Survey Report for 391656

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
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	391656	A. BUILDING __________ B. WING ______________	07/13/2021
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
HOSPICE OF THE SACRED HEART	53 GLENMAURA NATIONAL BOULEVARD SUITE 120, MOOSIC, PA, 18507
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)
L0519
L0519	19122 Based on review of hospice policies/procedures and clinical records, and based on interview with the administrator, the hospice failed to ensure the responsible party (power of attorney) for one (1) of one (1) hospice patients was notified of a planned reduction in hospice aide visit frequency. (Patient #1) Findings include: On July 6, 2021 at approximately 11:15 AM, review of the hospice "Patient Bill of Rights" policy/procedure revealed the following: 13. Be informed in advance of care (discipline, frequency and duration) to be furnished, participate in the development of, and changes to, the hospice plan, and be informed, in advance of any changes to the plan of care... Patient #1: Between July 6, 2021 at approximately 11:31 AM and July 12, 2021 at approximately 8:04 AM, review of the hospice clinical record revealed the start of care date was November 9, 2020, the patient resided at an assisted living facility (ALF) and that the primary hospice diagnosis was Alzheimer's disease, unspecified as documented on the "Patient Face Sheet". 04/14/2021: "Combined Disciplinary Plan of Care" documentation revealed the following: Hospice aide visit frequency: Two (2) times a week and as needed. 04/29/2021: "Physician Orders for Hospice Patient" documentation revealed the hospice aide frequency was reduced to "PRN" (as needed) effective May 8, 2021. Review of the clinical record failed to reveal that hospice aide services were provided during the week of May 2 through May 8, 2021. During interview on July 6, 2021 at approximately 4:50 PM, the administrator reported that a reduction of in-person visits occurred because the patient exhibited signs of COVID-19 and because the ALF did not obtain a negative COVID-19 test. There was no documentation in the clinical record which provided evidence that the patient's POA was notified that the hospice aide frequency was reduced from two (2) times a week and as needed to PRN. During interview conducted on July 13, 2021 at approximately 2:59 PM, the administrator confirmed there was no documentation in the clinical record which provided evidence that the POA was notified in the change in hospice aide visit frequency for patient #1.
L0533
L0533	19122 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 medical director and the administrator, the hospice failed to ensure a comprehensive assessment of wounds was completed for three (3) of three (3) hospice patients for whom skin integrity goals/interventions/orders were included on the updated hospice plan of care. (Patients #1, #2 and #3) Findings include: On July 6, 2021 at approximately 3:51 PM, review of the hospice policy titled "Assessment-Comprehensive Assessment of the Patient" revealed the following: Policy Statement: The hospice IDT (Interdisciplinary Team) conducts and documents a patient specific comprehensive assessment that identifies the patient's need for hospice care, including medical, nursing, psychosocial, emotional and spiritual care... Procedures...2. The RN (Registered Nurse) Case Manager coordinates the comprehensive assessment process and ensures that the patient's physical...needs are addressed...4. Discipline specific assessment tools obtain accurate and timely information that guide decisions for the development of the patient's plan of care. 5. The patient's comprehensive assessment is updated at a minimum every 15 days or more frequently if needed by the patient. 6. The hospice's assessment and reassessment tools contain data elements that allow for the measurement of outcomes. 7. The IDT treats and prevents symptoms of the patient's disease and/or comorbidity factors based on findings in the comprehensive assessment and reassessments. On July 6, 2021 at approximately 3:52 PM, review of the hospice policy titled "Assessment-Content of the Comprehensive Assessment" revealed the following: Procedures: 3. The IDT uses the information obtained from the comprehensive assessment tools to develop an effective plan of care with interventions that address the identified needs of the patient/caregiver. On July 6, 2021 at approximately 3:53 PM, review of the hospice policy titled "Assessment-Updates to the Comprehensive Assessment" revealed the following: Policy Statement: The hospice's IDT updates the comprehensive assessment and reassesses the patient's response to care on a regular basis. On July 12, 2021 at approximately 12:35 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 July 13, 2021 at approximately 2:35 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 July 13, 2021 at approximately 2:43 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... Patient #1: Between July 6, 2021 at approximately 11:31 AM and July 12, 2021 at approximately 8:04 AM, review of the hospice clinical record revealed the start of care date was November 9, 2020, the patient resided at an assisted living facility (ALF) and that the primary hospice diagnosis was Alzheimer's disease, unspecified as documented on the "Patient Face Sheet". 11/09/2020 (Start of Care): Review of the "Nurse Progress Note Initial Assessment" note revealed the following: -The patient resided at a private home and that personal care services (hospice aide) were requested twice a week; and -The following Stage 2 pressure wounds were present upon hospice admission: -Coccyx (tailbone): Measurements 2 cm (centimeters-length) by 2 cm (width) by 0.2 cm (depth); and -Right buttock: Measurements 1 cm by 2 cm by 0.2 cm. Review of "Physician Orders for Hospice Patient" documentation revealed the following: 02/28/2021: The patient was admitted to the hospice inpatient unit (IPU) for respite care. 03/05/2021: Soothe and Cool Inzo Barrier cream was discontinued and a new order was received for Inzo Barrier Cream to be applied to the buttocks for protection. 03/08/2021: "Inpatient Transfer/Discharge/Death Summary" note documentation revealed the patient was discharged from the hospice IPU, that a stage 2 pressure ulcer of the coccyx was present and that the patient was transferred to an ALF. "Inpatient Nurse Progress Note Routine Visit" documentation revealed the stage 2 coccyx wound measured 0.5 cm by 0.2 cm by 0.2 cm and that the surrounding skin (peri-wound) was red/purple in discoloration. 04/13/2021: "Nurse Progress Note Routine Visit" documentation revealed a single stage 2 coccyx wound was present, that the wound continued to measure 0.5 cm by 0.2 cm by 0.1 cm and that the surrounding skin continued to be red/purple in discoloration. 04/14/2021: "Combined Disciplinary Plan of Care" documentation revealed the following: -Skin Integrity...Issues: Goal....Skin integrity will be maintained or improved as feasible. Intervention: Assess, measure, describe wound/pressure area; -Physician Order Profile: Inzo Barrier cream to continue to the buttocks for protection and Gel cushion for pressure relief; and -Skilled nursing visit frequency effective 03/10/2021: One (1) time a week and as needed; and -Hospice aide visit frequency: Two (2) times a week and as needed. 04/23/2021: "Nurse Progress Note Routine Visit" documentation revealed the visit type was in-person and that the licensed practical nurse (LPN-employee #1) documented that while the patient was being undressed for a shower, an adhesive strip from the incontinence (unable to control bowel/bladder) brief was "against" (adhered to) the patient's skin and the following regarding the patient's wounds: -Three (3) stage 2 pressure areas were present: -Coccyx: Measured 0.5 cm by 0.2 cm by 0.1 cm and the surrounding skin appearance was red/purple in discoloration (unchanged); -Left buttock: Stage 2 with surrounding area deep purple (new wound): and -Right buttock: Stage 2 with surrounding area deep purple (new wound): and -New wound treatment orders: An order was received to apply Schraegers Paste and Bag Balm to the affected areas every shift. 04/27/2021: "Nurse Progress Note Recertification" documentation revealed the visit type was in-person and that registered nurse (RN-employee #2) documented the following wounds were present during the recertification assessment: -Coccyx: Measured 0.5 cm by 0.2 cm by 0.1 cm and the surrounding skin appearance was red/purple in discoloration; -Left buttock: Stage 2 with surrounding area deep purple: and -Right buttock: Stage 2 with surrounding area deep purple. 04/28/2021: "Hospice Aide Visit Note" documentation revealed the LPN (employee #1) documented that the coccyx and buttocks wounds "appear much improved" and that Schraegers Paste and Bag Balm were applied. 04/30/2021: "Nurse Progress Note Routine Visit" documentation revealed visit type was in-person and that the LPN (employee #3) documented the following: - Patient was minimally responsive; patient transferred to bed for personal care; barrier cream applied to buttocks; -Coccyx wound: Measured 0.5 cm by 0.2 cm by 0.1 cm and the surrounding skin appearance was red/purple in discoloration; -Left buttock wound: Stage 2 with surrounding area deep purple: and -Right buttock wound: Stage 2 with surrounding area deep purple. 05/01/2021: "Nurse Progress Note Routine Visit" documentation revealed the visit type was in-person and that the RN (employee #2) documented the following: -Coccyx wound: Measured 0.5 cm by 0.2 cm by 0.1 cm and the surrounding skin appearance was red/purple in discoloration; -Left buttock wound: Stage 2 with surrounding area deep purple: and -Right buttock wound: Stage 2 with surrounding area deep purple. 05/07/2021: "Nurse Progress Note Routine Visit" documentation revealed the visit type was telehealth and that the LPN (employee #4) documented the following: -The patient was seated in the recliner as observed by the LPN, patient was awake and alert; -Coccyx wound: Measured 0.5 cm by 0.2 cm by 0.1 cm and the surrounding skin appearance was red/purple in discoloration; -Left buttock wound: Stage 2 with surrounding area deep purple: and -Right buttock wound: Stage 2 with surrounding area deep purple. 05/11/2021: "Nurse Progress Note Routine Visit" documentation revealed the visit type was in-person and that the RN (employee #5) documented the following: -The patient was repositioned in the recliner; -Coccyx wound: Measured 0.5 cm by 0.2 cm by 0.1 cm and the surrounding skin appearance was red/purple in discoloration; -Left buttock wound: Stage 2 with surrounding area deep purple: and -Right buttock wound: Stage 2 with surrounding area deep purple. 05/12/2021: "Nurse Progress Note Routine Visit" documentation revealed the visit type was in-person and that the LPN (employee #6) documented the following: -Coccyx wound: Stage 3 (deterioration), measured 2.0 cm by 0.2 cm by 0.1 cm with a 0.2 cm deep area of tunneling (channels extending from the primary wound) were present at the 12 o'clock and 2 o'clock positions, that the wound was beefy red with white tissue present and that the wound edges were "rolled over", the wound was malodorous, the surrounding skin was macerated (deterioration in skin due to exposure to moisture) and that "sloughing"(shedding) tissue and "blood issue" was noted. The LPN documented that the patient was transferred to the hospital for wound evaluation. Review of the "Transfer/Discharge/Death Summary" revealed the patient was discharged from hospice services on 05/12/2021 due to the patient seeking "curative therapy" as the patient had been transferred to a hospital for wound evaluation. There is no documentation in the clinical record which provided evidence that the above referenced licensed nurses assessed the left and right buttock wound sizes and appearance on 04/23/2021 nor during the weeks of April 18 through April 24, 2021, April 25 through May 1, 2021 and May 2 through May 8, 2021. There was no documentation that the left buttock wound size and appearance was assessed on 05/11/2021 which was the first skilled nursing visit performed during the week beginning 05/09/2021. Patient #2: On July 12, 2021 at approximately 3:26 PM, review of the hospice clinical record revealed the start of care date was August 10, 2020 as documented on the "Patient Face Sheet". 05/26/2021: "Nurse Progress Note Recertification" documentation revealed the patient resided at an assisted living facility (ALF) and that the primary hospice diagnosis was Alzheimer's disease. Wound site assessment revealed the Stage 4 coccyx/sacral wound measured 5 cm by 6 cm by 3 cm and the Stage 3 left buttock wound measured 0.5 cm by 0.5 cm by 0.2 cm. 06/07/2021: "Combined Disciplinary Plan of Care" documentation revealed the following: -Skin integrity: Goal: Patient will have no worsening of wounds while on hospice services; Intervention: Measure wounds weekly when feasible; and -Physician Order Profile: Apply Santyl to necrotic tissue (if any) in wound bed daily. Review of "Nurse Progress Note Routine Visit" and "Hospice Aide Visit Note" revealed routine skilled nursing and hospice aide services were provided by licensed nurses (employees #7 (RN), #8 (RN) and #9(LPN)) on 06/08, 06/14, 06/16, 06/22, 06/24, 06/29 and 06/30/2021 and 07/01/2021. There was no documentation in the clinical record which provided evidence that the Stage 4 coccyx wound was measured or assessed by hospice nursing staff during the weeks of June 6 through June 12, 2021, June 20 through June 26, 2021 nor June 27 through July 2, 2021. There was no documentation in the clinical record which provided evidence that the Stage 3 coccyx wound was measured by hospice nursing staff during the weeks of June 6 through June 12, 2021, June 13 through June 19, 2021, June 20 through June 26, 2021 nor June 27 through July 2, 2021. Patient #3: On July 12, 2021 at approximately 8:48 AM, review of the hospice clinical record revealed the start of care date was April 26, 2021, that the patient's place of residence was a private home and that the primary hospice diagnosis was Alzheimer's disease, unspecified as documented on the "Patient Face Sheet". 06/23/2021: "Nurse Progress Note Routine Visit" documentation revealed the visit type was in-person and that the LPN (employee #10) documented the following: Right buttock excoriation 4.0 cm by 1.5 cm, reddened (new) but area was without drainage or odor. Review of hospice plan of care orders obtained on 06/23/2021 revealed Schaergers Paste was to be applied topically twice a day and as needed to affected areas on buttocks for skin breakdown. Review of "Nurse Progress Note Routine Visit" and "Hospice Aide Visit Note" revealed routine skilled nursing and hospice aide services were provided by licensed nurses (employees #4 (LPN) and #11 (RN)) on 06/28 or 06/30/2021. There was no documentation in the clinical record which provided evidence that the right buttock wound was measured nor assessed by hospice nursing staff during the week of June 27 through July 2, 2021. During interview conducted on July 6, 2021 at approximately 4:39 PM, the medical director confirmed wound size and appearance is to be measured upon identification of a new wound and weekly. During interview conducted on July 13, 2021 at approximately 2:59 PM, the administrator confirmed wound size and appearance was not assessed upon identification of a new wound and weekly for the above identified patients.
L0555
L0555	19122 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 the hospice nurse coordinated wound assessment with assisted living facility staff for one (1) of one (1) patients for whom a telehealth visit was performed. (Patient #1) Findings include: On July 6, 2021 at approximately 3:51 PM, review of the hospice policy titled "Assessment-Comprehensive Assessment of the Patient" revealed the following: Policy Statement: The hospice IDT (Interdisciplinary Team) conducts and documents a patient specific comprehensive assessment that identifies the patient's need for hospice care, including medical, nursing, psychosocial, emotional and spiritual care... Procedures...2. The RN (Registered Nurse) Case Manager coordinates the comprehensive assessment process and ensures that the patient's physical...needs are addressed... On July 12, 2021 at approximately 12:35 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... On July 13, 2021 at approximately 2:35 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: 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 July 13, 2021 at approximately 2:43 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... Patient #1: Between July 6, 2021 at approximately 11:31 AM and July 12, 2021 at approximately 8:04 AM, review of the hospice clinical record revealed the start of care date was November 9, 2020, the patient resided at an ALF and that the primary hospice diagnosis was Alzheimer's disease, unspecified as documented on the "Patient Face Sheet". 04/13/2021: "Nurse Progress Note Routine Visit" documentation revealed a single stage 2 coccyx wound was present, that the wound measured 0.5 cm by 0.2 cm by 0.1 cm and that the surrounding skin continued to be red/purple in discoloration. 04/14/2021: "Combined Disciplinary Plan of Care" documentation revealed the following: -Skin Integrity...Issues: Goal....Skin integrity will be maintained or improved as feasible. Intervention: Assess, measure, describe wound/pressure area; -Physician Order Profile: Inzo Barrier cream to continue to the buttocks for protection and Gel cushion for pressure relief; and -Skilled nursing visit frequency effective 03/10/2021: One (1) time a week and as needed. 04/23/2021: "Nurse Progress Note Routine Visit" documentation revealed the visit type was in-person and that the licensed practical nurse (LPN-employee #1) documented that while the patient was being undressed for a shower, an adhesive strip from the incontinence (unable to control bowel/bladder) brief was "against" (adhered to) the patient's skin and the following regarding the patient's wounds: -Three (3) stage 2 pressure areas were present: -Coccyx: Measured 0.5 cm by 0.2 cm by 0.1 cm and the surrounding skin appearance was red/purple in discoloration (unchanged); -Left buttock: Stage 2 with surrounding area deep purple (new wound): and -Right buttock: Stage 2 with surrounding area deep purple (new wound): and -New wound treatment orders: An order was received to apply Schraegers paste and Bag Balm to the affected areas every shift. Review of hospice visit documentation revealed a single hospice visit was provided during the week of May 2 through May 8, 2021 (skilled nursing visit on 05/07/2021). 05/07/2021: "Nurse Progress Note Routine Visit" documentation revealed the visit type was telehealth and that the LPN (employee #4) documented the following: -Skin Integrity...Issues: Intervention...Assess, measure describe wound/pressure area. Disciplines: Nurse, facility staff. -The patient was seated in the recliner as observed by the LPN; -Coccyx wound: Measured 0.5 cm by 0.2 cm by 0.1 cm and the surrounding skin appearance was red/purple in discoloration; -Left buttock wound: Stage 2 with surrounding area deep purple: and -Right buttock wound: Stage 2 with surrounding area deep purple. There was no documentation in the clinical record which provided evidence that the LPN (employee #4) coordinated wound assessment with facility staff to ensure wound size and appearance was assessed during the 05/07/2021 hospice skilled nursing visit. During interviews conducted on July 6, 2021 at approximately 4:50 PM and July 13, 2021 at approximately 2:59 PM, the administrator confirmed there was no documentation in the clinical record which provided evidence that the LPN coordinated wound assessment with facility staff to ensure wound size and appearance was assessed during the 05/07/2021 hospice skilled nursing visit.