DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
391617 A. BUILDING __________
B. WING ______________ 		06/30/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
EXCELA HEALTH HOME CARE & HOSPICE 501 WEST OTTERMAN STREET, GREENSBURG, PA, 15601
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0531      
42178 Based on review of Agency Policy and Clinical Record reviews (CR), the agency failed to complete and include in the Plan of Care (POC) an initial bereavement assessment of the needs of the patient's family focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death for one (1) of one (1) CR reviewed (CR1). Findings included: Review of Agency Policy on June 22, 2021 at approximately 12:30pm revealed: "...Bereavement Services...II. Guidelines A. Completion of the pre-bereavement Risk Assessment will begin with the first contact made to the identified bereaved by the Hospice Bereavement Counselor within five days of admission...B. The initial bereavement contact with the identified bereaved following death of the patient will be completed by the primary nurse. The Bereavement Counselor will make contact via phone with the identified bereaved to explain the Bereavement Program...C. The Bereavement Counselor will initiate a sympathy card to be completed by pertinent staff., D. An introductory letter, the sympathy card, and information about the bereavement program will be mailed to the identified bereaved following the death of the patient., E. The Bereavement Counselor will complete the Bereavement Assessment with the identified bereaved...Procedure: Follow-Up Phone Calls/No Response A. If the Bereavement Counselor is unable to reach the designated parties by phone to complete the post-death Bereavement Assessment, the Bereavement Counselor will leave a message for the bereaved including a contact number for follow-up., B. If no response, an "Unable to Reach" letter will be mailed." Review of CR on June 22, 2021 at approximately 9:30 am revealed: CR1, start of service (SOS) 4/23/2020, benefit period reviewed 12/19/2020-2/16/2021. CR failed to include a Bereavement Risk Assessment by Bereavement Coordinator within five days of admission, per agency policy. CR contained evidence that Bereavement Counselor (BC) placed a phone call to identified bereaved on 4/27/2021 and voicemail was full. "Will attempt contact at another time." No evidence of follow up contact/attempt. CR contained evidence at recert, 7/7/2020, BC left voicemail for identified bereaved. CR contained no additional evidence of BC contact or attempted contact until 2/2/2021. No evidence of contact or attempted contact to bereaved by nurse after patient death on 2/2/21, as per agency policy. No evidence of mailings, card, or Unable to Reach letter, as per agency policy. 2/5/21 BC note present states" left voicemail explaining voicemails." Findings confirmed on June 22, 2021 at approximately 2:00pm in Exit interview with Executive Director, Director of Clinical Services, Manager Palliative Hospice, Director of Transitional Care and Quality, and Director of Palliative Homecare and Hospice.
L0557      
42178 Based on review of Agency policy and documents, clinical record reviews (CR), and staff (EMP) interview, the agency failed to ensure the patient received effective symptom control for one (1) of one (1) CR reviewed (CR1). Findings included: Review of Agency documents on June 22, 2021 at approximately 9:00 am revealed complaint received by Manager of Palliative Hospice on 2/8/2021. Investigation revealed Case Manager reported patient "takes Zofran" daily for nausea and "thought emesis may be due to a virus" and "did not feel patient was imminent at time of visit." "Stated other than slightly elevated pressure which could have been due to recently vomiting remainder of assessment was at her baseline." Review of Agency policy also revealed: "...Coordination of Services...III. Guidelines...4. Any changes in the patient's plan of care..., the homecare staff will inform the patient/caregiver, in a timely manner, utilizing a method appropriate to the needs and abilities of the patient/caregiver. Review of CR on June 22, 2021 at approximately 9:30 am revealed: CR1, start of service (SOS) 4/23/2020, benefit period reviewed 12/19/2020-2/16/2021. CR revealed hospice diagnosis of Lewey Body Dementia. On call note on 2/1/21 at 11:08 pm documented agency "reports that the patient has been having nausea all day and had an emesis tonight..." Nurses visit note on 2/2/21 at 11:00 am documented evidence of blood pressure 160/100 and continued dark brown emesis. No evidence of hospice intervention at visit or coordination with doctor of symptoms exhibited. No evidence of communication to family. On call note 2/3/21 at 12:58 am documented that at 10:00 pm 2/2/21, facility called "reporting that the patient had CTB (ceased to breathe)." Documentation revealed daughter was at facility when nurse arrived to pronounce death. No evidence of communication to physician or family from time agency notified of patient change in condition 2/1/21at 11:08 pm until agency notified of death 2/2/21 at 10:00 pm. Interview with EMP5 on June 22, 2021 at approximately 12:00 pm confirmed complaint received. "The nurse felt the patient was at baseline." "I cannot remember for certain, but I probably reviewed the clinical notes at the time." Findings confirmed on June 22, 2021 at approximately 2:00 pm in Exit interview with Executive Director, Director of Clinical Services, Manager Palliative Hospice, Director of Transitional Care and Quality, and Director of Palliative Homecare and Hospice.
L0690      
42178 Based on review of Clinical Record reviews (CR), and staff (EMP) interview, the agency failed to ensure the Hospice nurse obtained a verbal order from a physician or a nurse practitioner for medication administered for one (1) of one (1) CR reviewed (CR1). Findings included: Review of CR on June 22, 2021 at approximately 9:30am revealed: CR1, start of service (SOS) 4/23/2020, benefit period reviewed 12/19/2020-2/16/2021. Original Plan of Care revealed comfort kit declined by facility until requested. Current POC and medication sheet contained no evidence of Haldol prescribed to be taken by patient. CR contained on call note indicating call from facility requesting nausea medication for patient. "No comfort kit in facility. Will call WRH (Westmoreland Regional Hospital) and order Haldol Intensol for STAT delivery." Nursing note on 2/2/21 at 11:00 am stated "...staff had trouble locating medication, SN (skilled nurse) contacted pharmacy who confirms 10 prefilled syringes were sent out 2/1/21..."Agency unable to provide evidence of physician order or verbal order for Haldol. Interview with EMP5 on June 22, 2021 at approximately 12:00 pm revealed: "I spoke with the nurse on call and confirmed that he/she did indeed incorrectly believe that there was an order for Haldol." Findings confirmed on June 22, 2021 at approximately 2:00pm in Exit interview with Executive Director, Director of Clinical Services, Manager Palliative Hospice, Director of Transitional Care and Quality, and Director of Palliative Homecare and Hospice.