Holly Trinity Hospice, Inc.

Organizational environment (42 CFR 418.100)

“Condition of Participation: Organization and administration of services. The hospice must organize, manage, and administer its resources to provide the hospice care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness and related conditions.”

Rule L0648. Condition-level.

Notice of rights and responsibilities (42 CFR 418.52(a)(1))

“Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient’s Rights and Responsibilities in a language and manner that the patient understands. Patient #11: Admission forms, including consent and hospice election are signed by patient with documented confusion and secondary diagnosis of dementia. Family was present during admission process, but only patient signed forms.”

Rule L0502. Standard-level.

Notice of rights and responsibilities (42 CFR 418.52(a)(2))

“Upon patient record review, 1 of 14 (Patient #11) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient #11: Admission forms, including consent and hospice election are signed by patient with documented confusion and secondary diagnosis of dementia. Family was present during admission process, but only patient signed forms.”

Rule L0503. Standard-level.

Notice of rights and responsibilities (42 CFR 418.52(a)(3))

“Upon patient record review, 1 of 14 (Patient #11) did not have evidence that the hospice obtained the patient’s or representative’s signature confirming that they received a copy of the Patient’s Rights and Responsibilities. Patient #11: Admission forms, including consent and hospice election are signed by patient with documented confusion and secondary diagnosis of dementia. Family was present during admission process, but only patient signed forms.”

Rule L0504. Standard-level.

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

“Upon observation, there was no evidence the patient has the right to voice grievances/complaints regarding treatment or care that is (or fails to be) furnished and lack of respect of property by anyone who is furnishing care/service on behalf of the hospice. Patient #11: Admission forms, including consent and hospice election are signed by patient with documented confusion and secondary diagnosis of dementia. Family was present during admission process, but only patient signed forms.”

Rule L0505. Standard-level.

Exercise of rights/respect for proprty/person (42 CFR 418.52(b)(3))

“Upon patient record review, 1 of 14 (Patient #11) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient’s rights to the extent allowed by state law. Patient #11: Admission forms, including consent and hospice election are signed by patient with documented confusion and secondary diagnosis of dementia. Family was present during admission process, but only patient signed forms.”

Rule L0507. Standard-level.

Rights of the patient (42 CFR 418.52(c)(2))

“Upon client record review, 1 of 14 (Patient #11) did not have evidence that the plan of care included IDG’s documentation of the patient’s or families level of understanding, involvement and agreement with the plan of care. Patient #11: Admission forms, including consent and hospice election are signed by patient with documented confusion and secondary diagnosis of dementia. Family was present during admission process, but only patient signed forms.”

Rule L0513. Standard-level.

Rights of the patient (42 CFR 418.52(c)(4))

“Upon patient record review, 1of 14 (Patient #11) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #11: Admission forms, including consent and hospice election are signed by patient with documented confusion and secondary diagnosis of dementia. Family was present during admission process, but only patient signed forms.”

Rule L0515. Standard-level.

Rights of the patient (42 CFR 418.52(c)(5))

“Upon patient record review, 1 of 14 (Patient #11) did not have evidence of the appropriate documentation for release of confidential information. Patient #11: Admission forms, including consent and hospice election are signed by patient with documented confusion and secondary diagnosis of dementia. Family was present during admission process, but only patient signed forms.”

Rule L0516. Standard-level.

Rights of the patient (42 CFR 418.52(c)(7))

“Upon patient record review, 1 of 14 (Patient #11) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #11: Admission forms, including consent and hospice election are signed by patient with documented confusion and secondary diagnosis of dementia. Family was present during admission process, but only patient signed forms.”

Rule L0518. Standard-level.

Rights of the patient (42 CFR 418.52(c)(8))

“Upon patient record review, 1 of 14 (Patient #11) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient #11: Admission forms, including consent and hospice election are signed by patient with documented confusion and secondary diagnosis of dementia. Family was present during admission process, but only patient signed forms.”

Rule L0519. Standard-level.

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

Rule L0545. Standard-level.

Prevention (42 CFR 418.60(a))

Rule L0579. Standard-level.

Core services (42 CFR 418.64)

Rule L0587. Standard-level.

Competency evaluation (42 CFR 418.76(c))

Rule L0615. Standard-level.

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

Rule L0625. Standard-level.

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

Rule L0651. Standard-level.

Medical director contract (42 CFR 418.102(a))

“Upon contract review, 2 of 4 (Dr. Soffwer and Dr Pines contracts) did not have evidence of a contract to fulfill the role of medical director or alternate medical director, if applicable. Both contracts presented as Medical Director. Dr. Soffwer is reported to be Medical Director and Dr. Pines is alternate.”

Rule L0666. Standard-level.

Content (42 CFR 418.104(a)(2))

“Upon patient client record review, 1 of 14 (Patient #11) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #11: Admission forms, including consent and hospice election are signed by patient with documented confusion and secondary diagnosis of dementia. Family was present during admission process, but only patient signed forms.”

Rule L0673. Standard-level.

Content (42 CFR 418.104(a)(6))

“Upon patient client record review, 1 of 14 (Patient #9) did not have evidence that each patient record contains Advance Directives. Patient #9: Patient SOC 7/14/23. Record identifies patient code status as Attempt CPR/Full Code in demographic information. MSW most recent assessment 9/5/24 identifies patient as full code. However, there is a POLST form dated 7/14/23, with option chosen as do not attempt CPR. There is no documented evidence of update at time of record review.”

Rule L0677. Standard-level.

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

“Upon client record review, 3 of 14 (Patient #10, 11, 12) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient’s attending physician: • A copy of the hospice discharge summary • The patient’s clinical record, if requested Patients #10, 11, 12: There is no documented evidence that patients’ discharge summary was forwarded to attending physician following revocation.”

Rule L0683. Standard-level.

Discharge or transfer of care (42 CFR 418.104(e)(3))

“Upon client record review, 4 of 14 (Patient #9, 10, 11, 12) did not have evidence that the discharge summary includes all required information. Patient 9, 10, 11, 12: Discharge Summary does not include a summary of the patient’s stay, current plan of care, orders”

Rule L0684. Standard-level.

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

“Upon client record review, 1 of 14 (Patient #11) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #11: Admission forms, including consent and hospice election are signed by patient with documented confusion and secondary diagnosis of dementia. Family was present during admission process, but only patient signed forms.”

Rule L0697. Standard-level.

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

“Upon personnel record review, 3 of 14 (Personnel #12, 13, 14 ) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel #12, 13, 14: No criminal background check prior to end of survey. (PT/OT/SLP)”

Rule L0795. Standard-level.