Every finding on record at Upmc Home Healthcare of Central Pennsylvania

Based on review of agency policy, clinical records (CR), 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 three (3) of four (4) active records who were prescribed antibiotics for infections (adverse patient event) (CR1, CR9, & CR10). Findings included: Review of agency policy on December 17, 2021, at 1 p.m. showed, "QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT - Policy ... Data Sources to be used to monitor performance and to identify opportunities for improvement include, but are not limited to the following components of the organization and available data sources: ... Infection prevention surveillance and reporting." Review of clinical records was conducted on December 14, 2021, and December 16, 2021 with EMP1 (administrator). Review of CR1 on December 14, 2021, at 12:30 p.m. showed patient was admitted on 11/5/2021 for an initial certification period ending 2/2/2022. On 12/5/2021, CR1 was prescribed Levaquin (antibiotic) for pneumonia (lung infection). Per 12/5/2021 nursing visit note, "ADDED THE LEVAQUIN ORDERED BY ER [emergency room] FOR ASPIRATION PNEUMONIA." Review of CR9 on December 16, 2021, at 10:15 a.m. showed patient was admitted on 5/19/2021 with a recertification period of 11/15/2021 to 1/13/2022. On 8/31/2021, and again on 12/16/2021, the patient was prescribed azithromycin (antibiotic) for respiratory infections. Per the 8/31/2021 nursing visit note, "Lungs diminished with wheezes noted ... Patient reports dyspnea [shortness of breath] increasing secondary to congestion. Sputum thin to thick in nature and yellow tinged. Patient's wife asking for z-pack [azithromycin] as that is what they had to do in the past to clear it up secondary to his trach." Review of CR10 on December 16, 2021, at 10:45 a.m. showed patient was admitted on 2/1/2021 with a recertification period of 11/28/2021 to 1/26/2022. Per coordination note, "Rcvd [received] call from [SNF RN] supervisor late Friday 12/3/2021. Patient acting differently wondering if could be UTI, ... [physician] ordered UA [urinalysis] C & S [culture and sensitivity], discussed with [SNF RN] ... we can treat symptoms and cover ABX [antibiotic] if feel there is UTI." On 12/4/2021, the patient was prescribed Cipro (antibiotic) for a UTI (urinary tract infection). Review of QAPI and "Infection Prevention Audit List" with EMP1 on December 17, 2021, at 10:30 a.m. confirmed agency's QAPI was not aware of the above patient infections for the purpose of improving processes of patient care. The list included parameters for patient name, type of infection and if and antibiotic was ordered. Interview with EMP1 on December 17, 2021, at 10:30 a.m. confirmed above findings and that infections are tracked and trended in QAPI per above audit list, but that CR1, CR9 and CR10's infections were not listed since agency staff had not reported them.

Based on review of CMS (Centers for Medicare/Medicaid Services) QSO-21-08-NLTC, CDC (Centers for Disease Control/Prevention) guidelines, observation, and staff (EMP) interview, the agency failed to follow accepted standards of practice for the screening of visitors. The agency failed to screen the Department of Health surveyor (visitor) for four (4) of four (4) days (December 14-December 17, 2021). Findings included: Per CMS QSO-21-08-NLTC, "Specifically, facilities should have a screening process to assess for signs/symptoms consistent with COVID-19 and for exposure to others with known or suspected COVID-19. CDC recommends options for screening symptoms that include but are not limited to: screening questions with an assessment of illness, self-monitored pre-arrival temperature checks with reported absence of fever and symptoms, and facility-monitored temperature checks upon arrival. CDC notes that 'although screening for symptoms will not identify asymptomatic or pre-symptomatic individuals with SARS-CoV-2 infection, symptom screening remains an important strategy to identify those who could have COVID-19 so appropriate precautions can be implemented.' Healthcare facilities are encouraged to review CDC's updated infection prevention and control (IPC) recommendations when developing or revising their screening policies and procedures." Per CDC Guidelines, "Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic Establish a Process to Identify and Manage Individuals with Suspected or Confirmed SARS-CoV-2 Infection ... Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following so that they can be properly managed: 1) a positive viral test for SARS-CoV-2, 2) symptoms of COVID-19, or 3) who meets criteria for quarantine or exclusion from work. Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which individuals can self-report any of the above before entering the facility. ... Visitors meeting any of the 3 above criteria should generally be restricted from entering the facility until they have met criteria to end isolation or quarantine, respectively." Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html During 4-day Medicare recertification survey from December 14 to December 17, 2021, the agency failed to screen the Department of Health surveyor for the entire survey. Interview with EMP1 on December 17, 2021, at 10 a.m. confirmed findings. He/she noted that agency office is not required to screen visitors.

According to § 418.22 (b)(3), "Certification of terminal illness. ... (3) The physician must include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification and recertification forms, or as an addendum to the certification and recertification forms. (i) If the narrative is part of the certification or recertification form, then the narrative must be located immediately prior to the physician's signature. (ii) If the narrative exists as an addendum to the certification or recertification form, in addition to the physician's signature on the certification or recertification form, the physician must also sign immediately following the narrative in the addendum. (iii) The narrative shall include a statement directly above the physician signature attesting that by signing, the physician confirms that he/she composed the narrative based on his/her review [emphasis] of the patient's medical record or, if applicable, his/her examination of the patient." Based on review of a clinical (CR), and interviews with nursing staff (EMP) and the medical director (MD), the agency failed to ensure the physician composed the narrative for initial certification of terminal illness based on his/her review (emphasis) of the clinical record or examination of the patient in accordance with § 418.22 for (1) of (1) clinical record reviewed during an interdisciplinary team meeting (IDT) (CR14). The registered nurse composed the initial certification while reviewing and reading the clinical record to the medical director (MD) during a teleconferenced IDT. Findings included: Surveyor attended IDT on December 15, 2021, at 10 a.m. The team (administrator, registered nurses, social worker, and chaplain) met in-person at agency office while the medical director attended remotely from a Hospital in Farrell (owned by same company) appearing on an opened laptop computer. At 10:28 a.m., EMP3 (registered nurse) began reading information to the medical director from CR14 and the MD could be heard typing on his/her computer keyboard and said, "ok tell me a story." At this time, surveyor began taking notes as to what EMP3 told the MD during the meeting. EMP3 continued to read and noted one of CR14's diagnoses to the MD was "poly neuropathy" to which the medical director replied, "other musculoskeletal findings ... want me to put that?" EMP3 then noted "unrelated UTI [urinary tract infection]" to which the MD replied and typed, "I'll put history of [UTI]." EMP3 kept reading while the MD typed and the MD would interject with, "Got it," and "OK." The medical director then concluded as he/she continued to type, "I expect his [CR14] prognosis to be 6 months or less." After IDT was completed, surveyor interviewed the medical director with EMP1 (administrator) at 11:25 a.m. The MD confirmed the nurses compose the initial certification of terminal illness by reading the clinical record information to him/her. When asked why he/she relied on the nurses to review the record for him/her he/she noted that it's because the agency's electronic medical record is difficult to use and "it takes too long," and "it's a waste of my time ... they [nurses] can read and speak faster." At 11:39 a.m., surveyor interviewed another nurse (EMP2) who was present during team since EMP3 had left. He/she confirmed that the registered nurses read and review the clinical record for the MD while he/she types the narrative for initial certification of terminal illness. Review of CR14 on December 17, 2021, at 11 a.m. showed an admission date of 12/9/2021 for an initial certification period ending 3/8/2022. Review of CR14's "HOSPICE CERTIFICATION OF TERMINAL ILLNESS" showed the "Narrative composed by Hospice Physician" contained the same information read to him/her by EMP3 during the 12/15/2021 IDT meeting. The narrative was electronically authenticated by the MD on 12/16/2021 at 7:15 a.m. to show that, according to the certification document, "By signing this certification, the hospice Physician, named below, confirms that he/she composed the narrative based on his/her review of the patient's medical record or his/her examination of the patient." Interview with EMP1 during the above clinical record review confirmed findings. At this time, EMP1 also confirmed that the MD had not examined the patient either when he/she noted that a face-to-face encounter had not yet been done.