Wellcare Specialist Hospice Incorporated

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

“Observed in Data Tracer. On review of the agency’s QAPI plan it was noted that the organization did not identify the frequency of the data collection for any of their goals and as a result the frequency had not been approved by the governing body. Reviewed and discussed this with agency leaders and how to correct this element.”

Rule L0565. Standard-level.

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

“Observed in Record Review. In 1 of 3 patient records reviewed the organization did not have a bereavement plan of care. On review of RRNHV #3, it was noted that the organization had done a risk assessment on admission but had not initial bereavement care plan. This was reviewed and discussed with agency leadership.”

Rule L0596. Standard-level.

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

“Observed in Tracer Activities. Leaders did not review, approve, and manage the implementation of policies and procedures to guide and support patient care, treatment or services as evidenced by condition level findings at 418.56 for significant issues with the plan of care and care planning/coordination and 418.58 related to the effective quality assessment and performance improvement of hospice care/services. This was reviewed and verified with the Administrator-Designee.”

Rule L0651. Condition-level.

Initial & comprehensive assessment of patient (42 CFR 418.54)

Rule L0520. Standard-level.

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

“Observed in Record Review. In 1 of 10 patient records reviewed, the organization did not ensure the patient record was complete, promptly/accurately documented, readily accessible, and systematically organized to facilitate retrieval. In RRHV#1, the note of a visit completed by the Spiritual Care Counselor 29 days prior was not included/documented in the patient’s hospice record. This was reviewed and verified with the RN Care Manager.”

Rule L0535. Standard-level.

Content of plan of care (42 CFR 418.56(c)(2))

Rule L0547. 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 ))

Rule L0552. Standard-level.

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

Rule L0555. Standard-level.

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

“Observed in Data Session. Leaders did not establish priorities for performance improvement by ensuring the quality assessment and performance improvement (QAPI) program demonstrated improvement related to improved palliative outcomes and hospice services. During the Data Session it was noted the organization’s QAPI program included a measure and goal for pain management, but no data was compiled, trended, and evaluated by leaders for improvement. This was reviewed and confirmed with the Administrator-Designee.”

Rule L0561. Standard-level.

Program data (42 CFR 418.58(b)(2)(i))

“Observed in Data Session. The organization did not compile and analyze data. During the data session, it was noted the hospice had collected data that focused specifically on palliative outcomes for pain management, but the data was not used by the organization to determine if effectiveness and safety was achieved. This was reveiwed and verified with the Administrator-Designee.”

Rule L0564. Standard-level.

Performance improvement projects (42 CFR 418.58(d)(1))

“Observed in Data Session. The organization did not improve performance by ensuring the number and scope of annual performance improvement projects were based on the patient/organization needs and reflect the scope, complexity, and past performance of the organization’s services and operations. During the Data Session is was noted the organization had no documented Performance Improvement Projects for the past 3 years. This was reveiwed and confirmed with the Administrator-Designee.”

Rule L0572. Standard-level.

Performance improvement projects (42 CFR 418.58(d)(2))

“Observed in Data Session. The organization did not document what performance improvement projects were being conducted, the reason for the projects, and the measurable progress achieved on them. During the data session, it was noted there was no documentation of the organization’s performance improvement projects and measurable progress achieved. This was reveiwed and verified with the Administrator-Designee.”

Rule L0573. 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 information regarding hospice care, treatment, and services to other providers upon the patient’s discharge. In RRDC#2, at the patient’s revocation and discharge from hospice and transfer to the hospital, the organization did not provide the receiving facility/provider a copy of the hospice discharge summary. This was reviewed and verified with the RN Care Manager.”

Rule L0682. Standard-level.

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

“Observed in Patient Home. In 3 of 3 home visits conducted, the organization did not provide patient education and training based on each patient’s needs and abilities, including procedures to follow if care, treatment, or services are disrupted by a natural disaster or emergency. In RRHV#1, RRHV#2, and RRHV#3, the patient’s individual emergency plan was documented in the hospice record, but the plan was not provided to the patient/family in the home. This was reveiwed and verified with the RN Care Manager.”

Rule L0702. Standard-level.