Supreme Hospice and Palliative Care

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

“Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement service it was noted that the hospice had not developed a bereavement plan of care and as a result had not made bereavement services available to the family and other individuals specified in the bereavement plan of care. This was discussed and confirmed with the Administrator.”

Rule L0596. Condition-level.

Rights of the patient (42 CFR 418.52(c)(2))

“Observed in Record Review. In 1 of 1 patient records reviewed, for extended prognosis discharge it was noted that the patient and caregiver did ot participate in decisions about their care. For example, in RRDC#1 the Notice of Medicare Non-Coverage was signed and dated the day of discharge, not 2 days prior as required. This was discussed with the Administrator.”

Rule L0513. Standard-level.

Content of comprehensive assessment (42 CFR 418.54(c)(8))

Rule L0532. 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)(2))

“Observed in Record Review. In 1 of 1 patient records reviewed, that included volunteer services, it was noted that the POC did not include a complete statement of the scope and frequency of the services necessary to meet the patient’s need. For example In record RRNHV#6 there was documentation that volunteer visits had been made, but no frequency of volunteer visits. This was discussed the Clinical Manager present.”

Rule L0547. Standard-level.

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

“Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement services it was noted that while a post death assessment had been completed there was no documentation of the interdisciplinary group reflecting on the bereaved and bereavement plan of care. For example, in records RRBR#1 and RRBR#2 there was no documentation of an IDG discussion taking place after the patient death. In both cases the last IDG documentation was prior to death. This was discussed and confirmed with the Administrator.”

Rule L0552. Standard-level.

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

“Observed in Record Review. In 1 of 1 patient records reviewed, that included volunteer services it was noted that the services provided were not based on the individualized plan of care. In record RRNHV#6 there was no POC developed for the volunteer. There was a check list of items to complete during a visit and the volunteer documented completion of 5 of 7 items and documented providing 1 additional item that had not been identified. This was discussed and confirmed with the Clinical Manager present.”

Rule L0555. Standard-level.

Program data (42 CFR 418.58(b)(2)(ii))

“Observed in Data Session. During the Data session it was noted that the hospice had collected a large amount of data, however there was no data analysis performed over time to determine trends in performance. For example, hand hygiene data had been collected monthly, but there was no analysis or trending completed. This was discussed with the Administrator, Assistant Administrator, Alternate Administrator and Clinical Manager present.”

Rule L0564. Standard-level.

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

“Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement services it was noted that the hospice had not developed a bereavement plan of care that specified the type of bereavement services to be offered and the frequency of service delivery. For example in RRBR#1 and RRBR#2 the comment Follow usual Bereavement POC. was documented in the area for the plan of care with no goals or interventions. This was discussed with the Administrator.”

Rule L0596. Standard-level.

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

“Observed in Record Review. In 1 of 7 patient records reviewed, that included aide services it was noted that the patient care instructions for the hospice aide were incomplete. For example, in record RRHV#3 the patient had a wound dressing on his right heel, but the aide POC did not provide directions regarding the dressing. This was discussed with the Administrator.”

Rule L0625. Standard-level.

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

“Observed in Record Review. In 1 of 7 patient records reviewed, it was noted that the patient care and services provided were not according to the patient’s plan of care. For example, in record RRHV#3 the hospice aide did not follow the POC that required the patient’s teeth to be brushed at each visit, and hair to be shampooed and blow dried each visit, however these were not completed. This was discussed with the Administrator.”

Rule L0626. Standard-level.

Hospice aide assignments and duties (42 CFR 418.76(g)(4))

Rule L0628. Standard-level.

Supervision of hospice aides (42 CFR 418.76(h)(1)(i))

“Observed in Record Review. In 1 of 7 patient records reviewed, that included aide services it was noted that the hospice aide supervision was not done every 14 days. For example, in record RRHV#1 during the past 4 months aide supervision was documented at 15 days twice and at 20 days once. This was discussed with the Administrator.”

Rule L0629. Standard-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 treatment and services as evidenced by condition level finding at 418.64.”

Rule L0651. Standard-level.

Services (42 CFR 418.100(c)(1))

“Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement service it was noted that the hospice had not developed a bereavement plan of care and as a result had not made bereavement services available to the family and other individuals specified in the bereavement plan of care. This was discussed and confirmed with the Administrator.”

Rule L0652. Standard-level.

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

“Observed in HR File Review. In 1 of 7 HR files reviewed, it was noted that staff competence was not initially assessed and documented. For example in file HR-SC/BR Coordinator it was noted that a competency was documented for Spiritual Counselor, but no competency was documented for Bereavement Coordinator. This was discussed with the Administrator and HR employee.”

Rule L0663. Standard-level.

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

“Observed in Patient Home. During 1 of 1 visits that included medication disposal it was noted that the nurse did not follow the organization’s policy for disposal of medications. During visit HOS RRHV#1 the nurse placed tablets in a bag and mixed with water and disposed and the organization’s Medication Disposal policy stated that the medication was to be placed in cat litter or coffee grounds. This was discussed with the administrator.”

Rule L0694. Standard-level.