23 at approximately 2:45 p.m. with the agency administrator and the agency vice president of operations directly and with the director of nursing via zoom confirmed the above findings. Also in attendance via zoom was the agency chief operations officer and the vice president of growth and development.

Based on a review of personnel files (PF), agency policy and staff interview (EMP), the agency failed to obtain criminal background checks, prior to direct patient contact for two (2) of ten (10) personnel files reviewed (PF6 and PF9). --- Findings include: A review of agency policy ";Orientation Policy No.1-027" was conducted on 9/8/23 at approximately 1:30 p.m. Policy: ";Purpose: To provide guidelines for the orientation process. Procedure...8. A Personnel Orientation Checklist... will be completed for all new personnel...9. The supervisor will sign and date the checklist when new personnel have completed all the required activities..." Review of the ";Addendum 1-027.A Personnel orientation checklist ...3. Completion of all employment forms, 4. Personnel file...Criminal background check..." Review of PFs on 9/7/23 between approximately 2:00 p.m. and 3:00 p.m. revealed: PF6, date of hire 6/5/22. No documented evidence of a criminal history report completed at the time of hire. PF contained a Pennsylvania (PA) State Police Record Check dated 8/18/22. PF9, date of hire 3/1/22. No documented evidence of a criminal history report completed at the time of hire. PF contained a Pennsylvania (PA) State Police Record Check with date of request of 5/11/22 and a request still pending statement present. PF did not contain evidence of the result of the criminal history report. An exit conference conducted on 9/8/23 at approximately 2:45 p.m. with the agency administrator and the agency vice president of operations directly and with the director of nursing via zoom confirmed the above findings. Also in attendance via zoom was the agency chief operations officer and the vice president of growth and development.