Hospice of Nation, Inc.

Content of comprehensive assessment (42 CFR 418.54(c)(6)(i))

Rule L0530. Standard-level.

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

“Observed in Record Review. In 1 of 12 patient records reviewed, the hospice did not conduct and document a patient-specific comprehensive assessment and reassessment that identified the patient’s need for hospice care and services. In RRNHV#6, the Initial Bereavement Assessment not completed/documented. This was reviewed and verified with the Administrator and LVN. 
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Rule L0531. Standard-level.

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

“Observed in Regulatory Review. In 1 of 10 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including interventions to manage pain and symptoms. In RRHV#2 and RRNHV#6, the order for the prn oxygen the patient was using was not included/documented in the hospice plan of care. This was reveiwed and verified with the LVN and Administrator.”

Rule L0546. Standard-level.

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

“Observed in Record Review. In 1 of 10 patient records reviewed, the organization did not plan the patient’s care in ensuring the interdisciplinary group (IDG) in collaboration with the patient’s attending physician reviewed and revised the plan of care as frequently as the patient’s condition required, and at least every 15 days. In RRNHV#7, the most recent documented IDG note was over one (1) month prior to the patient’s revocation and hospitalization. This was reviewed and verified with the Administrator and LVN.”

Rule L0552. Standard-level.

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

“Observed in Record Review. In 1 of 10 patient records reviewed, the organization did not provide care, treatment, or services for the patient according to the individualized plan of care. In RRNHV#1, the patient’s plan of care included weekly hospice aide visits. Although the Aide Assignment was completed by the RN, there was no documentation of any hospice aide visits completed or explanation why the aide services were not provided. This was reviewed with the Administrator and LVN.”

Rule L0555. Standard-level.

Prevention (42 CFR 418.60(a))

“Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not implement the infection prevention and control activities it had planned, including standard precautions. In RRHV#3, after performing hand hygiene in the home, the LVN placed the wet paper towel used for drying hands in the scrubs side pocket. This practice was not in compliance with CDC hand hygiene guidelines/organization policy. This was reviewed and verified with the Administrator and LVN.”

Rule L0579. Standard-level.

Recertification of the terminal illness (42 CFR 418.102(c))

“Observed in Record Review. In 1 of 10 patient records reviewed, the Medical Director/Physician did not review the patient’s clinical information prior to recertification. In RRHV#3, the recertification CTI entry in the hospice record was initiated and signed by the Medical Director, but was incomplete and did not include review of the patient’s clinical information. This was reviewed and verified by the Administrator and LVN.”

Rule L0668. Standard-level.

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

“Observed in Record Review. the patient record did not contain information that reflected the patient’s care, treatment, or services. In RRHV#1, RRHV#2, RRHV#3, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#5, RRNHV#6, and RRNHV#7, the registered nurse’s update to the comprehensive assessment and plan of care was not documented for several IDG meetings per organization policy. The section of the IDG Note for the RN’s updated assessment was blank. This was reveiwed and verified with the Administrator and LVN.”

Rule L0674. Standard-level.

Authentication (42 CFR 418.104(b))

Rule L0679. 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, the organization did not provide a written discharge summary to the patient’s physician or other provider in accordance with law and regulation. In RRDC#2, the patient’s attending physician/provider was not informed of the availability of a discharge summary available to be provided upon request. There was no completed/documented discharge summary in the hospice record. This was reviewed and verified with the Administrator and LVN.”

Rule L0682. Standard-level.

Label dispose storage drugs (42 CFR 418.106(e)(2)(ii))

Rule L0698. Standard-level.

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

“Observed in Patient Home. In 2 of 3 home visits conducted, the organization did not provide patient education and training based on each patient’s condition, needs, and abilities, including procedures to follow if care, treatment, or services were disrupted by a natural disaster or an emergency. In RRHV#1 and RRHV#2, there was no individualized emergency plan developed and reviewed with the patient and family and placed in the home per the organization’s process/policy. This was reveiwed and verified with the Administrator/Director of Patient Care Services-Designee.”

Rule L0702. Standard-level.

N/a (42 CFR 418.110(k))

“Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not implement its infection prevention and control activities to minimize, reduce, or eliminate the risk of infection. In RRHV#3, the LVN placed and transported care equipment (temporal thermometer, BP monitor...) in an open fabric tote bag. The bag had one (1) general open compartment for all items, with no designated closed section for clean equipment/supplies. This was not in compliance with the organization’s Bag Technique Policy and Procedure. This was reveiwed with the Administrator and LVN.”

Rule L0834. Standard-level.