Intra Care Hospice Inc.

Medical director (42 CFR 418.102)

“Observed in HR File Review. During the HR session, surveyor noted that the organization failed to ensure that when the medical director was not available, a physician designated by the hospice assumes the same responsibilities as the medical director. The organization did not have a backup medical director under contract or directly employed by the organization. This was reviewed with the Director of Patient Care Services Designee.”

Rule L0664. Condition-level.

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

Rule L0545. Standard-level.

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

“Observed in Patient Home. In 3 of 3 home visits, surveyor noted that the organization failed to provide the patient with care, treatment, or services according to the patient’s individualized plan of care. For example, In HOSHV#1, HOSHV#2, and HOSHV#3, the nurse did not perform a skin assessment, to be performed each nursing visit per the organization’s policy, increasing the risk for skin breakdown on patient’s with compromised skin integrity related to disease processes and impaired mobility. This was reviewed with the Director of Patient Care Services.”

Rule L0555. Standard-level.

Competency evaluation (42 CFR 418.76(c)(5))

“Observed in HR File Review. During the HR session, surveyor noted in 6 of 12 records reviewed, that the organization failed to ensure staff are competent to perform their responsibilities. For example, in HR#4 (Administrator), HR#5 (LVN), HR#6 DPCS-Designee), HR#8 Chaplain), HR#10 (SW), HR#12 (Medical Director) had not had a competency assessment documented annually per the organization’s policy. This was reviewed with the Director of Patient Care Services Designee.”

Rule L0619. Standard-level.

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

“Observed in Record Review. in 1 of 10 records reviewed, surveyor noted that the organization failed to ensure that a registered made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered meet the patient’s needs. For example, in HOSRRHV#1, the surveyor noted that the registered nurse went 28 days without performing an on-site aide supervisory visit. This was reviewed with the Director of Patient Care Services.”

Rule L0629. Standard-level.

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

“Observed in HR File Review. During the HR session, the surveyor noted in 1 of 12 records reviewed, that the organization failed to ensure staff were competent to perform their responsibilities. For example In HR#9, the Volunteer Coordinator’s initial competency assessment was not documented per the organization’s policy. This was reviewed with the Director of Patient Care Services Designee.”

Rule L0663. Standard-level.

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

“Observed in Record Review. In 5 of 10 records reviewed, surveyor noted that the organization failed to ensure that patients’ records contained information that reflects the patient’s care, treatment, or services per the organization’s policy. For example, in HOSRRHV#1, HOSRRHV#2, HOSRRHV#3, HOSRRNHV#1, and HOSRRNHV#5 the social worker entered a narrative statement indicating that a visit was made, however, the social worker did not complete the comprehensive assessment documentation; the assessment form for each patient was blank. This was reviewed with the Director of Patient Care Services.”

Rule L0674. Standard-level.

Inpatient care provided under arrangements (42 CFR 418.108(c)(6))

“Observed in Document Review. During the review of contracted service agreements, surveyor noted that the organization failed to evaluate contracted services as defined in their policy. There was no documentation present to validate that contracted services are being evaluated to ensure services are being provided safely and effectively. This was reviewed with the Director of Patient Care Services Designee.”

Rule L0716. Standard-level.

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

“Observed in Tracer Activities. During the review of contracted service agreements, surveyor noted that the organization failed to include 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 reviewed with the Director of Patient Care Services.”

Rule L0771. Standard-level.