Every finding on record at Signal PA Hospice, LLC

Based upon review of hospice policy/procedure, clinical records, personnel files, documentation and guidance from the Pennsylvania (PA) Department of Aging, and based on interview with the hospice administrator (Employee #5), the hospice failed to ensure a Pennsylvania State Police "Response for Criminal Record" (PSP criminal background check) was obtained in accordance with the requirements under the PA Older Adults Protective Services Act (OAPSA) for four (4) of seven (7) hospice staff members whose date of hire was after October 28, 2021. (Employees #2, #5, #6 and #8) --- Findings include: On October 25, 2024 at approximately 12:18 PM, review of the hospice policy titled "Personnel Records" revealed the following under "Procedure": 1. The personnel record or personnel information for an employee will include, but not be limited to, the following: Criminal history check, if required by law. On October 25, 2025 at approximately 12:20 PM, review of the Older Adults Protective Services Act and Act 28 Summary sheet ( https://www.pa.gov/en/agencies/aging/resources-for-aging-professionals/criminal-history-bkgnd-check.html ) revealed the following: Provisional Hire Period: The Act does allow for the provisional hire of an employee who requires only a PSP check for 30 days if the employee can provide proof they have applied for the background check. On October 25, 2024 at approximately 12:30 PM, review of the chaplain/spiritual counselor visit record revealed employee #6 provided spiritual counseling services between March and June 2024. Patient #1: On October 23, 2024 at approximately 2:02 PM, review of the clinical record revealed the medical director (Employee #1) certified the patient's terminal illness on 10/02/2024. Patient #2: Between October 23, 2024 at approximately 2:20 PM and October 25, 2024 at approximately 12:36 PM, review of the clinical record revealed the hospice aide (Employee #8) provided aide services on 10/15/2024 and 10/17/2024. Patient #11: On October 25, 2024 at approximately 2:25 PM, review of the clinical record revealed the administrator/CRNP was assigned to provide skilled nursing services in August 2024 based on start of care assessment documentation dated 08/07/2024. Between October 23, 2024 at approximately 11:45 AM and October 25, 2024 at approximately 12:20 PM, review of personnel file documentation revealed the following: Employee #2: The medical director was contracted to provide physician services effective 06/01/2024. The PSP criminal history clearance report was obtained on 10/23/2024 which was more than 4 months after the contract date. Employee #5: The date of hire of the administrator/certified registered nurse practitioner was 06/18/2024. The PSP criminal history clearance report was obtained on 08/01/2024 which was more than 30 days after the date of hire. Employee #6: The date of hire of the chaplain/spiritual counselor was 03/06/2024. The PSP criminal history clearance report was obtained on 08/01/2024 which was more than four (4) months after the date of hire. Employee #8: The date of hire of the hospice aide was 09/19/2024. The PSP criminal history clearance report was obtained on 10/23/2024 which was more than 30 days after the date of hire. During interview conducted on October 25, 2024 at approximately 4:15 PM, the administrator confirmed that a PSP "Response for Criminal Record" had not been obtained in accordance with the requirements of the OAPSA for the above referenced hospice employees.

Based on review of hospice policies/procedures, clinical records, the National Pressure Ulcer Advisory Panel pressure wound staging guidelines and hospice wound assessment presentations/guidance, and based on interview with the administrator, the hospice failed to ensure an initial comprehensive assessment of wounds was completed for three (3) of four (4) hospice patients for whom wound care was provided by hospice nursing staff. (Patients #5, #8 and #11) Findings include: On October 28, 2021 at approximately 11:35 AM, review of the hospice policy titled "Initial Assessment/Comprehensive Assessment" revealed the following: Policy...Each patient admitted by hospice will have an appropriate initial assessment and comprehensive assessment performed and documented which promotes the patient's well-being, comfort and dignity during the dying process... Procedure...The initial assessment includes the patient's immediate physical...status related to the terminal illness and related conditions. The initial assessment gathers essential information necessary to begin the plan of care and provide the immediate necessary care and services... On October 28, 2021 at approximately 2:59 PM, review of the Accreditation University/Home Health Solutions, LLC/Accreditation Commission for Health Care presentation titled "Hospice Documentation: Painting the Picture of the Terminal Patient" revealed the following under "Documentation Requirements": Hospice nursing documentation must be very descriptive. This requires the nurse to look at the patient's improvements and declines from visit to visit. Some items will need to be documented at least weekly: Any wound characteristics to include size, drainage, odor, wound bed, peri-wound (area surrounding the wound), tunneling/undermining... On October 28, 2021 at approximately 3:26 PM, review of the National Pressure Ulcer Advisory Panel pressure wound staging guidelines revealed the following: Stage 2...Partial-thickness skin loss with exposed dermis (layer of tissue below the skin). The wound bed is viable (healing), pink or red, moist, and may also present as an intact or ruptured serum-filled (fluid) blister... On October 28, 2021 at approximately 3:42 PM, review of the Gordian Medical, Inc. (doing business as American Medical Technologies) presentation titled Palliative Wound Care: Balancing the Burdens & (and) Benefits for Patients on Hospice Care revealed the following on page 28: Set a goal to enhance quality of life, even if the pressure ulcer cannot be healed or treatment does not lead to closure/healing. Assess the individual initially and at any change in their condition to re-evaluate the plan of care. Assess the pressure ulcer initially and with each dressing change, but at least weekly (unless death is imminent), and document findings. Monitor the pressure ulcer in order to continue to meet the goals of comfort and reduction in wound pain, addressing wound symptoms that impact quality of life such as malodor (unpleasant odor) and exudate (drainage). Patient #5: On October 28, 2021 at approximately 7:44 AM, review of the hospice clinical record revealed the start of care date was 09/16/2021, that the primary hospice diagnosis was atherosclerotic (plague build-up in the artery walls) heart disease and that pain related to amputated toes on both feet was included as a hospice problem as documented on the "Plan of Care Order" for the certification period of 09/16/2021 through 12/14/2021. Review of the initial nursing assessment titled "RN Initial Assessment" dated 09/16/2021 revealed open wounds were present on the left and right great toes and the left second toe and that the registered nurse (RN-employee #6) provided wound care (cleansed with normal saline solution (NSS) followed by the application of a dry dressing and Kerlix (gauze) wrap) to the aforementioned wounds. There was no documentation on the "RN Initial Assessment" which provided evidence that the RN obtained wound measurements, nor that the RN assessed the wound bed appearance, of the left and right great toes and the left second toe on 09/16/2021. Patient #8: On October 28, 2021 at approximately 8:32 AM, review of the hospice clinical record revealed the start of care date was 10/18/2021, that the primary hospice diagnosis was heart failure and that impaired skin integrity was included as a hospice problem as documented on the "Plan of Care Order" for the initial certification period of 10/18/2021 through 01/15/2022. Review of the initial nursing assessment titled "RN Initial Assessment" dated 10/18/2021 revealed an open skin tear was present on the left arm and that the registered nurse (RN-employee #4) provided wound care (Polysporin application after which a by a dry dressing and Kling (gauze wrap) was applied) to the aforementioned wound. There was no documentation on the "RN Initial Assessment" which provided evidence that the RN obtained wound measurements, nor that the RN assessed the wound bed appearance, for left arm skin tear on 10/18/2021. Patient #11: On October 28, 2021 at approximately 9:20 AM, review of the hospice clinical record revealed the start of care date was 10/20/2021 and that the primary hospice diagnosis was dementia with Lewy bodies (protein deposits in the brain) as documented on the "Plan of Care Order" for the initial certification period of 10/20/2021 through 01/17/2021. Review of the initial nursing assessment titled "RN Initial Assessment" dated 10/20/2021 revealed a stage-2 pressure wound was present on the coccyx, that the wound length was 5.0 cm and the width was 5.0 cm and that the registered nurse (RN-employee #6) provided wound care (cleansed with NSS followed by the application of a Calmoseptine (wound treatment) after which the wound was covered with a wound dressing) to the coccyx wound. There was no documentation on the "RN Initial Assessment" which provided evidence that the RN measured the wound depth, nor that the RN assessed the wound bed appearance, of the coccyx wound on 10/20/2021. During interview conducted on October 28, 2021 at approximately 11:45 AM, the administrator confirmed there was no documentation on the "RN Initial Assessment" which provided evidence that complete wound measurements were obtained (length, width and/or depth), nor that the wound bed appearance was assessed, during the initial skilled nursing comprehensive assessment for the above identified patients.

Based on review of hospice policies/procedures and clinical records, and based on interview with the administrator, the hospice failed to ensure an initial "Plan of Care Order" included oxygen administration and wound care orders for four (4) of six (6) active patients. (Patients #2, #3, #5 and #8) Findings include: On October 28, 2021 at approximately 11:38 AM, review of the hospice policy titled "Physician Orders" revealed the following: Procedure...1. The IDG (Interdisciplinary Group) plan of care is established in consultation with the physician, Medical Director...The plan of care may include...Medications and treatments...Equipment and supplies required...oxygen including flow rate, delivery device...hours of use... Patient #2: On October 27, 2021 at approximately 3:32 PM, review of the hospice clinical record revealed the start of care date was 09/08/2021, that the primary hospice diagnosis was heart failure and that dyspnea (difficulty breathing) was included as a hospice problem as documented on the "Plan of Care Order" for the certification period of 09/08/2021 through 11/06/2021. Review of the initial nursing assessment titled "RN Initial Assessment" dated 09/08/2021 revealed oxygen was being administered at 4 liters per minute via nasal cannula (oxygen tubing). There was no documentation on the initial hospice "Plan of Care Order" which provided evidence that a physician order had been obtained for the oxygen flow rate, delivery device nor hours of use. Patient #3: On October 27, 2021 at approximately 4:13 PM, review of the hospice clinical record revealed the start of care date was 09/30/2021, that the primary hospice diagnosis was malignant neoplasm of the bronchus (airway)/lung and that ineffective breathing pattern was included as a hospice problem as documented on the "Plan of Care Order" for the initial certification period of 09/30/2021 through 12/28/2021. Review of the initial nursing assessment titled "RN Initial Assessment" dated 09/30/2021 revealed oxygen was being administered at 4 liters per minute via nasal cannula. There was no documentation on the initial hospice "Plan of Care Order" which provided evidence that a physician order had been obtained for the oxygen flow rate, delivery device nor hours of use. Patient #5: On October 28, 2021 at approximately 7:44 AM, review of the hospice clinical record revealed the start of care date was 09/16/2021, that the primary hospice diagnosis was atherosclerotic (plague build-up in the artery walls) heart disease and that pain related to amputated toes on both feet was included as a hospice problem as documented on the "Plan of Care Order" for the certification period of 09/16/2021 through 12/14/2021. Review of the initial nursing assessment titled "RN Initial Assessment" dated 09/16/2021 revealed open wounds were present on the left and right great toes and the left second toe and that the registered nurse (RN-employee #6) provided wound care (cleansed with normal saline solution (NSS) followed by the application of a dry dressing and Kerlix (gauze) wrap) to the aforementioned wounds. There was no documentation on the initial hospice "Plan of Care Order" which provided evidence that a physician order had been obtained to provide the above referenced wound care on 09/16/2021. Patient #8: On October 28, 2021 at approximately 8:32 AM, review of the hospice clinical record revealed the start of care date was 10/18/2021 and that the primary hospice diagnosis was heart failure as documented on the "Plan of Care Order" for the initial certification period of 10/18/2021 through 01/15/2022. Review of the initial nursing assessment titled "RN Initial Assessment" dated 09/30/2021 revealed oxygen was being administered at 3 liters per minute via nasal cannula. There was no documentation on the initial hospice "Plan of Care Order" which provided evidence that a physician order had been obtained for the oxygen flow rate, delivery device nor hours of use. During interview conducted on October 28, 2021 at approximately 11:45 AM, the administrator confirmed there was no documentation in the clinical record which provided evidence that physician orders for oxygen flow rate/delivery device/hours of use and wound care orders had been included on the initial "Plan of Care Order" for the above identified patients.

Based on review of hospice policies/procedures, clinical records and the National Pressure Ulcer Advisory Panel pressure wound staging guidelines and hospice wound guidance, and based on interview with the administrator, the hospice failed to ensure the hospice care plan update included documentation that the hospice interdisciplinary group (IDG) evaluated wound status for two (2) of two (2) hospice patients who received hospice services for more than 15 days and for whom wound assessment was performed by hospice nursing staff. (Patients #5 and #9) Findings include: On October 28, 2021 at approximately 11:39 AM, review of the hospice policy titled "IDG Care Planning Process" revealed the following: Procedure...9. The IDG...reviews...and documents the individualized plan as frequently as the patient's condition requires but no less than every 15 calendar days. The revised plan of care includes information from the patient's updated comprehensive assessment and notes the patient's progress towards outcomes and goals specified in the plan of care... On October 28, 2021 at approximately 3:26 PM, review of the National Pressure Ulcer Advisory Panel pressure wound staging guidelines revealed the following: Stage 2...Partial-thickness skin loss with exposed dermis (layer of tissue below the skin). The wound bed is viable (healing), pink or red, moist, and may also present as an intact or ruptured serum-filled (fluid) blister... On October 28, 2021 at approximately 3:42 PM, review of the Gordian Medical, Inc. (doing business as American Medical Technologies) presentation titled Palliative Wound Care: Balancing the Burdens & (and) Benefits for Patients on Hospice Care revealed the following on page 28: Set a goal to enhance quality of life, even if the pressure ulcer cannot be healed or treatment does not lead to closure/healing. Assess the individual initially and at any change in their condition to re-evaluate the plan of care. Assess the pressure ulcer initially and with each dressing change, but at least weekly (unless death is imminent), and document findings. Monitor the pressure ulcer in order to continue to meet the goals of comfort and reduction in wound pain, addressing wound symptoms that impact quality of life such as malodor (unpleasant odor) and exudate (drainage). Patient #5: On October 28, 2021 at approximately 7:44 AM, review of the hospice clinical record revealed the start of care date was 09/16/2021, that the primary hospice diagnosis was atherosclerotic (plague build-up in the artery walls) heart disease and that pain related to amputated toes on both feet was included as a hospice problem as documented on the "Plan of Care Order" for the certification period of 09/16/2021 through 12/14/2021. Review of the initial nursing assessment titled "RN Initial Assessment" dated 09/16/2021 revealed open wounds were present on the left and right great toes and the left second toe and that the registered nurse (RN-employee #6) provided wound care (cleansed with normal saline solution (NSS) followed by the application of a dry dressing and Kerlix (gauze) wrap) to the aforementioned wounds. Review of skilled nursing (SN) visit assessment documentation revealed SN documentation included, but was not limited to, the following: 09/20/2021: The right great toe was draining an odorous yellow exudate (wound drainage) and that wound care was provided by the RN (employee #6); 09/28/2021: The license practical nurse (LPN-employee #8) documented that the bilateral foot wounds were open, that a moderate amount of foul serosanguineous (bloody with yellow fluid) drainage was present and that the wound care was provided by the LPN; and 10/18/2021: The RN (employee #6) documented that an odorous slough (dead tissue) was noted on the left second toe amputation site and that wound care was provided by the RN. There was no documentation in the clinical record which provided evidence that the hospice IDG had evaluated the above referenced wound changes during the IDG meetings conducted on 09/22/2021, 10/06/2021 and 10/20/2021. Patient #9: On October 28, 2021 at approximately 8:50 AM, review of the hospice clinical record revealed the start of care date was 05/02/2021, that the primary hospice diagnosis was congestive heart failure and that wound care orders were included on the "Plan of Care Order" for the recertification period of 10/18/2021 through 12/16/2021. Review of the SN visit documentation dated 10/19/2021 revealed the RN (employee #6) documented that a small open area (size of tip of pen) of the coccyx was present. There was no documentation in the clinical record which provided evidence that the hospice IDG had evaluated the coccyx wound status during the IDG meeting conducted on 10/20/2021. During interview conducted on October 28, 2021 at approximately 11:45 AM, the administrator confirmed there was no documentation in the clinical record which provided evidence that the hospice IDG had evaluated the wound status for the above identified patients during the IDG meetings conducted on the above referenced dates.