Compassion Hospice & Palliative Care

EP Training Program (42 CFR 418.113(d)(1)(iii))

“Observed in HR File Review. In 3 out of 5 applicable HR files, Emergency Preparedness training was not provided at least every 2 years. Examples: In HR#2 (MD), HR#4 (RN), and HR#6 (CH) emergency preparedness training was not provided at least every 2 years. This was confirmed by the Administrator Designee.”

Rule E0037. Standard-level.

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

“Observed in Record Review. In 1 out 2 discharge records, the organization did not involve the patient in making decisions about their care, treatment, or services. Example: In RRDC#1, discharge documentation indicated the patient wanted aggressive treatment and choose to revoke hospice services. However, there’s not a revocation form signed by the patient or designee within the patient record validating this choice. This was confirmed by the Administrator.”

Rule L0505. Standard-level.

Patient outcome measures (42 CFR 418.54(e)(2))

“Observed in Tracer Visit. In 1 out 3 home visit records, the medication profile in the medical record was inaccurate. Example: In RRHV#2, the medication profile was inaccurate in the medical record. The following medications were not included in the profile: Levetiracetam 500 mg tablet; Memantine Hydrochloride 10mg Tablet; Sertraline Hydrochloride 25mg Tablet. This was confirmed with the Administrator who contacted their EMR platform Hospice MD for evaluation of the discrepancy.”

Rule L0535. Standard-level.

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

“Observed in Tracer Activities. In 1 out of 4 records, the plan of care did not clearly define prn medication parameters to meet the patient needs. Example: In RRHV#2, the orders to address pain prn was not clearly defined. The patient plan of care included Acetaminophen 325mg Tablets every 4 hours as needed for pain and Morphine Sulfate 15 mg every 4 hours as needed for pain.. This was confirmed by the Administrator.”

Rule L0549. Standard-level.

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

Rule L0555. Standard-level.

Education (42 CFR 418.60(c))

“Observed in Infection Control System Tracer. In 3 out of 6 HR files, the organization did not provide ongoing infection control education to staff. Examples: In HR#2 (MD), HR#4 (RN), and HR#6 (CH) ongoing infection control education was not provided annually. This was confirmed by the Administrator Designee.”

Rule L0582. Standard-level.

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

“Observed in Tracer Activities. In 2 out of 3 bereavement record reviews, the organization did not develop a bereavement plan of care that noted the kind of bereavement services to be offered and the frequency of service delivery. Example: In RRBR#2 and RRNHV#5, a bereavement plan of care was not developed. This was confirmed with the Administrator.”

Rule L0596. Standard-level.

Counseling services (42 CFR 418.64(d)(3)(i))

“Observed in Tracer Activities. In 3 out of 3 bereavement records, the organization did not conduct the post-death reassessment of the bereaved family per policy. Example: The bereavement policy indicates that the post-death bereavement assessment would take place 3-5 weeks after the patient’s death. In RRBR#1, the assessment occurred 8 months after the patient passed. In RRBR#2, the post-death bereavement assessment was done 9 months after the patient passed. In RRNHV#5, the post-death bereavement assessment was done 7 months after the patient passed. This was confirmed by the Administrator.”

Rule L0598. Standard-level.

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

“Observed in Tracer Activities. In 1 out of 4 records, the registered nurse did not supervise the hospice aide during an on-site visit to the patient’s home no less frequently than every 14 days. Example: In RRDC#2, the Aide Supervisory visit was late by 1 day in week 3 of benefit period 4 and by 12 days in week 7 of benefit period 4. This was confirmed by the Administrator.”

Rule L0629. Standard-level.

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

“Observed in Record Review. In 1 out of 5 applicable charts, the hospice did not provide the patient’s attending physician with a copy of the hospice discharge summary and, if requested, a copy of the patient’s clinical record. Example: In RRNHV#2, the Hospice did not send a copy of the discharge summary to the Attending MD after the patient was discharged for extended prognosis. This was confirmed by the Administrator.”

Rule L0683. Standard-level.