Together Hospice Care LLC

Hospice Follow up for Staff (42 CFR 418.113(b)(1))

“Observed in Emergency Management Session. During review of the emergency management plan it was noted lack of the method to be used to inform state and local officials of any on-duty staff or patients that the organization was unable to contact. This was discussed with the organization leadership.
”

Rule E0016. Standard-level.

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

“Observed in Record Review. In 2 of 14 patient records reviewed, During RR#1 it was noted lack of an initial bereavement assessment in the patient record 18 days after the comprehensive assessesment without documentation of the reason. During RR#8 it was noted the SC called to set up a visit to complete the bereavement assessment on the 6th day after the RN initial assessment. This was discussed with leadership.”

Rule L0531. Standard-level.

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

“Observed in Record Review. In 1 of 14 patient records reviewed, During RR#3 it was noted goals that were not individualized or measurable. They included patient will maintain peripheral circulation, patient will have BM managed with bowel care regimen, Pt/Family/PCG will verbalize having urinary elimination needs met at an acceptable level and Pt will have adequate food and fluids as tolerated or desired. This was discussed with the organization leadership.”

Rule L0545. Standard-level.

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

Rule L0546. Standard-level.

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

“Observed in Record Review. In 11 of 14 patient records reviewed, During HV#1 and #4 record review, RR#1, RR#2, RR#3, RR#4, RR#8, RR#7, RR#6, RR#5, RR#9 it was noted an oxygen therapy order for 2-5 L/NC, titrate for comfort PRN SOB. The order lacked the parameters to increase the liter flow. This was discussed with the leadership. This was discussed with the leadership.”

Rule L0549. Standard-level.

Program scope (42 CFR 418.58(a)(1))

“Observed in Data Tracer. During review of the QAPI program it was noted lack of reivew of bereavement services, and contracted services including pharmacy, DME, therapy, and hospice care in contracted skilled nursing facilities. This was discussed with leadership.”

Rule L0561. Standard-level.

Executive responsibilities (42 CFR 418.58(e)(1))

“Observed in Data Session. During review of the organization QAPI program it was noted lack of documentation of annual program reviews for 2022, and 2023. The QAPI team provided the surveyor with an updated QAPI plan for 2024 during the survey. This was reviewed with leadership.”

Rule L0574. Standard-level.

Control (42 CFR 418.60(b)(2)(i))

“Observed in Infection Control System Tracer. During reivew of the infection control plan it was noted lack of a description of the geographic locations of population served and the care, treatment, or services it provided for 2022, 2023 and 2024 to date. QAPI team provided surveyor with an updated infection control plan for 2024 during the survey. This was discussed with the leadership.”

Rule L0581. Standard-level.

Control (42 CFR 418.60(b)(2)(ii))

Rule L0581. Standard-level.

Licensed professional services (42 CFR 418.62(c))

“Observed in Data Session. During review of the sign in forms for QAPI meetings, it was noted the participants were the Administrator, QAPI Coordiantor and DPCS. The QAPI committee lacked other professionals members such as the MSW, Chaplain, and Medical Director. This was discussed with the Administrator.”

Rule L0586. Standard-level.

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

“Observed in Record Review. In 11 of 12 patient records reviewed, who were receiving hospice aide serivce. During HV#1- HV#4 record review, RR#1, RR#2, RR#4, RR#8, RR#6, RR#5, RR#9 it was noted the hospice aide assignment form contained ranges for oxygen therapy, prepared by the RN. The assignments included use of oxygen at 2-5 L/NC PRN SOB. This was discussed with leadership.”

Rule L0625. Standard-level.

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

“Observed in Record Review. In 1 of 2 patient records reviewed, who were discharged from hospice. During Live D/CRR#2 it was noted the completed d/c summary lacked documentation that a copy was sent to the hospital where the patient was admitted. This was discussed with leadership.”

Rule L0682. Standard-level.

Label dispose storage drugs (42 CFR 418.106(e)(2)(i)(A))

“Observed in Document Review. During reivew of the organization admission packet and in discussion with the DPCS, although there was information on disposal of medications, it was noted lack of a copy of the hospice’s written policies and procedures on the management and disposal of controlled medications has been given to the patient or the patient’s representative and family during care.”

Rule L0695. Standard-level.

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

“Observed in Regulatory Review. During review of the admission packet and in discussion with the leadership it was noted lack of a written individualized disaster preparedness form in the patient medical record or in the home. This was discussed and verified with the organization leadership.”

Rule L0702. Standard-level.

Personnel qualification (42 CFR 418.114(b)(3)(ii))

“Observed in HR File Review. In 1 of 12 HR files reviewed, During HR#1 review it was noted the employee did not meet the experience requirement in the job description of a minimum one year experience in health care. This was discussed with the organization leadership.”

Rule L0787. Standard-level.

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

“Observed in Document Review. In 2 of 4 contracts reviewed, During reivew of the pharmacy, and DME contracts it was noted lack of a stipulation that the outside agency will complete criminal background checks on employees who provide direct patient care or have access to patient records. This was discussed with organization leadership.”

Rule L0795. Standard-level.