Caring Hands Palliative and Hospice Care, Inc.

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

“Observed in Record Review. On 1 of 2 patient records reviewed, the nurse surveyor noted that the goals were not measurable or individualized to the patient. On RRNHV #1, it was noted that the goals were not measurable and specific to the patient. For example, “being free of fall injury” and “maintaining dignity and support through patient’s final hours”. Finding was verified by the RN Administrator and the Director of Patient Care Services.”

Rule L0545. Standard-level.

Content of plan of care (42 CFR 418.56(c)(2))

“Observed in Record Review. In 1 of 2 patient records reviewed, the organization did not have detail on the scope of services needed to provide care. On RRNHV #1, it was noted on review of the assessment that the patient was using 5 L of oxygen but this was not reflected on the plan of care. This finding was reviewed and verified with the administrator.”

Rule L0547. Standard-level.

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

“Observed in Record Review. In 10 of 10 patient records reviewed, it was noted by the nurse surveyor that patient orders were not individualized. All patients had the same order for oxygen 2-4 liters as needed for shortness of breath and may insert #14 to #18 FR foley catheter for urinary problems. Findings were discussed with the RN Administrator and the Director of Patient Care Services.”

Rule L0536. Condition-level.

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

Rule L0549. Condition-level.

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

“Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care and treatment and services as evidence by Condition Level deficiencies §418.56 and §418.102. Findings were discussed with Leadership.”

Rule L0651. Condition-level.

Medical director (42 CFR 418.102)

“Observed in Tracer Activities. It was noted by the nurse surveyor that there was no backup medical director under contract or directly employed by the organization. Finding was validated by the Medical Director and the Administrator.”

Rule L0664. Condition-level.

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

“Observed in Tracer Activities. During the review of the Bereavement Program, it was noted by the nurse surveyor that post death bereavement risk assessments had not been completed and documented for patients who had passed away during the last ten months. Finding was verified by the Administrator who had been managing the program and stated that post death risk assessments had not been completed for the bereaved.”

Rule L0531. Standard-level.

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

Rule L0545. Standard-level.

Counseling services (42 CFR 418.64(d)(1)(i))

“Observed in Tracer Activities. During the review of the Bereavement Program, the surveyor noted that the Nursing Administrator who is a Registered Nurse had been managing the provision of bereavement services. The Nursing Administrator did not have experience or education in grief or loss counseling which was self-validated.”

Rule L0596. Standard-level.

Counseling services (42 CFR 418.64(d)(1)(iv))

“Observed in Tracer Activities. During the review of the Bereavement Program, it was noted by the nurse surveyor that bereavement plans of care had not been developed and documented for patients who had passed away during the last ten months. Finding was verified by the Administrator who had been managing the program and stated that care plans had not been developed for the bereaved.”

Rule L0596. Standard-level.

Competency evaluation (42 CFR 418.76(c)(1))

“Observed in HR File Review. In 1 of 1 HR files reviewed, for the Hospice Aide, t was noted by the nurse surveyor that for HR#5 (Hospice Aide), her competencies were competed using verbal confirmation. Finding was validated by the Administrator and the Director of Patient Care Services.”

Rule L0615. Standard-level.

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

Rule L0625. Standard-level.

Cost saving (42 CFR 418.78(d))

“Observed in Tracer Activities. It was noted by the nurse surveyor that the organization was not able to demonstrate cost savings achieved through the use of volunteers since despite recruitment efforts, they do not have any volunteers. Finding was verified by the Administrator and the Volunteer Coordinator.”

Rule L0646. Standard-level.

Level of activity (42 CFR 418.78(e))

“Observed in Tracer Activities. It was noted by the nurse surveyor that volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff for the last ten months. From April of 2024 to the end of January 2025, the percentage of volunteer to paid hours is 0.00% There currently are no active patient care volunteers or office volunteers. Recruitment efforts have been unsuccessful. Finding was verified by the Administrator, DPCS, and the Volunteer Coordinator.”

Rule L0647. Standard-level.

Content (42 CFR 418.104(a)(3))

Rule L0674. Standard-level.

Use and mintenance of equipment and supplies (42 CFR 418.106(f)(2))

“Observed in Patient Home. In 1 of 3 home visits conducted, it was noted by the nurse surveyor that for RRHV#2 the backup E-tank was secured in a stand behind some items in the patient’s closet. Findings were verified by the Director of Patient Care Services. Tank was immediately removed from the closet and put in a secure location in the patient room.”

Rule L0702. Standard-level.