Passion and Love Hospice Inc.

Content of comprehensive assessment (42 CFR 418.54(c)(7))

“Observed in Record Review. In 1 of 2 patient records reviewed, that were admissions it was noted in record RRNHV#2 that there was no initial bereavement assessment documented. This was confirmed with the RN QAPI Coordinator present”

Rule L0531. Standard-level.

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

“Observed in Record Review. In 1 of 1 patient records reviewed, for bereavement serivces. During BRRR#1 it was noted the organization did not follow their policy, Bereavement Services # 2-010 that after a death occurs the bereavement assessment will be updated and the family/caregiver needs will be discussed at the next IDG meeting. There was lack of documentation that the post death bereavement assessment and proposed bereavement POC was discussed at an IDG after the patient expired. This was discussed with the RN/QAPI Coordinator present.”

Rule L0552. Standard-level.

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

Rule L0555. Standard-level.

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

“Observed in Record Review. In 6 of 10 patient records reviewed, During HV#1, HV#3, RR#1, #2, and #3 it was noted the choice of physician on the consent was blank. During RR#6 it was noted the notification of non covered serivces was signed however the form was blank. This was discussed with the DPCS.”

Rule L0505. Standard-level.

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

“Observed in Record Review. In 1 of 10 patient records reviewed, During RR#1 it was noted the goals were not individualized as follows: Patient will manifest blood pressure and pulses within acceptable limits throughout the episode of care. Patient will achieve and maintain blood glucose levels within acceptable range throughout the episode of care. Pain will remain in comfortable level during care with current intervention throughout the episode of care. This was discussed with the organization leadership.
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Rule L0545. 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))

“Observed in Record Review. In 2 of 10 patient records reviewed, During HV#1 record review it was noted the patients was prescribed Plavix 75 mg every Monday, Wednesday and Friday. During RR#5 it was noted the patient was prescribed Plavix 75 mg daily. The POCs lacked instruction to the patient and PCG on s/s bleeding and bleeding precautions. This was discussed with the organization leadership.”

Rule L0549. Standard-level.

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

“Observed in Record Review. In 10 of 10 patient records reviewed, During RR#1-7 and HV#1-3, it was noted the same order was not individualized for the use of oxygen therapy as needed. The order for oxygen 2-4L/min, titrate to comfort lacked the clinical parameters for liter flow choice. This was discussed with the organization leadership.”

Rule L0550. 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 serivces. During BRRR#1 and #2 it was noted the organization did not follow their policy, Bereavement Services # 2-010 that after a death occurs the bereavement assessment will be updated and the family/caregiver needs will be discussed at the next IDG meeting. There was lack of documentation that the post death bereavement assessment and proposed bereavement POC was discussed at an IDG after the patient expired. This was discussed with the organization leadership.”

Rule L0552. Standard-level.

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

“Observed in Record Review. In 1 of 10 patient records reviewed, During HV#3 record review it was noted a frequency for the spiritual counselor for visits once a month. There was lack of documentation of a visit in October 2024 without documentation of the reason the visit was missed. This was reviewed with the organization leadership.”

Rule L0555. Standard-level.

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

“Observed in Record Review. In 1 of 10 patient records reviewed, During RR#1 it was noted an order for the aide to take vital signs every visit without parameters of when to notify the RN. This was discussed with the organization leadership.”

Rule L0625. Standard-level.

Level of activity (42 CFR 418.78(e))

“Observed in Document Review. During reivew of the volunteer program it was noted the volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff for Quarter 1-3, 2024. this was discussed with the organization leadership.
”

Rule L0647. Standard-level.

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

“Observed in Document Review. In 2 of 4 contracts reviewed, During review of the therapy contract and pharmacy contract it was noted the contract did not include how the organization would coordinate, supervise and evaluate their contracted services. This was discussed with the organization leadership.

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Rule L0655. 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 reivew of Live D/CRR#2, there was lack of documentation that the organization provided the hospital where the patient was admitted with a copy of the hospice discharge summary and, if requested, a copy of the patient’s clinical record. This was discussed with the organization leadership.”

Rule L0682. Standard-level.

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

“Observed in Record Review. In 1 of 2 patient records reviewed, who were discharge alive. During Live D/C RR#1, there was lack of documentation that the organization provided the patient’s attending physician with a copy of the hospice discharge summary and, if requested, a copy of the patient’s clinical record. This was discussed with the organization leadership.
”

Rule L0683. Standard-level.

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

Rule L0685. Standard-level.

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

“Observed in Document Review. During review of the admission information packet in the office and in the homes during HVs, it was noted information was not found in admission packets, patient handbooks or documents provided to patient and family with a copy of the organization policy on the disposal of controlled medications. This was discussed with the organization leadership.”

Rule L0695. Standard-level.

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

“Observed in Document Review. During review of the SNF contract is 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 organization leadership.”

Rule L0771. Standard-level.

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

“Observed in Document Review. In 2 of 4 contracts reviewed, The therapy contract and the DME contract lacked the provision that the contracting 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 organization leadership.”

Rule L0795. Standard-level.