Every finding on record at VNA of Greater Philadelphia

Based on document review and interview, it was determined the facility failed to ensure exit signs were maintained, affecting one of nine floors. --- Findings include: 1. Document review on April 25, 2023, at 9:30 am, revealed the facility could not produce documentation showing monthly exit sign inspections were conducted. Exit Interview with the Executive Director and Maintenance Director on April 25, 2023, at 11:50 am, confirmed the missing documentation.

Based on document review and interview, it was determined the facility failed to maintain Fire Alarm components, affecting one of two required inspections. --- Findings include: 1. Document review on April 25, 2023, at 9:30 am, revealed the facility could not produce documentation showing a semi-annual fire alarm inspection had been performed. Exit Interview with the Executive Director and Maintenance Director on April 25, 2023, at 11:50 am, confirmed the missing documentation.

Based on document review and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting the entire facility. --- Findings include: 1. Document review on April 25, 2023, at 9:30 am, revealed the facility lacked documentation indicating monthly fire pump runs had been performed during the prior 12 months. Exit Interview with the Executive Director and Maintenance Director on April 25, 2023, at 11:50 am, confirmed the missing documentation.

Based on observation and interview, it was determined the facility failed to maintain the fire rating of the smoke barrier walls, affecting one of nine floors. --- Findings include: 1. Observations on April 25, 2023, revealed unsealed penetrations of smoke barrier walls in the following locations: a. 10:00 am, 6th floor, above smoke doors by the quiet room, unsealed penetration around a data bundle;b. 10:45 am, 6th floor, above smoke doors by family room, around conduit. Exit Interview with the Executive Director and Maintenance Director on April 25, 2023, at 11:50 am, confirmed the unsealed penetrations.

Based on document review and interview, it was determined the facility failed to maintain inspection of Heating, Ventilating and Air Conditioning (HVAC) equipment at required intervals, affecting the entire facility. --- Findings include: 1. Document review on April 25, 2023, at 9:30 am, revealed the facility lacked documentation that a four-year inspection of the fire/smoke dampers was performed. Exit Interview with the Executive Director and Maintenance Director on April 25, 2023, at 11:50 am, confirmed damper inspection documentation was not on-site during the time of the survey.

Based on observation and interview, it was determined the facility failed to maintain alarm annunciation for the Essential Electrical System, affecting the entire building. --- Findings Include: 1. Observation on April 25, 2023, at 10:30 am, revealed a remote annunciator panel at a continuously monitored location during the hours of operation could not be located within the facility, for the emergency generator. Exit Interview with the Executive Director and Maintenance Director on April 25, 2023, at 11:50 am, confirmed emergency generator components were not monitored.

Based on document review and interview, it was determined the facility failed to maintain required testing of emergency generator components, affecting one generator. --- Findings Include: 1. Document review on April 25, 2023, at 9:30 am, revealed the facility lacked verifying documentation of the following emergency generator maintenance items: a. monthly battery conductance testing;b. annual 90-minute load test. Exit Interview with the Executive Director and Maintenance Director on April 25, 2023, at 11:50 am, confirmed the missing documentation.

Based on observation and interview, it was determined the facility failed to maintain storage of oxygen cylinders, affecting one of nine floors. --- Findings include: 1. Observation on April 25, 2023, at 10:15 am, revealed 2- freestanding oxygen cylinders in the 6th floor oxygen storage room. Exit Interview with the Executive Director and Maintenance Director on April 25, 2023, at 11:50 am, confirmed the unsecured oxygen cylinders.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records, interview, and observation. 1 of 16 (6%) records reviewed revealed the agency did not ensure the drug profile included all of the patient's medications.. Record #2 was reviewed and identified the patient elected hospice care on 6/5/2022. The patient's diagnosis was documented as Chronic Obstructive Pulmonary Disease (COPD). The comprehensive assessment completed by registered nurse (RN) on 7/12/2022 documented the patient's use of continuous oxygen at 3 liters per minute per nasal cannula. During the home visit conducted on 7/12/2022, the patient was observed using the oxygen. The plan of care (POC) dated 6/5/2022 documented an order for oxygen. The patient's drug profile dated 7/12/2022 did not include the oxygen. The Senior Director of Hospice confirmed oxygen was not documented on the drug profile as it should be, during an interview conducted on 7/14/2022.

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group; included in the plan of care; permitted to be performed under state law and regulation; and are consistent with the hospice aide training. This standard was not met as evidenced by a review of clinical records and interview.. 4 of 8 (50%) records reviewed of patients receiving hospice aide services revealed the hospice did not ensure the aide provided services included in the plan of care (POC). . Record #1 The plan of care (POC) for the benefit period dated 4/24/22-6/22/22 documented the aide visit frequency as "two times per week." Aide visits were not provided as ordered for the following weeks: week of 5/8/22 no visits were documented as completed; week of 5/15/22 one visit was documented as completed; week of 6/12/22 one visit was documented as completed. Aide services were discontinued on 6/15/22. Record #9 The POC for the benefit period dated 3/18/22-5/17/22 documented the aide visit frequency as "two times per week." Aide visits were not provided as ordered for the following weeks: week of 3/20/22 no visits were documented as completed; week of 3/27/22 no visits were documented as completed; week of 4/10/22 no visits were documented as completed; week of 4/17/22 one visit dated 4/20/22 was documented as completed; week of 5/8/22 no visits were documented as completed; week of 5/15/22 no visits were documented as completed. Record #10 The POC for the benefit period dated 4/26/22-7/24/22 documented the aide visit frequency as "three times per week." Aide visits were not provided as ordered for the following weeks: week of 5/15/22 two visits were documented as completed; week of 5/29/22 one visit was documented as completed; week of 6/5/22 two visits were documented as completed. Record #13 The POC for the benefit period dated 6/1/22-7/20/22 documented the aide visit frequency as "three times a week for one week and five times a week" for the remainder of the benefit period. Aide visits were not provided as ordered for the following weeks: week of 6/26/22 no aide visits were documented as completed; week of 7/3/22 no aide visits were documented as completed. During an interview conducted on 7/15/2022, the Quality Manager confirmed that the aide visit frequency did not follow the plan of care for the records listed above, and they were unable to locate any additional documentation regarding reasons for missed visits or changes to the aide visit frequency orders.

Based on review of agency policies, clinical record (CR) and interview with hospice director, it was determined the hospice failed to conduct a Interdisciplinary Group Meeting (IDG) no less frequently than every 15 days for one (1) of one (1) clinical records reviewed (CR #1) Findings include: Review of agency policy, conducted October 1, 2021 at 9:00 AM. Policy titled "Interdisciplinary Group Meeting" stated, "The Interdisciplinary group will meet on at least every 15 days or sooner to discuss patient/family/caregiver updates in the plan of care...Each patient's plan of care will be reviewed no less frequently than every 15 calendar days..." Review of clinical record was conducted on September 28, 2021 between 9:30 AM- 12:00PM and revealed the following: CR #1, start of care (SOC) dated 10/2/20, there were IDG/Care Plan meetings documented on 7/20/21 and 8/19/21 (30 days in between meetings). Interview conducted on 9/28/21 at 2:00 PM with the hospice director who confirmed the above findings.

Based on review of agency policies, clinical record (CR), and staff interviews and a review of the National Pressure Ulcer Advisory Panel pressure wound staging guidelines and hospice wound assessment presentations/guidance, the hospice nurses failed to ensure the nursing needs of the patient were met for one (1) of one (1) clinical records reviewed (CR# 1). Findings included: Review of agency policy was conducted on September 28, 2021 at approximately 1:00 PM and revealed the following. On 9/28/21 at approximately 1:00 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... Stage 3...Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue (formation of new tissue/blood vessels during the healing process) and epibole (rolled wound edges) are often present... Stage 4...Full-thickness skin and tissue loss with exposed or directly palpable fascia (thin coating of connective tissue), muscle, tendon, ligament, cartilage or bone in the ulcer...Depth varies by anatomical location... On 9/28/21 at approximately 1:00 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)." On 9/28/21 at approximately 1:00 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..." Review of agency policy titled, "Care of the Dying Patient" occurred on 9/28/21 at 12:00 PM and stated, "Care provided for the dying patient will be responsive and respectful, and will be planned, implemented and monitored in order to: optimize the patient's comfort and dignity, manage pain and symptoms....Assess skin integrity at each visit. Observe for areas of breakdown...Observe skin for deterioration. May measure wound monthly if needed..." Review of agency policy titled, "On-Going Assessment" occurred on 9/28/21 at 12:00 PM and stated, "During each home visit, the RN Case Manager or other discipline will re-evaluate the patients according to the problems identifed during the initial visit and thereafter..." Review of agency policy titled, "Entries into Clinical Records" occurred on 9/28/21 at 12:00 PM and stated, "Documentation in the EMR (Electronic Medical Record) must be completed within 24 hours. detailed, accurate and reflects the care or services provided..." A review of CR1 was conducted on September 28, 2021, at 9:30 a.m. The patient's start of care was 10/2/2020 .The patient passed away on 9/22/2021. The certification period reviewed was 7/29/21-9/26/21. Orders included the following: Skilled Nursing (SN) effective 8/1/21 1 wk, 3 PRN, additional order effective 8/8/21: 2 Wk 6, 5 wk 1. Medical Social Worker (MSW) order: 1 Wk 1, additional order effective 8/29/21: 1 X 30 days, 3 PRN. And Chaplain order effective 9/21: 1 X 30 days, 3 PRN. The patient's diagnoses included: Cerebrovascular disease (conditions that affect the blood vessels of the brain and the cerebral circulation), Hypertension (high blood pressure), unspecified convulsions (episode in which you experience rigidity and uncontrolled muscle spasms along with altered consciousness), peripheral vascular disease (narrowing of arteries which results in reduced blood flow), atherosclerotic heart disease (condition where the arteries become narrowed and hardened due to buildup of plaque (fats)) and obesity. Nursing Assessments were reviewed for the entire certification period 7/29/21-9/22/21. Notes by LPN (PF #1) for visits on 8/3/21, 8/4/21, 8/13/21, 8/20/21, 9/3/21, 9/17/21 contained no Nursing Assessments for the following areas: respiratory, genitourinary, musculoskeletal, activity, mental/cognitive Note by LPN for visit on 9/10/21- No nursing assessment for the following areas: cardiac, genitourinary, Gastrointestinal, and neurological. The patient's plan of care update (Interdisciplinary Team Meeting- IDT) noted were reviewed on 9/28/21 at approximately 10AM. IDT note from physcian at previous meeting held on 7/20/21 stated "the patient continues with a stage 3 in the buttock area that previously was a stage 2." , note from IDT held on 8/19/21 by RN stated, "progression of sacral wound to stage IV, extensive tissue and muscle loss, wound requires excessive packing." IDT meeting note on 9/2/21 by RN states, "Deterioration of Stage IV sacral wound, requiring packing and daily wound dressing changes. Wound nearly encompasses entire left and right buttock. Coccyx visible." Physican note from IDT meeting held on 9/16/21 stated, "patient continues to show decline as evidenced by a deteriorating stage IV sacral wound (previously was a stage 3) that is now encompassing the entire buttock area with tunneling that requires extensive packing is difficult to measure." Wound measurements for Stage IV pressure wound on coccyx first noted on 7/21/21. Additional measurement taken on 8/24/21. There were no other measurements noted in the "wound record report." RN assessment note from visit conducted on 8/24/21 noted a new Deep Tissue Injury (DTI) on patient ' s right thigh. There were no noted measurements on the wound noted on discovery of wound or if any of the wound documentation notes afterwards. SN assessments from visits conducted on 8/20/21, 9/3/21 and 9/17/21 were documented late. Per agency policy SN documentation must be made within 24 hours. SN note from visit conducted on 8/20/21 was documented on 8/23/21 (three days later), 9/3/21 was documented on 9/5/21 (two days later) and 9/17/21 was documented on 9/21/21 (four days later). Interviews with administator on September 28, 2021 at approximatley 2:00 PM confirmed above findings.

Based upon review of agency policy, personnel file (PF), interview with director, the agency failed to show documentation of a completed initial competency checklist when hired for one (1) of one (1) PFs reviewed (PF #1). Findings included: Review of agency policy on 9/28/21 at approximately 12:30 PM titled, "Scope of Assessments/Qualifications" and stated, "All clinicians employed or under contract...will be qualified by education, training, and experience to perform appropriate assessments within their scope of care/service...and will complete required competency assessment... Review of agency policy on 9/28/21 at approximately 12:00 titled, "Orientation" stated, "The orientation process, for all personnel with consist of both didactic and field supervision...During the orientation process, the supervisor will be responsible for evaluating the knowledge and skills of the personnel being oriented..." PF reviewed on 9/28/21 between approximately 9:30 AM-12:30 PM revealed: PF # 1, Date of Hire: 1/4/21; no documentation of skills validation by nurse educator for the following areas on "Home Health/Hospice RN/LPN Competency" completed on 1/4/21: Wound Care, Collection of Specimen, Neurological Care & Assessment, Cardiovascular Care & Assessment, Respiratory Care & Assessment, Gastrointestinal Care & Assessment, Genitourinary Care & Assessment, Orthopedic Care & Assessment, Endocrine Care & Assessment, and Special Considerations. Interview with administrator on 9/28/21 at approximately 2:00 PM confirmed the above findings.