Blessed Hope Hospice, Inc.

Content of plan of care (42 CFR 418.56(c)(1))

“Observed in Record Review. In 2 of 4 patient records reviewed, During #3 and #4 it was noted although the MSW documented a frequency of visits and identified goals, the POCs lacked interventions to accomplish the goals. This was discussed with Leadership.”

Rule L0546. Standard-level.

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

“Observed in Record Review. In 1 of 2 patient records reviewed, who were discharged alive from hospice. During Live D/C-RR#2 it was noted the patient representative signed and dated a Notice of Non Medicare Coverage (NOMNC) prior to the patient discharge. The date the serivce would end was blank on the form. This was discussed with the organization leadership.”

Rule L0505. Standard-level.

Content of plan of care (42 CFR 418.56(c)(1))

Rule L0546. 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)(2))

“Observed in Record Review. In 1 of 14 patient records reviewed, During Live D/C-RR#1 it was noted an order for a paracentesis weekly performed via a pluerix catheter. There was documentation of one paracentesis performed during the patients hospice admission that spanned more than two weeks. This was discussed with the organization leadership.”

Rule L0555. Standard-level.

Program scope (42 CFR 418.58(a)(1))

“Observed in Data Session. During review of the QAPI program it was noted since the organization did not analyze data collected on palliative outcomes and hospice services, the organization could not demonstrate improved outcomes. This as discussed with the organization leadership.”

Rule L0561. Standard-level.

Program data (42 CFR 418.58(b)(1))

“Observed in Data Session. During review of the QAPI program it was noted lack of quality indicators reported at quarterly QAPI meetings. For example patient/family perception of care, patient complaints, results of patient record review were not included in QAPI meetings reviewed for 2022-2024. This was discussed with the organization leadership.”

Rule L0563. Standard-level.

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

“Observed in Data Session. During reivew of the organization QAPI program it was noted, although, data was collected and reported at QAPI meetings, there was lack of documentation of data analysis and therefore the organization was not able to monitor the effectiveness and safety of services and the quality of care. This was discussed with the organization leadership.”

Rule L0564. Standard-level.

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

“Observed in Data Session. During review of the QAPI program with the Administrator and DPCS designee it was noted although data was collected and reported at QAPI meetings there was lack of documentation of an analysis of the data.”

Rule L0564. Standard-level.

Performance improvement projects (42 CFR 418.58(d)(2))

“Observed in Data Session. During reivew of the QAPI program with the Administrator and DPCS designee it was noted there were performance improvement projects for 2022-2024 that were being conducted, however, progress was not documented or reported at QAPI meetings.”

Rule L0573. Standard-level.

Prevention (42 CFR 418.60(a))

“Observed in Patient Home. In 1 of 3 home visits conducted, During HV#2 it was noted the SN used his clean hand to turn off the faucet and then used the patient’s cloth towel to dry his hands. This was discussed with the organization leadership.”

Rule L0579. Standard-level.

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

Rule L0625. Standard-level.

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

“Observed in Record Review. In 1 of 10 patient records reviewed, who were receiving aide services. During review of HR#2 record review it was noted the aide assignment form was blank. The aide notified the RN to ask the type of bath to provide to the patient however the aide did not notify the RN that the instruction form was blank. This was discussed with the DPCS designee.”

Rule L0626. Standard-level.

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

“Observed in Record Review. In 1 of 10 patient records reviewed, who were receiving aide visits. During HV#2 record review it was noted lack of documentation that the hospice aide was supervised no less frequently than every 14 days. There was one supervisory visit documented in 2 months. The hospice aide was visiting the patient without a completed RN assignment from. This was discussed with the organization leadership.”

Rule L0629. Standard-level.

Professional management responsibility (42 CFR 418.100(e)(1))

Rule L0655. Standard-level.

Professional management responsibility (42 CFR 418.100(e)(3))

“Observed in Document Review. During review of the contract for therapy services (PT, OT, ST) it was noted lack of a stipulation that services will be delivered in accordance with the patient’s plan of care. This was discussed with the organization leadership.”

Rule L0655. Standard-level.

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

“Observed in Record Review. In 2 of 14 patient records reviewed, During RR#2 it was noted during the IDG meeting, the MSW summary included findings from the initial visit and the need for visits 1x/month however, the frequency of visits on the POC stated the MSW was refused. During RR#4 it was noted on an IDG summary that an MSW visit had been conducted. There was lack of the MSW visit note in the EMR for the date stated. This was discussed with the organization leadership.”

Rule L0685. Standard-level.

Use and mintenance of equipment and supplies (42 CFR 418.106(f)(2))

“Observed in Record Review. In 1 of 14 patient records reviewed, During HV#2 record review it was noted lack of education provided on an individualized disaster/emergency plan. This was discussed with the organization leadership.
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Rule L0702. Standard-level.