Survey Report for 391769

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	391769	A. BUILDING __________ B. WING ______________	01/17/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
TRANSITIONS HOSPICE	200 CEDAR RIDGE DRIVE SUITE 201, PITTSBURGH, PA, 15205
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)
L0536
L0536	37775 Based on a review of clinical records, hospice policies, and interviews with staff (EMP), the facility Interdisciplinary group (IDG) care planning failed to to ensure that each patient and the primary caregiver(s) received education and training provided by the hospice as appropriate to their responsibilities for the care and services (L544); care planning failed to include interventions to manage pain and symptoms (L546); care planning failed to include measurable outcomes anticipated from implementing and coordinating the plan of care (L548); care planning failed to include necessary drugs and treatments to meet patient's needs (L549); care planning failed to provide ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions (L558). Findings included: This condition is not met, but did not result in immediate jeopardy, as evidenced by the following standards: Cross reference the following tags: L544, Education/training to patient/caregiver L546, Interventions to manage pain and symptoms L548, Measurable outcomes anticipated L549, Necessary drugs and treatments to meet patient needs L558, Sharing information with non-hospice providers An exit conference was conducted on 1/17/19 at approximately 1:30 PM with the facility administrator (EMP2) and director of clinical services (EMP1). Above findings were reviewed with EMP1 and EMP2. EMP1 stated " ...the [electronic medical record] plan of care does not populate the information that is needed..."
L0544
L0544	37775 Based on a review of agency policies, clinical records (CRs), and staff interview (EMP), the agency failed to ensure that each patient and the primary care giver(s) received education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care for four (4) of four (4) clinical records reviewed with completed written plans of care (CR1-CR4). Findings Included: A review of agency policies conducted on 1/17/20 at approximately 12:35 PM revealed: "THE PLAN OF CARE...Policy No. H:2-030.1...POLICY...A written individualized patient and family/caregiver plan of care will be established and maintained...care provided must be in accordance with the plan of care..will meet the documentation requirements of the physician-directed medical orders and the care planning process...plan will focus on identified problems, goals, and interventions...PROCEDURE...4. The plan of care will identify the patient's needs and services...including management of pain and discomfort and symptom relief. It must state , in detail, the scope and frequency of services needed to meet the patient's...family/caregivers needs...11. The written plan of care will contain, but will not be limited to, the following:...C. Reduction in risk factors...L. Individualized interventions to assist with end-of-life-care M. Patient and family/caregiver educational needs...N. Statement of treatment goals...P. Pain and symptom management interventions Q. Drugs and treatments (including allergies) R. Physician-directed instruction...S. Physician...orders T. Measurable outcomes..." Review of CR1 on 1/16/20 and 1/17/20 certification period 2/18/19 to 4/18/19 revealed election of hospice benefit 12/30/16. "...Primary Diagnosis: Alzheimer's Disease...Orders/Frequencies...Nurse to evaluate/monitor/assess need: 2xweek; Administer and/or teach prescribed medications; Monitor and control pain level; Pronounce death; Laxative/Enema of choice PRN (as needed) constipation/impaction; Diet order as tolerated..." There was no documented evidence in the plan of care (POC) that included individualized interventions/specified patient/caregiver(s) education and training ordered by the physician for patient primary diagnosis and/or symptom management. Review of CR2 on 1/16/20 and 1/17/20 certification period 4/29/19 to 6/28/19 revealed election of hospice benefit 5/2/18. "...Primary Diagnosis: Senile degeneration of brain...Orders/Frequencies...Nurse to evaluate/monitor/assess need: 2xwk; Administer and/or teach prescribed medications; Monitor and control pain level; Pronounce death; Laxative/Enema of choice PRN (as needed) constipation/impaction; Foley catheter PRN s/s (signs/symptoms) of retention or pat/cg (patient/caregiver) request; Diet order as tolerated..." There was no documented evidence in the plan of care (POC) that included individualized interventions/specified patient/caregiver(s) education and training ordered by the physician for patient primary diagnosis and/or symptom management. Review of CR3 on 1/16/20 and 1/17/20 certification period 4/1/19 to 5/30/19 revealed election of hospice benefit 12/5/17. "...Primary Diagnosis: Heart disease...Orders/Frequencies...Nurse to evaluate/monitor/assess need: 2xw; Administer and/or teach prescribed medications; Monitor and control pain level; Pronounce death; Laxative/Enema of choice PRN (as needed) constipation/impaction; Foley catheter PRN s/s (signs/symptoms) of retention or pat/cg (patient/caregiver) request; Diet order as tolerated..." There was no documented evidence in the plan of care (POC) that included individualized interventions/specified patient/caregiver(s) education and training ordered by the physician for patient primary diagnosis and/or symptom management. Review of CR4 on 1/16/20 certification period 11/29/19 to 1/27/20 revealed election of hospice benefit 10/10/17. "...Primary Diagnosis: Alzheimers disease...Orders/Frequencies...Nurse to evaluate/monitor/assess need: 1xw; Administer and/or teach prescribed medications; Monitor and control pain level; Pronounce death; Laxative/Enema of choice PRN (as needed) constipation/impaction; Foley catheter PRN s/s (signs/symptoms) of retention or pat/cg (patient/caregiver) request; Diet order as tolerated..." There was no documented evidence in the plan of care (POC) that included individualized interventions/specified patient/caregiver(s) education and training ordered by the physician for patient primary diagnosis and/or symptom management. An exit conference was conducted on 1/17/19 at approximately 1:30 PM with the facility administrator (EMP2) and director of clinical services (EMP1). Above findings were reviewed with EMP1 and EMP2.
L0546
L0546	37775 Based on a review of agency policies, clinical records (CRs), and staff interview (EMP), the agency failed to ensure that the individualized written plan of care included interventions for symptom management for four (4) of four (4) clinical records reviewed with completed written plans of care (CR1-CR4). Findings Included: A review of agency policies conducted on 1/17/20 at approximately 12:35 PM revealed: "THE PLAN OF CARE...Policy No. H:2-030.1...POLICY...A written individualized patient and family/caregiver plan of care will be established and maintained...care provided must be in accordance with the plan of care..will meet the documentation requirements of the physician-directed medical orders and the care planning process...plan will focus on identified problems, goals, and interventions...PROCEDURE...4. The plan of care will identify the patient's needs and services...including management of pain and discomfort and symptom relief. It must state , in detail, the scope and frequency of services needed to meet the patient's...family/caregivers needs...11. The written plan of care will contain, but will not be limited to, the following:...C. Reduction in risk factors D. Functional limitations F. safety measures...G. Nutritional requirements...L. Individualized interventions to assist with end-of-life-care M. Patient and family/caregiver educational needs...N. Statement of treatment goals...P. Pain and symptom management interventions Q. Drugs and treatments (including allergies) R. Physician-directed instruction...S. Physician...orders T. Measurable outcomes..." Review of CR1 on 1/16/20 and 1/17/20 certification period 2/18/19 to 4/18/19 revealed election of hospice benefit 12/30/16. "...Primary Diagnosis: Alzheimer's Disease...Orders/Frequencies...Nurse to evaluate/monitor/assess need: 2xweek; Administer and/or teach prescribed medications; Monitor and control pain level; Pronounce death; Laxative/Enema of choice PRN (as needed) constipation/impaction; Diet order as tolerated..." There was no documented evidence in the plan of care (POC) that identified individualized interventions/specified treatments ordered by the physician for symptom management including but not limited to: Specific nursing system evaluations and assessments, specific medication teaching interventions, specific interventions to monitor and control pain, specific interventions to monitor and treat constipation/impaction. Review of CR2 on 1/16/20 and 1/17/20 certification period 4/29/19 to 6/28/19 revealed election of hospice benefit 5/2/18. "...Primary Diagnosis: Senile degeneration of brain...Orders/Frequencies...Nurse to evaluate/monitor/assess need: 2xwk; Administer and/or teach prescribed medications; Monitor and control pain level; Pronounce death; Laxative/Enema of choice PRN (as needed) constipation/impaction; Foley catheter PRN s/s (signs/symptoms) of retention or pat/cg (patient/caregiver) request; Diet order as tolerated..." There was no documented evidence in the plan of care (POC) that identified individualized interventions/specified treatments ordered by the physician for symptom management including but not limited to: Specific nursing system evaluations and assessments, specific medication teaching interventions, specific interventions to monitor and control pain, specific interventions to monitor and treat constipation/impaction, specific interventions and treatments for inserting Foley catheter. Review of CR3 on 1/16/20 and 1/17/20 certification period 4/1/19 to 5/30/19 revealed election of hospice benefit 12/5/17. "...Primary Diagnosis: Heart disease...Orders/Frequencies...Nurse to evaluate/monitor/assess need: 2xw; Administer and/or teach prescribed medications; Monitor and control pain level; Pronounce death; Laxative/Enema of choice PRN (as needed) constipation/impaction; Foley catheter PRN s/s (signs/symptoms) of retention or pat/cg (patient/caregiver) request; Diet order as tolerated..." There was no documented evidence in the plan of care (POC) that identified individualized interventions/specified treatments ordered by the physician for symptom management including but not limited to: Specific nursing system evaluations and assessments, specific medication teaching interventions, specific interventions to monitor and control pain, specific interventions to monitor and treat constipation/impaction, specific interventions and treatments for inserting Foley catheter. Review of CR4 on 1/16/20 certification period 11/29/19 to 1/27/20 revealed election of hospice benefit 10/10/17. "...Primary Diagnosis: Alzheimers disease...Orders/Frequencies...Nurse to evaluate/monitor/assess need: 1xw; Administer and/or teach prescribed medications; Monitor and control pain level; Pronounce death; Laxative/Enema of choice PRN (as needed) constipation/impaction; Foley catheter PRN s/s (signs/symptoms) of retention or pat/cg (patient/caregiver) request; Diet order as tolerated..." There was no documented evidence in the plan of care (POC) that identified individualized interventions/specified treatments ordered by the physician for symptom management including but not limited to specific nursing system evaluations and assessments, specific medication teaching interventions, specific interventions to monitor and control pain, specific interventions to monitor and treat constipation/impaction, specific interventions and treatments for inserting Foley catheter. An exit conference was conducted on 1/17/19 at approximately 1:30 PM with the facility administrator (EMP2) and director of clinical services (EMP1). Above findings were reviewed with EMP1 and EMP2.
L0548
L0548	37775 Based on a review of agency policies, clinical records (CRs), and staff interview (EMP), the agency failed to ensure that the individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care for four (4) of four (4) clinical records reviewed with completed written plans of care (CR1-CR4). Findings Included: A review of agency policies conducted on 1/17/20 at approximately 12:35 PM revealed: "THE PLAN OF CARE...Policy No. H:2-030.1...POLICY...A written individualized patient and family/caregiver plan of care will be established and maintained...care provided must be in accordance with the plan of care..will meet the documentation requirements of the physician-directed medical orders and the care planning process...plan will focus on identified problems, goals, and interventions...PROCEDURE...4. The plan of care will identify the patient's needs and services...including management of pain and discomfort and symptom relief. It must state , in detail, the scope and frequency of services needed to meet the patient's...family/caregivers needs...11. The written plan of care will contain, but will not be limited to, the following:...F. safety measures...G. Nutritional requirements...L. Individualized interventions to assist with end-of-life-care M. Patient and family/caregiver educational needs...N. Statement of treatment goals...P. Pain and symptom management interventions Q. Drugs and treatments (including allergies) R. Physician-directed instruction...S. Physician...orders T. Measurable outcomes..." Review of CR1 on 1/16/20 and 1/17/20 certification period 2/18/19 to 4/18/19 revealed election of hospice benefit 12/30/16. "...Primary Diagnosis: Alzheimer's Disease...Orders/Frequencies...Nurse to evaluate/monitor/assess need: 2xweek; Administer and/or teach prescribed medications; Monitor and control pain level; Pronounce death; Laxative/Enema of choice PRN (as needed) constipation/impaction; Diet order as tolerated..." There was no documented evidence in the plan of care (POC) that identified measurable outcomes anticipated from implementing and coordinating the patient plan of care. Review of CR2 on 1/16/20 and 1/17/20 certification period 4/29/19 to 6/28/19 revealed election of hospice benefit 5/2/18. "...Primary Diagnosis: Senile degeneration of brain...Orders/Frequencies...Nurse to evaluate/monitor/assess need: 2xwk; Administer and/or teach prescribed medications; Monitor and control pain level; Pronounce death; Laxative/Enema of choice PRN (as needed) constipation/impaction; Foley catheter PRN s/s (signs/symptoms) of retention or pat/cg (patient/caregiver) request; Diet order as tolerated..." There was no documented evidence in the plan of care (POC) that identified measurable outcomes anticipated from implementing and coordinating the patient plan of care. Review of CR3 on 1/16/20 and 1/17/20 certification period 4/1/19 to 5/30/19 revealed election of hospice benefit 12/5/17. "...Primary Diagnosis: Heart disease...Orders/Frequencies...Nurse to evaluate/monitor/assess need: 2xw; Administer and/or teach prescribed medications; Monitor and control pain level; Pronounce death; Laxative/Enema of choice PRN (as needed) constipation/impaction; Foley catheter PRN s/s (signs/symptoms) of retention or pat/cg (patient/caregiver) request; Diet order as tolerated..." There was no documented evidence in the plan of care (POC) that identified measurable outcomes anticipated from implementing and coordinating the patient plan of care. Review of CR4 on 1/16/20 certification period 11/29/19 to 1/27/20 revealed election of hospice benefit 10/10/17. "...Primary Diagnosis: Alzheimers disease...Orders/Frequencies...Nurse to evaluate/monitor/assess need: 1xw; Administer and/or teach prescribed medications; Monitor and control pain level; Pronounce death; Laxative/Enema of choice PRN (as needed) constipation/impaction; Foley catheter PRN s/s (signs/symptoms) of retention or pat/cg (patient/caregiver) request; Diet order as tolerated..." There was no documented evidence in the plan of care (POC) that identified measurable outcomes anticipated from implementing and coordinating the patient plan of care. An exit conference was conducted on 1/17/19 at approximately 1:30 PM with the facility administrator (EMP2) and director of clinical services (EMP1). Above findings were reviewed with EMP1 and EMP2.
L0549
L0549	37775 Based on a review of agency policies, clinical records (CRs), and staff interview (EMP), the agency failed to ensure that the individualized written plan of care included drugs and treatment necessary to meet the needs of the patient for four (4) of four (4) clinical records reviewed with completed written plans of care (CR1-CR4). Findings Included: A review of agency policies conducted on 1/17/20 at approximately 12:35 PM revealed: "THE PLAN OF CARE...Policy No. H:2-030.1...POLICY...A written individualized patient and family/caregiver plan of care will be established and maintained...care provided must be in accordance with the plan of care..will meet the documentation requirements of the physician-directed medical orders and the care planning process...plan will focus on identified problems, goals, and interventions...PROCEDURE...4. The plan of care will identify the patient's needs and services...including management of pain and discomfort and symptom relief. It must state , in detail, the scope and frequency of services needed to meet the patient's...family/caregivers needs...11. The written plan of care will contain, but will not be limited to, the following:...G. Nutritional requirements...L. Individualized interventions to assist with end-of-life-care...P. Pain and symptom management interventions Q. Drugs and treatments (including allergies) R. Physician-directed instruction...S. Physician...orders..." Review of CR1 on 1/16/20 and 1/17/20 certification period 2/18/19 to 4/18/19 revealed election of hospice benefit 12/30/16. "...Primary Diagnosis: Alzheimer's Disease...Orders/Frequencies...Nurse to evaluate/monitor/assess need: 2xweek; Administer and/or teach prescribed medications; Monitor and control pain level; Pronounce death; Laxative/Enema of choice PRN (as needed) constipation/impaction; Diet order as tolerated..." There was no documented evidence in the plan of care (POC) that identified physician ordered medications and/or specified treatments necessary for the patient primary diagnosis and/or related conditions. Review of CR2 on 1/16/20 and 1/17/20 certification period 4/29/19 to 6/28/19 revealed election of hospice benefit 5/2/18. "...Primary Diagnosis: Senile degeneration of brain...Orders/Frequencies...Nurse to evaluate/monitor/assess need: 2xwk; Administer and/or teach prescribed medications; Monitor and control pain level; Pronounce death; Laxative/Enema of choice PRN (as needed) constipation/impaction; Foley catheter PRN s/s (signs/symptoms) of retention or pat/cg (patient/caregiver) request; Diet order as tolerated..." There was no documented evidence in the plan of care (POC) that identified physician ordered medications and/or specified treatments necessary for the patient primary diagnosis and/or related conditions. Review of CR3 on 1/16/20 and 1/17/20 certification period 4/1/19 to 5/30/19 revealed election of hospice benefit 12/5/17. "...Primary Diagnosis: Heart disease...Orders/Frequencies...Nurse to evaluate/monitor/assess need: 2xw; Administer and/or teach prescribed medications; Monitor and control pain level; Pronounce death; Laxative/Enema of choice PRN (as needed) constipation/impaction; Foley catheter PRN s/s (signs/symptoms) of retention or pat/cg (patient/caregiver) request; Diet order as tolerated..." There was no documented evidence in the plan of care (POC) that identified physician ordered medications and/or specified treatments necessary for the patient primary diagnosis and/or related conditions. Review of CR4 on 1/16/20 certification period 11/29/19 to 1/27/20 revealed election of hospice benefit 10/10/17. "...Primary Diagnosis: Alzheimers disease...Orders/Frequencies...Nurse to evaluate/monitor/assess need: 1xw; Administer and/or teach prescribed medications; Monitor and control pain level; Pronounce death; Laxative/Enema of choice PRN (as needed) constipation/impaction; Foley catheter PRN s/s (signs/symptoms) of retention or pat/cg (patient/caregiver) request; Diet order as tolerated..." There was no documented evidence in the plan of care (POC) that identified physician ordered medications and/or specified treatments necessary for the patient primary diagnosis and/or related conditions. An exit conference was conducted on 1/17/19 at approximately 1:30 PM with the facility administrator (EMP2) and director of clinical services (EMP1). Above findings were reviewed with EMP1 and EMP2.
L0558
L0558	37775 Based on a review of agency policies, clinical records (CRs), and staff interview (EMP), the facility failed to ensure staff maintained a system of communication and integration with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions for two (2) of four (4) clinical records reviewed during home visit observations (CR2, CR4). Findings Included: A review of agency policies conducted on 1/17/20 at approximately 12:35 PM revealed: "INTERDISCIPLINARY GROUP COORDINATION OF CARE...Policy No. H:2-035.1...POLICY...will utilize a case management system to guide an interdisciplinary group to provide comprehensive, coordinated health care to patients and family/caregivers serviced by the hospice...PROCEDURE...11. Continuity of care will be maintained throughout the patient's course with hospice. Exchange of information between hospice staff and contracted providers will be documented in the clinical record..." "MEDICATION PROFILE...Policy No. H:2-055.1...POLICY...Patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record...PROCEDURE...3. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen...This includes, but will not be limited to:...C. Using the medication profile as a communication tool for other clinicians involved in care 4. Each patient will receive written material for specific medications he/she is receiving..." Home visits were conducted on 1/16/20 between approximately 9:55 AM and 12:00 PM at Personal Care Home (PCH) where patients CR2 and CR4 reside. The Home visits revealed the following: PCH maintained location for all hospice patient residents charts in a chart room located in PCH on fourth floor. Surveyor1 and Surveyor2 reviewed CR2 and CR4 hospice facility charts located in PCH at approximately 10:45 AM which revealed: PCH hospice facility CR2, There was no documented evidence of a current plan of care, hospice aide plan of care, medication profile, or home visit progress notes in the CR for PCH staff to review. PCH hospice facility CR4, There was no documented evidence of a current plan of care, hospice aide plan of care, medication profile, or home visit progress notes in the CR for PCH staff to review. Interview conducted with hospice facility registered nurse EMP5 (visiting skilled nurse) conducted 1/16/20 at 11:00 AM. EMP5 confirmed the above findings. Interview conducted with PCH administrator on 1/16/20 at approximately 11:15 AM. PCH administrator stated "...we like to know when hospice [staff] is here visiting...need communication and coordination for new orders...changes to plan of care..." Administrator confirmed PCH staffing includes a registered nurse (3 days a week), medication technicians, and aides. An exit conference was conducted on 1/17/19 at approximately 1:30 PM with the facility administrator (EMP2) and director of clinical services (EMP1). Above findings were reviewed with EMP1 and EMP2. EMP1 stated "...copy of plan of care, medication profile should have been in the charts (PCH CR2 and CR4)..."