Allied Care Hospice, Inc.

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

“Observed in Tracer Activities. During EM tracer review the hospice surveyor noted that the organization failed to develop a mitigation plan from their HVA. This was reviewed and validated with the DCPS.”

Rule E0006. Standard-level.

Integrated EP Program (42 CFR 418.113(e)(4))

“Observed in Tracer Activities. During EM tracer activity the surveyor noted that the organization failed to complete a continuity of operations plan. This was reviewed and validated with the DPCS.”

Rule E0042. Standard-level.

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

“Observed in Record Review. In 3 of 3 patient records reviewed, the hospice surveyor noted that neither the Admission Consent nor the Election of Benefits included language where the patient could request a copy of non covered items from the organization. The organization failed to notify the patient of their right to a copy of non covered items at admission. This was reviewed and validated with the DCPS.”

Rule L0505. Standard-level.

Rights of the patient (42 CFR 418.52(c)(4))

“Observed in Record Review. In 3 of 3 patient records reviewed, the hospice surveyor noted that neither the Admission Consent nor the Election of Benefit included language where the patient could select the Hospice Provider or another provider for their care. The hospice failed to offer the patient a choice of using either the hospice medical director or another provider. This was reviewed and validated with the DCPS.”

Rule L0515. Standard-level.

Content of comprehensive assessment (42 CFR 418.54(c)(5))

“Observed in Record Review. In 1 of 3 patient records reviewed, the hospice surveyor noted in HOSRRHV #1 that the fall risk assessment had not been completed at admission in the comprehensive assessment. The fall risk assessment was not performed at admission per the organization’s policy Initial Assessment Policy Number 2-029.1. This was reviewed and validated with the DPCS. .”

Rule L0529. Standard-level.

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

“Observed in Record Review. In 2 of 3 patient records reviewed, the hospice surveyor observed in HOSRRHV #2 the were 22 days between IDT meetings and in HOSRRHV #3 there was 28 days between hospice IDT meetings. The organization failed to complete an IDT meeting every 15 days per regulation and their policy, Interdisciplinary Group Meeting Policy No. 2-050.1. This was reviewed and validated with the DCPS.”

Rule L0533. Standard-level.

Content of plan of care (42 CFR 418.56(c)(3))

“Observed in Record Review. In 1 of 3 patient records reviewed, the hospice surveyor noted that in HOSRRHV #1 where the patient was deemed a fall risk per the home health aide care plan and a bleeding precaution as he was on an anticoagulant the POC for the RN did not include a care plan addressing either of theses precautions. This was reviewed and validated with the DPCS.”

Rule L0548. Standard-level.

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

Rule L0549. Standard-level.

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

Rule L0557. Standard-level.

Prevention (42 CFR 418.60(a))

Rule L0579. Standard-level.

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

“Observed in Record Review. In 2 of 3 patient records reviewed, where the home health aide was ordered the hospice surveyor noted that in HOSRRHV #1 that the aide care plan failed to include bleeding precautions as the patient is on an anticoagulant. In HOsRRHV #3 the aide care plan failed to include seizure precautions. This was reviewed and validated with the DCPS.”

Rule L0625. Standard-level.

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

“Observed in Record Review. HCO failed to implement policies related to patient rights resulting in a condition level deficiency at 418.52. Discussed and validated with the DCPS.”

Rule L0651. Standard-level.

Training (42 CFR 418.100(g)(3))

“Observed in HR File Review. In 1 of 10 HR files reviewed, the hospice surveyor noted during HR tracer that the Medical Director did not have an initial competency in his file at hire. This was reviewed and validated with the DCPS.”

Rule L0663. Standard-level.

Content (42 CFR 418.104(a)(7))

“Observed in Record Review. In 1 of 3 patient records reviewed, treatments performed such as foley catheter changes were not fully described in the record of care. The surveyor noted in HOSRRHV #3 the RN documented foley catheter change performed. No documentation as to the size of the foley catheter used, the amount or type of fluid used to inflate the balloon or if a securement device was used. This was reviewed and validated with the DPCS.”

Rule L0678. 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, the hospice surveyor noted In HOSRRDC #1 the patient was transferred to a hospital and the organization failed to send a discharge summary to the receiving organization. The organization failed to follow their policy Transfer Information # 2.070.1. This was reviewed and validated by the DPCS.”

Rule L0682. Standard-level.

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

“Observed in Record Review. In 1 of 2 patient records reviewed, the hospice surveyor noted in HOSRRDC #2 the patient’s family revoked from Hospice. The community provider was not sent a discharge summary after a live discharge. The organization did not follow its policy on Revocation of Hospice Benefit Election # 2-068.1. This was reviewed and validated by the DPCS.”

Rule L0683. Standard-level.