St Joseph’s Care Hospice Services Inc.

Content of comprehensive assessment (42 CFR 418.54(c)(6))

“Upon patient record review, 1 of 14 (Patient #1) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1 had medications on the POC that had been discontinued on the medication profile. (Oxybutynin and Trazadone).”

Rule L0530. Standard-level.

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

Rule L0553. Standard-level.

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

“Upon client record review, 2 of 14 (Patient #5,6) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #5,6 were transfers to another Hospice. There was evidence of a transfer form. However; no evidence of a transfer summary. The Discharge Summary was completed however; no evidence of what information was sent to receiving Hospice”

Rule L0682. Standard-level.

Label dispose storage drugs (42 CFR 418.106(e)(1))

“Upon client record review, 1 of 14 (Patient #1) did not have evidence that all drugs and biologicals are labeled in accordance with currently accepted professional practice and include appropriate usage and cautionary instructions, as well as an expiration date, if applicable. Patient #1 had Anti-Diarrheal 2mg oral tablets with instructions of “take 2 tablets initially, then 1 tablet at each stool as needed for diarrhea”. The label did not contain the cautionary instructions of “not to exceed 4 tablets in 24 hours”.”

Rule L0693. 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 deficiencies in §418.56 and §418.104. The concern with the continued noncompliance with standards was reviewed with the organization.”

Rule L0651. Condition-level.

Clinical records (42 CFR 418.104)

Rule L0670. Condition-level.

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

Rule L0505. Standard-level.

Timeframe for completion of assessment (42 CFR 418.54(b))

“Observed in Record Review. On 1 of 2 active patient records reviewed the organization failed to complete initial assessment within the 5 day window of Hospice Election. On RRHV #1, all disciplines went into the home within the required timeframes, however the RN visit notes are blank and it has been 27 days since admission. This finding was reviewed with agency leaders regarding the need to have completed documentation.”

Rule L0523. Standard-level.

Content of comprehensive assessment (42 CFR 418.54(c)(6)(iii))

Rule L0530. Standard-level.

Approach to service delivery (42 CFR 418.56(a)(1)(iv))

“Observed in Record Review. In 1 of 2 active patient records reviewed, the organization failed to provide interdisciplinary, collaborative treatment, or services. During record review for RRHV #1, it was noted in the IDG notes that the chaplain was not involved in the IDG meeting as evidence by no signature of attendance or notes from the chaplain demonstrating that the chaplain was present in the care planning process. This was reviewed with agency leadership.”

Rule L0541. 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))

Rule L0547. Standard-level.

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

“Observed in Record Review. In 1 of 2 active patient records reviewed the Interdisciplinary team did not review the plan of care at least every 15 days. On RRNHV #1, the Interdisciplinary Group had not reviewed the POC every 15 days. Last one was 6/28 was due on 7/12 and today is 7/18. This finding was reviewed with agency leaders.”

Rule L0552. Standard-level.

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

Rule L0555. Standard-level.

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

“Observed in Record Review. In 1 of 1 bereavement records reviewed the bereavement care plans did not include specific, individualized interventions and care to be provided. On review of RRBR #1, the surveyor was unable to review the bereavement records beyond the initial and post death assessment because the MSW has the documentation in a binder that is not at the office. Reviewed with leadership that records of care need to be available and retrievable during the survey process to assess compliance.”

Rule L0596. Standard-level.

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

“Observed in Record Review. In 1 of 2 patient active records reviewed that had aide services ordered, the organization did not conduct a hospice aide supervision every 14 days. During record review of RRNHV #1, there had not been an aide supervision done in the month. This finding was discussed with agency leaders.”

Rule L0629. Standard-level.

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

“Observed in HR File Review. On 1 of 3 HR files reviewed, ongoing competency was not assessed by the organization. On review of HR # 3, it was noted that the MSW did not have a competency assessment done in the last three years. Agency policy is that staff have a competency completed at least every 3 years. The administrator stated it wasn’t done because they don’t have a MSW to do the competency assessment. This finding reviewed with the agency leadership.”

Rule L0663. Standard-level.

Content (42 CFR 418.104(a)(3))

Rule L0674. Standard-level.

Authentication (42 CFR 418.104(b))

Rule L0679. Standard-level.

Initial & comprehensive assessment of patient (42 CFR 418.54)

“Observed in Record Review. In 2 of 3 patient records reviewed, the hospice did not assess and re-assess its patients as required. In record RRHV#1 the RN used the template for a routine visit note for the initial comprehensive assessment. This did not include all components of a comprehensive assessment. And in RRNHV#1 both the RN and MSW initial comprehensive assessment templates were blank. This RFI was reviewed with the Administrator and DPCS.”

Rule L0520. Condition-level.

Approach to service delivery (42 CFR 418.56(a)(1)(iii))

“Observed in Record Review. In 2 of 3 patient records reviewed, the hospice did not consistently provide documentation of an interdisciplinary process. In record RRNHV#1 and RRDC#1 the MSW and Spiritual Coordinator did not sign five of seven notes, thus it was not possible to know if all required core services were present at the meeting. This RFI was reviewed with the Administrator and DPCS.”

Rule L0541. Condition-level.

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

“Observed in Record Review. In 3 of 3 patient records reviewed, the hospice did not develop and individualized plan of care with patient and family goals based on identified problems. No goals were documented in the records reviewed. This RFI was reviewed with the Administrator and DPCS.”

Rule L0545. Condition-level.

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

“Observed in Record Review. In 3 of 3 patient records reviewed, the hospice did not insure that plans of care included measurable outcomes anticipated from implementing and coordinating the plan of care. In every record there no goals documented, thus no outcomes were identified. This RFI was reviewed with the Administrator and DPCS.”

Rule L0548. Condition-level.

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

“Observed in Record Review. In 2 of 3 patient records reviewed, where aide services were ordered the hospice did not ensure that care was documented as having been provided. In record RRNHV#1 three of three aide visit templates were blank. And in record RRDC#1 15 of 21 aide visit templates were blank. This RFI was reviewed with the Administrator and DPCS.”

Rule L0626. Condition-level.

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

“Observed in Record Review. In 3 of 3 patient records reviewed, the hospice did not assess care and services provided by hospice aides. In record RRHV#1 two of two templates were blank. In record RRNHV#1 no assessment was documented in the first 17 days the patient was receiving care. And in record RRDC#1 no assessment was documented for the first five weeks the patient was receiving care. This RFI was reviewed with the Administrator and DPCS.”

Rule L0629. Condition-level.

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

“Observed in Tracer Activities. Leaders did not manage implementation of patient care policies and procedures governing the provision of care as evidenced by condition level findings at §418.54, §418.56, §418.76, and §418.104. This RFI was reviewed with the Administrator and DPCS.”

Rule L0651. Condition-level.

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

Rule L0678. Condition-level.

Authentication (42 CFR 418.104(b))

“Observed in Record Review. In 3 of 3 patient records reviewed, the hospice did not ensure that entries in the clinical record were authenticated. In record RRHV#1 the comprehensive assessments were not signed by the MSW and Spiritual Coordinator. In record RRDC#1 a visit note by the MSW was not signed. And in all three records the RN did not sign the verbal certification section on the CTIs. This RFI was reviewed with the Administrator and DPCS.”

Rule L0679. Condition-level.

Retrieval of clinical records (42 CFR 418.104(f))

“Observed in Record Review. In 2 of 3 patient records reviewed, the hospice did not maintain complete and accurate records. In record RRNHV#1 two RN visit notes were blank. And in RRCD#1 one MSW visit note was blank. This RFI was reviewed with the Administrator and DPCS.”

Rule L0685. Condition-level.

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

“Observed in Record Review. In 1 of 3 patient records reviewed, the hospice did not plan review and revise plans of care every 15 days or less. In the record of RRDC#1 only one comprehensive reassessment was documented in 12 weeks. This RFI was reviewed with the Administrator and DPCS.”

Rule L0533. Standard-level.

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

“Observed in Record Review. In 1 of 1 patient records reviewed, where the patient was discharged, a summary was not documented, and the attending physician was not notified of the availability of that summary. This RFI was reviewed with the Administrator and DPCS.”

Rule L0682. Standard-level.

IDG, care planning, coordination of services (42 CFR 418.56)

“Observed in Record Review. In 3 of 3 patient records reviewed, the Surveyor had been unable to validated the patient plans of care had been updated nor that there had been an IDG to review and discuss the patients as all the IDG meeting notes had been blank. RRNHV #1 had no plan of care established. RRNHV #2 and RRNHV #3 there had been no updates to the poc since the evaluation visit 2 months ago. This was validated with the DPCS and the Administrator.”

Rule L0536. Condition-level.

Approach to service delivery (42 CFR 418.56(a)(1)(iii))

“Observed in Record Review. In 3 of 3 patient records reviewed, the Surveyor noted that all IDG meeting notes had been blank, so the Surveyor had been unable to validate that all members had attended and participated. This was validated with the DPCS and the Administrator.”

Rule L0541. Condition-level.

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

Rule L0545. Condition-level.

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

“Observed in Record Review. In 3 of 3 patient records reviewed, the Surveyor had been unable to validated the patient plans of care had been updated nor that there had been an IDG to review and discuss the patients as all the IDG meeting notes had been blank. The Surveyor had also not been able to validate that an RN had made a comprehensive visit to the patient every 15 days. This was present in all records reviewed. This was validated with the DPCS and the Administrator.”

Rule L0552. Condition-level.

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

“Observed in Record Review. In 2 of 2 patient records reviewed, where the patient had Hospice Aide services (HA) ordered, the Surveyor had been unable to validated that the visits had occurred as ordered nor that care had been provided according to the POC as both records had been missing documentation to support that the visits occurred. . This was validated with the DPCS and the Administrator.”

Rule L0626. Condition-level.

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

“Observed in Record Review. In 3 of 3 patient records reviewed, the Surveyor had been unable to validate any Hospice Aide Supervisory visits. There have not been any supervisory visits documented. They appear to have been scheduled; however they are all blank. Discussion with the DPCS and she reports that they have not implemented any of the changes required to clear the CLD’s. This finding was reviewed with the DPCS and Administrator.”

Rule L0629. Condition-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 deficiencies in §418.102, §418.104, §418.112, §418.56, §418.76. 


”

Rule L0651. Condition-level.

Recertification of the terminal illness (42 CFR 418.102(c))

“Observed in Record Review. In 1 of 1 patient records reviewed, where the patient had been recertified for ongoing hospice care, the Medical Director failed to review the clinical information and sign the CTI prior to recertification. The CTI for the current episode of care is blank and unsigned. The surveyor had been unable to validate that the patient had been discussed with the physician as there had been no IDG to review. This was validated with the DPCS and the Administrator.”

Rule L0668. Condition-level.

Content (42 CFR 418.104(a)(3))

Rule L0674. Condition-level.

Authentication (42 CFR 418.104(b))

“Observed in Record Review. In 3 of 3 patient records reviewed, The Surveyor had been unable to validate that the patient care documentation had not been authenticated in accordance with state law, as all the patient clinical notes had been blank, including all IDG’s. . This was validated with the DPCS and the Administrator.”

Rule L0679. Condition-level.

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

Rule L0682. Condition-level.

Retrieval of clinical records (42 CFR 418.104(f))

“Observed in Record Review. In 3 of 3 patient records reviewed, the Surveyor had unable to validate that the care ordered was provided as all patient visit notes had been blank. This was validated with the DPCS and the Administrator.”

Rule L0685. Condition-level.

Hospice plan of care (42 CFR 418.112(d))

“Observed in Record Review. In 3 of 3 patient records reviewed, the Surveyor had been unable to validated that the patient had an active plan of care and that visits had been made per the plan of care as no visits had been documented. Visits dates had been present; however, all had been blank. No interventions implemented to bring CLD’s into compliance. This was validated with the DPCS and the Administrator.”

Rule L0773. Condition-level.