Lifelink Hospice & Palliative Care

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

“Observed in Record Review. In 1 of 10 patient records reviewed, During RR6 it was noted the last comprehensive assessment documented by the RN was the end of August without an update for 28 days. This was discussed with the DPCS and Administrator.”

Rule L0533. 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 4 of 10 patient records reviewed, During RR1 and RRHV3 it was noted the patients were prescribed Plavix daily however there was lack of interventions on the POC related to S/S bleeding and bleeding precautions on the POC. During RR4 it was noted lack of interventions for the respiratory deficit on the POC. During RR2 the patient was prescribed Xarelto daily however the POC lacked interventions related to S/S bleeding and bleeding precautions. This was discussed with the DPCS.”

Rule L0547. Standard-level.

Content of plan of care (42 CFR 418.56(c)(5))

“Observed in Record Review. In 1 of 10 patient records reviewed, During RR1 it was noted interventions and goals on the POC for oxygen therapy as needed for SOB however there was lack of an order for oxygen therapy and the RN initial assessment for an oxygen safety assessment is documented as N/A. This was discussed with the DPCS.”

Rule L0550. Standard-level.

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

Rule L0555. Standard-level.

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

“Observed in Record Review. In 2 of 10 patient records reviewed, During RR2 and RR3 it was noted the aide visits were ordered for 3x/week however the first aide visit in each record was documented 10 days after the assignment was completed by the RN. There was lack of documentation that the IDG was notified of the delay. This was discussed with the Administrator and DPCS.”

Rule L0557. Standard-level.

Executive responsibilities (42 CFR 418.58(e)(2))

“Observed in Data Session. During review of the QAPI plan it was noted lack of the activities or frequency for evaluating contract services that include pharmacy, DME, therapy and SNFs. This was discussed with the Administrator.”

Rule L0575. Standard-level.

Prevention (42 CFR 418.60(a))

“Observed in Patient Home. In 1 of 3 home visits conducted, During RRHV1 the SN, after disinfecting the equipment used to assess vital signs, placed the equipment immediately back in her bag and did not follow the manufacture’s guidelines for undisturbed wait time of 2 minutes before moving the equipment. This was discussed with the leadership team.”

Rule L0579. Standard-level.

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

“Observed in Record Review. In 1 of 10 patient records reviewed, During RR6 it was noted lack of documentation that the RN performed an aide supervisory visit at least once every 14 days with a gap of 28 days from the end of August 2025 to date. This was discussed with the Administrator and DPCS.”

Rule L0629. Standard-level.

Recruiting and retaining (42 CFR 418.78(c))

“Observed in Regulatory Review. During review of the volunteer program it was noted lack of documentation of recruitment efforts to attract volunteers. This was discussed with the Administrator and DPCS.”

Rule L0645. Standard-level.

Cost saving (42 CFR 418.78(d))

“Observed in Regulatory Review. During review of the volunteer program it was noted lack of documentation of the cost savings achieved through the use of volunteers. This was corrected during the survey. This was discussed with the Administrator.”

Rule L0646. Standard-level.

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

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, who were discharged alive. During live d/c 1 it was noted the inpatient facility was not provided a summary of care on transfer. This was discussed with the Administrator and DPCS.”

Rule L0682. Standard-level.

Written agreement (42 CFR 418.112(c)(8))

“Observed in Document Review. In 1 of 5 contracts reviewed, During review of the SNF contract it was noted lack of a provision stating that the hospice will report all mistreatment, neglect, or verbal, mental, sexual, and physical abuse to the SNF, NF, or ICF/IID administrator within 24 hours of the hospice becoming aware of the alleged violation, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice. This was discussed with the Administrator”

Rule L0771. Standard-level.

Written agreement (42 CFR 418.112(c)(9))

“Observed in Document Review. In 1 of 5 contracts reviewed, During review of the SNF contract is was noted lack of the delineation of the responsibilities of the hospice and the SNF, NF, or ICF/IID to provide bereavement services to SNF, NF, or ICF/IID staff. This was discussed with the Administrator.”

Rule L0772. Standard-level.

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

“Observed in Document Review. In 1 of 5 contracts reviewed, During review of the therapy contract it was noted lack of a stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This was discussed with the Administrator.”

Rule L0795. Standard-level.