Family Care Hospice

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

“Observed in Tracer Activities. Leaders did not manage implementation of patient care policies and procedures governing the provision of care as evidenced by condition level findings at:418.102. This was discussed with the Administrator, Administrative Assistant and Hospice DON.”

Rule L0651. Condition-level.

Initial certification of terminal illness (42 CFR 418.102(b))

Rule L0667. Condition-level.

Initial & comprehensive assessment of patient (42 CFR 418.54)

Rule L0520. Standard-level.

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

“Observed in Record Review. In 1 of 4 patient records reviewed, the organization did not document the completion of an initial comprehensive assessment in 5 calendar days. For example, in record HOSRR#2 the psychosocial assessment was documented on day 28 after admission. This was discussed with the Hospice DON.”

Rule L0523. Standard-level.

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

Rule L0545. Standard-level.

Establishment of the Emergency Program (EP) (42 CFR 418.113)

Rule E0001. Condition-level.

Initial & comprehensive assessment of patient (42 CFR 418.54)

Rule L0520. Condition-level.

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

“Observed in Record Review. In 1 of 2 discharge records reviewed, where the patient was leaving hospice for an extended prognosis there was no order written in record RRDC#2. This RFI was reviewed with the Administrators and the Hospice Director of Nursing.”

Rule L0536. Condition-level.

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

“Observed in Tracer Activities. Leaders did not manage implementation of patient care policies and procedures governing the provision of care as evidenced by condition level findings at §418.52, §418.56, §418.78, §484.102, and §484.110. This RFI was reviewed with the Administrators and Directors of Nursing.”

Rule L0651. Condition-level.

Plan Based on All Hazards Risk Assessment (42 CFR 418.113(a)(1))

Rule E0006. Standard-level.

Plan Based on All Hazards Risk Assessment (42 CFR 418.113(a)(2))

Rule E0006. Standard-level.

EP Program Patient Population (42 CFR 418.113(a)(3))

Rule E0007. Standard-level.

Local, State, Tribal Collaboration Process (42 CFR 418.113(a)(4))

“Observed in Emergency Management Session. During review and discussion of the Emergency Management plan for Home Health and Hospice, the Surveyor noted that the organization’s emergency operations plan had not included a process for cooperating and collaborating with other health care organizations, relevant community partners (such as fire, police, local incident command, public health departments), and relevant authorities (such as federal, state, tribal, regional, and local emergency preparedness staff). This finding was verified by the Administrator.”

Rule E0009. Standard-level.

Homebound HHA/Hospice Inform EP Officials (42 CFR 418.113(b)(2))

“Observed in Emergency Management Session. During review and discussion of the Emergency Management plan for Home Health and Hospice, the Surveyor noted that the organization had not had a plan for providing patient care and clinical support includes policies and procedures that describe how it will inform state and local emergency preparedness officials about its patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. This finding was verified by the Administrator.”

Rule E0019. Standard-level.

Arrangement with Other Facilities (42 CFR 418.113(b)(5))

“Observed in Emergency Management Session. During review and discussion of the Emergency Management plan for Home Health and Hospice, the Surveyor noted that the organization had not had a plan for providing patient care and clinical support includes written procedures and arrangements with other health care providers for how it will share patient care information and medical documentation and how it will provide transportation to other health care facilities to maintain continuity of care. This finding was verified by the Administrator.”

Rule E0025. Standard-level.

Primary/Alternate Means for Communication (42 CFR 418.113(c)(3)(i))

“Observed in Emergency Management Session. During review and discussion of the Emergency Management plan for Home Health and Hospice, the Surveyor noted that the organization’s communications plan identifies its primary and alternate means for communicating with staff and relevant authorities (such as federal, state, tribal, regional, and local emergency preparedness staff). The plan includes procedures for the following: - How and when alternate/backup communication methods are used - Testing the functionality of the organization’s alternate/backup communication systems or equipment. This finding was verified by the Administrator.”

Rule E0032. Standard-level.

Primary/Alternate Means for Communication (42 CFR 418.113(c)(3)(ii))

“Observed in Emergency Management Session. During review and discussion of the Emergency Management plan for Home Health and Hospice, the Surveyor noted that the organization’s communications plan identifies its primary and alternate means for communicating with staff and relevant authorities (such as federal, state, tribal, regional, and local emergency preparedness staff). The plan includes procedures for the following: - How and when alternate/backup communication methods are used - Testing the functionality of the organization’s alternate/backup communication systems or equipment. This finding was verified by the Administrator.”

Rule E0032. Standard-level.

Methods for Sharing Information (42 CFR 418.113(c)(4))

Rule E0033. Standard-level.

Information on Occupancy/Needs (42 CFR 418.113(c)(7))

Rule E0034. Standard-level.

EP Testing Requirements (42 CFR 418.113(d)(3)(iii))

“Observed in Emergency Management Session. During review and discussion of the Emergency Management plan for Home Health and Hospice, the Surveyor noted that the organization had not had a committee that oversees the emergency management program reviews and evaluates all exercises and actual emergency or disaster incidents. The committee reviews after-action reports (AARs), identifies opportunities for improvement, and recommends actions to take to improve the emergency management program. The AARs and improvement plans are documented. This finding was verified by the Administrator.”

Rule E0039. Standard-level.

Notice of rights and responsibilities (42 CFR 418.52(a)(2))

“Observed in Patient Home. In 4 of 4 home visits conducted, the hospice’s advance directive policy and information from the state of Arizona was not found in the handbook in patients’ homes, nor was there documentation in the record that the information was provided and reviewed. This RFI was reviewed with the Administrators and the Hospice Director of Nursing.”

Rule L0503. Standard-level.

Exercise of rights/respect for proprty/person (42 CFR 418.52(b)(1)(i))

“Observed in Record Review. In 1 of 2 discharge records reviewed, a Notice of Medicare Non-Coverage was not signed by the patient’s guardian a minimum of 48 hours prior to discharge as required by law. In RRDC#2 there was no documentation of the document having been signed. This was confirmed by an Administrator.”

Rule L0505. Standard-level.

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

“Observed in Record Review. In 2 of 14 active patient records reviewed, the organization did not document the completion of an initial comprehensive assessment. In record RRHV#1, and RRNHV#1there was no psychosocial, spiritual, or bereavement assessment documented. This RFI was reviewed with the Administrators and the Hospice Director of Nursing”

Rule L0531. Standard-level.

Update of comprehensive assessment (42 CFR 418.54(d))

“Observed in Record Review. In 11 of 14 active patient records reviewed, where the interdisciplinary group met two or more times the organization failed to update the comprehensive assessment based on changes occurring since the initial assessment. Interdisciplinary group meeting notes did not document patient decline, progress towards desired outcomes and goals, and plans for the following two weeks. This RFI was reviewed with the Administrators and the Hospice Director of Nursing.”

Rule L0533. Standard-level.

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

Rule L0545. Standard-level.

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

“Observed in Patient Home. In 1 of 4 fire barrier wall checks, an order was not obtained to change a medication. At the home visit for RRHV#1 the RN stated that Atropine sulfate ophthalmic ointment 1% was discontinued because it was no longer available from the contracted pharmacy. The list provided to the surveyor for the visit still included the medication because the physician was not contacted for an order to discontinue it. This RFI was reviewed with and confirmed by the Hospice Director of Nursing.”

Rule L0549. Standard-level.

Infection control (42 CFR 418.60)

“Observed in Infection Control Tracer. During review and discussion of the Infection Prevention and Control program for Home Health and Hospice, the surveyor noted that the organization had not had current written policies and procedures to guide its activities and methods for preventing and controlling the transmission of infections and communicable diseases. The policies and procedures are in accordance with applicable law and regulation and nationally recognized evidence-based guidelines, and standards of practice. This finding was verified by the Administrator.”

Rule L0577. Standard-level.

Recruiting and retaining (42 CFR 418.78(c))

“Observed in Tracer Activities. During a discussion with the volunteer coordinator and review of available volunteer recruitment initiatives, the pharmacy Hospice surveyor noted that current documentation of this requirement was not available for 2024. .The validation of this missing information was reviewed with the volunteer coordinator at thew time of the survey”

Rule L0645. Standard-level.

Cost saving (42 CFR 418.78(d)(3))

“Observed in Tracer Activities. During a discussion with the volunteer coordinator and review of any available records prepared in 2024, the pharmacy Hospice surveyor noted that current documentation of this requirement was not available for 2024--no estimates of the dollar amount saved by volunteers providing services and care rather than employees providing care was available. The validation of this missing information was reviewed with the volunteer coordinator at thew time of the survey”

Rule L0646. Standard-level.

Level of activity (42 CFR 418.78(e))

“Observed in Tracer Activities. During a discussion with the volunteer coordinator and review of available records prepared in 2024, the pharmacy Hospice surveyor noted that current documentation of direct patient care and administrative to equal 5% was not available for 2024--no estimates of the amount saved by volunteers providing services and care rather than employees providing care was now ongoing. The validation of this missing information was reviewed with the volunteer coordinator at thew time of the survey”

Rule L0647. Standard-level.

Initial certification of terminal illness (42 CFR 418.102(b))

Rule L0667. Standard-level.

Discharge or transfer of care (42 CFR 418.104(e)(1)(i))

“Observed in Record Review. In 2 of 2 patient records reviewed, discharge summaries were not written and attending physicians were not notified of the availability of the summaries in records RRDC#1 and RRDC#2. This RFI was reviewed with the Administrators and the Hospice Director of Nursing.”

Rule L0682. Standard-level.