Hospice Providers of the Desert, Inc.

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

“Observed in Record Review. In 1 of 1 live discharge records reviewed, the patient discharged from service without the completion of a Notice of Medicare Non Coverage (NOMNC) completed prior to discharging patient from service. On review of RRDC #1, the agency did not have record that the NOMNC was completed prior to discharging the patient due to no longer qualifying for Hospice. This finding was reviewed with the Administrator.”

Rule L0505. Standard-level.

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

“Observed in Record Review. In 1 of 2 active patient records review, the interdisciplinary group (IDG) had not updated the comprehensive assessment no less frequently than every 15 days. On review of RRNHV #1, it was noted the Spiritual Counselor for the last 2 months has not documented any input on the IDG but has made 2 visits to the patient during that timeframe. This was discussed with the Administrator.”

Rule L0533. Standard-level.

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

“Observed in Record Review. On 2 of 2 patient records review, goals were not measurable and specific to the patients needs. On review of RRNHV #1, goals were not measurable and specific with examples of minimize episode, no injury for anxiety and disorientation and alleviate frustration due to difficulty remembering specially recent past. On review of RRNHV #2, the goals were not measurable and specific with examples of Increased strength to his fullest and Will maintain comfort for a problem with pain. This was discussed with the Administrator.”

Rule L0545. Standard-level.

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

“Observed in Record Review. In 1 of 2 active patient records reviewed, care was not provided according to the plan of care. On RRNHV #1 it was noted that the orders were for aide visits 2 times per week the order started at the beginning of service and it took a month before the first documented aide visit occurred. There was one communication note of a cancelled aide visit during that time but that only covered 1 visit day. This finding was reviewed with the administrator.”

Rule L0555. Standard-level.

Program data (42 CFR 418.58(b)(3))

“Observed in Data Session. During review of the organization’s quality program, the governing body had not approved the frequency and detail of the data collection associated to QAPI measures for 2024. The governing body had met but the frequency of the collection was not approved by the governing board for 2024. This was reviewed and validated with the administrator.”

Rule L0565. Standard-level.

Control (42 CFR 418.60(b)(2)(ii))

“Observed in Infection Control System Tracer. On review of the organizations infection control plan, the hospice organization failed to establish hand hygiene goals that were measurable and only noted it would limit the spread of infection with a strategy of maintaining hand hygiene compliance. This finding was reviewed with the administrator.”

Rule L0581. Standard-level.

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

Rule L0596. Standard-level.

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

“Observed in Record Review. In 1 of 1 patient records reviewed with aide services order, the registered nurse had not supervised the aide at least every 14 days. On review of RRNHV #1, it was noted that the last sup visit on the patient was 19 days ago. This finding was reviewed with the administrator.”

Rule L0629. Standard-level.

Clinical records (42 CFR 418.104)

“Observed in Record Review. In 2 of 2 active patient record reviews, documentation in the patient record is not entered timely. Agency policy 5-006.2 is that documentation is entered on day care is provided and turned in at the end of the workday. In RRNHV #1 the aide documentation has not been completed for the last 19 days of visits. On review of RRNHV #2, it was noted that the RN note from one week ago has not been signed by the RN. This was reviewed with the administrator. 
”

Rule L0670. Standard-level.

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

“Observed in Record Review. In 1 of 1 discharged patient records reviewed where patient discharged from service, a discharge summary for care and treatment was not sent to the provider or a notification given that it was available. In RRDC #1, the discharge summary indicated the patient was discharged for an extended prognosis and the discharge summary was written but it was not sent to physician and notification of it’s availability was not completed. This was reviewed and validated with Administrator. 
”

Rule L0682. Standard-level.

Quality assessment & performance improvement (42 CFR 418.58)

“Observed in Data Session. The organization’s governing body had not ensured the quality assessment and performance improvement program (QAPI) meets the required criteria. The organization’s QAPI program failed to include services provided under contract. Additionally, though some data was collected by the DPCS on bereavement and volunteer services, these activities were not included in the organization’s QAPI plan. This was discussed with the DPCS and Administrator.”

Rule L0559. Condition-level.

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

“Observed in Record Review. In 3 of 3 patient records reviewed, the hospice had not developed a bereavement plan of care that specified the type of bereavement services to be offered and the frequency of service delivery. There was no bereavement POC in the charts for RRBR#1, RRBR#2 nor RRBR#3. There was documentation that bereavement mailings had occurred, however no planned type nor frequency of bereavement services were found as confirmed with the Administrator and DPCS.
”

Rule L0596. 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 observations at 418.54, 418.58, 418.64, 418.100 and 418.102. This was discussed with the DPCS and Administrator.”

Rule L0651. Condition-level.

Medical director (42 CFR 418.102)

“Observed in Tracer Activities. There was no backup medical director under contract or directly employed by the organization as confirmed with the Administrator.”

Rule L0664. Condition-level.

EP Program Patient Population (42 CFR 418.113(a)(3))

“Observed in Emergency Management Session. The organization’s continuity of operations plan did not identify in writing how and where it will continue to provide its essential business functions when the location of the essential or critical service has been compromised due to an emergency or disaster incident. This was discussed with the Administrator and DPCS.”

Rule E0007. Standard-level.

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

Rule L0531. Standard-level.

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

Rule L0533. Standard-level.

Patient outcome measures (42 CFR 418.54(e)(2))

“Observed in Record Review. In 1 of 14 patient records reviewed, the patient record was not accurately documented. In the chart for RRNHV#5, the spiritual care update in the IDT contained the exact same verbiage for the past 5 meetings, despite the patient having been seen twice during that time by the spiritual care counselor. This was discussed with the DPCS and Administrator.”

Rule L0535. 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)(4))

Rule L0549. Standard-level.

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

“Observed in Record Review. In 1 of 14 patient records reviewed, the plan of care was not revised based on information from updates to the patient’s comprehensive assessment. In the chart for RRNHV#5, the RN documented that based upon a conversation with the aide and the facility staff, aide visits would be discontinued. The hospice plan of care was not updated to remove the aide services. This was discussed with the DPCS and Administrator.”

Rule L0553. Standard-level.

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

“Observed in Data Session. The quality assessment and performance improvement program did not demonstrate improvement in indicators related to improved palliative outcomes and hospice services. As the organization had not identified any palliative outcomes for improvement activities, they were not able to demonstrate improvement. This was discussed with the DPCS and Administrator.”

Rule L0561. Standard-level.

Program activities (42 CFR 418.58(c)(1)(iii))

“Observed in Data Session. The hospice had not selected performance improvement activities that affect palliative outcomes, patient safety, and the quality of care. The only documented performance improvement projects for the past two years were staff compliance with CMS’ COVID vaccination requirement. This was confirmed with the Administrator and DPCS.”

Rule L0568. Standard-level.

Control (42 CFR 418.60(b)(2)(ii))

Rule L0581. Standard-level.

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

“Observed in Record Review. In 1 of 14 patient records reviewed, the registered nurse had not supervised the aide during an on-site visit no less frequently than every 14 days. In the chart for RRHV#3, 43 days lapsed between documented aide supervisory visits in the past two months. This was discussed with the DPCS.”

Rule L0629. Standard-level.

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

“Observed in Record Review. In 1 of 14 patient records reviewed, the organization did not educate the patient about the safety risks of smoking with oxygen therapy. In the chart for RRNHV#5, there were multiple RN notes documenting that the patient continued to smoke, even though oxygen was ordered and used prn. There was no documentation that the patient was educated about the risks of smoking with oxygen. This was discussed with the Administrator and DPCS.”

Rule L0674. Standard-level.

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

“Observed in Record Review. In 1 of 3 patient records reviewed, of patient’s discharged alive, the discharge summary did not include the required elements. In the chart for RRDC#1, there was no discharge summary for the patient as confirmed with the DPCS.”

Rule L0684. Standard-level.