Expert Hospice Care Inc.

IDG, care planning, coordination of services (42 CFR 418.56)

“Condition of participation: Interdisciplinary group, care planning, and coordination of services. The hospice must designate an interdisciplinary group or groups as specified in paragraph (a) of this section which, in consultation with the patient’s attending physician, must prepare a written plan of care for each patient. The plan of care must specify the hospice care and services necessary to meet the patient and familyspecific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions.”

Rule L0536. Condition-level.

Coordination of services (42 CFR 418.56(e)(3))

Rule L0556. Standard-level.

Coordination of services (42 CFR 418.56(e)(4))

Rule L0557. Standard-level.

Coordination of services (42 CFR 418.56(e)(5))

Rule L0558. Standard-level.

Content (42 CFR 418.104(a)(2))

“Upon patient record review, 5 of 5 (Patients 1,2,3,4,5) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patients 1,2,3,4,5: The election statement did not have Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) contact information on the form.”

Rule L0673. Standard-level.

Authentication (42 CFR 418.104(b))

Rule L0679. Standard-level.

Patients rights (42 CFR 418.52)

“Condition of Participation: Patient’s rights. The patient has the right to be informed of his or her rights, and the hospice must protect and promote the exercise of these rights.”

Rule L0500. Condition-level, immediate jeopardy.

Rights of the patient (42 CFR 418.52(c)(1))

“Upon patient record review, 1 of 16 (Patient #4) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient #4, No evidence of patient right to effective pain management and symptom control was provided to patient.”

Rule L0512. Standard-level, immediate jeopardy.

Rights of the patient (42 CFR 418.52(c)(6))

“Upon patient record review, there was no evidence the patient has the right to be free of mistreatment, neglect, or verbal, mental, sexual and physical abuse, including injuries of unknown source, and misappropriation of patient property. Patient #4, No evidence patient right to be free of neglect and mistreatment was prevented.”

Rule L0517. Standard-level, immediate jeopardy.

IDG, care planning, coordination of services (42 CFR 418.56)

“Condition of participation: Interdisciplinary group, care planning, and coordination of services. The hospice must designate an interdisciplinary group or groups as specified in paragraph (a) of this section which, in consultation with the patient’s attending physician, must prepare a written plan of care for each patient. The plan of care must specify the hospice care and services necessary to meet the patient and familyspecific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions.”

Rule L0536. Condition-level, immediate jeopardy.

Approach to service delivery (42 CFR 418.56(a)(1))

“Upon patient record review, 1 of 16 (Patient #4) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #4, No evidence of RN continued assessment and coordination with members of the IDG.”

Rule L0540. Standard-level, immediate jeopardy.

Content of plan of care (42 CFR 418.56(c))

Rule L0545. Standard-level, immediate jeopardy.

Content of plan of care (42 CFR 418.56(c)(1))

“Upon patient record review, 1 of 16 (Patient #4) did not have evidence that the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions which including interventions to manage pain and symptoms. Patient #4, No evidence of interventions for pain and symptoms management for deep coccyx wound and bilateral heel wounds in patient chart.”

Rule L0546. Standard-level, immediate jeopardy.

Content of plan of care (42 CFR 418.56(c)(4))

“Upon patient record review, 1 of 16 (Patient #4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #4, No evidence of wound care orders in patient chart for deep coccyx wound and bilateral heel wounds.”

Rule L0549. Standard-level, immediate jeopardy.

Review of the plan of care (42 CFR 418.56(d))

“Upon patient record review, 1 of 16 (Patient #4) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient #4, No evidence of Plan of Care was updated for deep coccyx wound and bilateral heel wounds.”

Rule L0553. Standard-level, immediate jeopardy.

Coordination of services (42 CFR 418.56(e)(3))

“Upon patient record review 1 of 16 (Patient #4) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #4, No evidence of care provided based on assessment of the patient needs.”

Rule L0556. Standard-level, immediate jeopardy.

Coordination of services (42 CFR 418.56(e)(5))

“Upon patient record review, 1 of 16 (Patient #4) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Patient #4, No evidence of documentation to reflect coordination of care with Wound Pro or facility.”

Rule L0558. Standard-level, immediate jeopardy.

Core services (42 CFR 418.64)

Rule L0587. Standard-level, immediate jeopardy.

Physician services (42 CFR 418.64(a))

Rule L0590. Standard-level, immediate jeopardy.

Nursing services (42 CFR 418.64(b))

Rule L0591. Standard-level, immediate jeopardy.

Organizational environment (42 CFR 418.100)

“Condition of Participation: Organization and administration of services. The hospice must organize, manage, and administer its resources to provide the hospice care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness and related conditions.”

Rule L0648. Condition-level.

Timeframe for completion of assessment (42 CFR 418.54(b))

Rule L0523. Standard-level.

Content of comprehensive assessment (42 CFR 418.54(c))

“Upon patient record review 1 of 16 (Patient #7) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. Patient #7, SC initial assessment refused, no evidence that the RN completed the spiritual assessment.”

Rule L0524. Standard-level.

Content of comprehensive assessment (42 CFR 418.54(c)(7))

“Upon patient record review, 4 of 16 (Patient #2,6,7,10) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #2,6,7,10, No evidence of bereavement assessment completed.”

Rule L0531. Standard-level.

Content of plan of care (42 CFR 418.56(c)(5))

“Upon patient record review, 8 of 16 (Patient #1,2,3,4,5,8,9,10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1,2,3,4,5,8,9,10, No evidence of DME equipment listed on the Plan of care.”

Rule L0550. Standard-level.

Coordination of services (42 CFR 418.56(e)(2))

“Upon patient record review, 2 of 16 (Patient #3,7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3, No evidence visits followed the SC frequency of 1x/month and 3 PRN. SC visits completed on 12/6/24 and 12/30/24, both visits were documented as scheduled visits. Patient #7, SC frequency 1x/month with 3 PRN every 30 days. No evidence to change frequency since patient declined SC visits.”

Rule L0555. Standard-level.

Hospice aide assignments and duties (42 CFR 418.76(g)(1))

Rule L0625. Standard-level.

Hospice aide assignments and duties (42 CFR 418.76(g)(2))

Rule L0626. Standard-level.

Serving the hospice patient and family (42 CFR 418.100(a))

“Upon observation, there was no evidence the hospice provides care directly or under contract that optimizes comfort and dignity of the patient and is consistent with the patient/ family needs and goals. The patient needs and goals are a priority. Patient #4, There was no evidence of hospice nurses managing deep coccyx wound and bilateral heel wounds that occurred after admission to the hospice.”

Rule L0650. Standard-level.

Governing body and administrator (42 CFR 418.100(b))

Rule L0651. Standard-level.

Medical director contract (42 CFR 418.102(a))

“Upon contract review, 1 of 4 (#2, Alt Medical Director Contract) did not have evidence of a contract to fulfill the role of medical director or alternate medical director, if applicable Contract#2: No evidence of Alt Medical Director was contracted or employed until the last day of the survey.”

Rule L0666. Standard-level.

Authentication (42 CFR 418.104(b))

“Upon patient record review, 6 of 16 (Patient #2,3,4,5,7,9) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #2,3,4,5,7,9, No evidence of completion of form stating what was covered under hospice or not. Form was signed and dated.”

Rule L0679. Standard-level.

Discharge or transfer of care (42 CFR 418.104(e)(2))

“Upon patient record review, 2 of 16 (Patient #11,12) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient’s attending physician: • A copy of the hospice discharge summary • The patient’s clinical record, if requested Patient #11, #12, No evidence of discharge summary was sent to MD.”

Rule L0683. Standard-level.

Discharge or transfer of care (42 CFR 418.104(e)(3))

“Upon patient record review, 2 of 16 (Patient #11,12) did not have evidence that the discharge summary includes all required information. Patient #11, #12, No evidence of a discharge summary in the chart.”

Rule L0684. Standard-level.

Personnel qualification (42 CFR 418.114(b)(4))

“Upon personnel record review, 1 of 13 (Personnel #13) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state’s Speech-Language Pathology Practice Act and the hospice’s policies and procedures and/or job descriptions. Personnel #13, No evidence of a Speech Therapy HR record.”

Rule L0788. Standard-level.

Personnel qualification (42 CFR 418.114(b)(5))

“Upon personnel record review, 1 of 13 (Personnel #12) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state’s Occupational Therapy Practice Act and the hospice’s policies and procedures and/or job descriptions. Personnel #12, No evidence of a Occupational Therapy HR record.”

Rule L0789. Standard-level.

Personnel qualification (42 CFR 418.114(b)(7))

“Upon personnel record review, 1 of 13 (Personnel #11) did not have evidence all Physical Therapy Services are provided by a qualified licensed Physical Therapist (PT) in accordance with the state’s Physical Therapy Practice Act and the hospice’s policies and procedures and/or job descriptions. Personnel #11, No evidence of a Physical Therapy HR record.”

Rule L0791. Standard-level.

Criminal background checks (42 CFR 418.114(d)(1))

“Upon personnel record review, 3 of 13 (Personnel #11,12,13) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel 11, 12, 13: No evidence of criminal background checks.”

Rule L0795. Standard-level.