Heart of Angel Hospice & Palliative Inc.

IDG, care planning, coordination of services (42 CFR 418.56)

“Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536”

Rule L0536. Condition-level.

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

“Upon patient record review, 1 of 11 (Patient 1) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 1: The EOB does not contain evidence that the patient chose a health care provider including attending physician.”

Rule L0515. Standard-level.

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

Rule L0524. Standard-level.

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

“Upon patient record review, 1 of 11 (Patient 1) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: Patient 1: The POC contains an order for Tylenol Q8 hours prn, the medication profile has Tylenol Q4 hours prn. Corrected on site.”

Rule L0530. Standard-level.

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

“Upon patient record review, 3 of 11 (Patient #9,10,11) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the Patients 9,10,11: The medical records of these patients do not include a bereavement assessments being completed upon admission.”

Rule L0531. Standard-level.

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

“Upon patient record review, 3 of 11 (Patient 9,10,11) did not have evidence in the patient record that the comprehensive assessment is updated including and by: Patients 9,10,11: The medical records do not contain: Changes that have taken place since the initial assessment, Information on the patient’s progress toward desired outcomes, Reassessment of the patient’s response to care, The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days.”

Rule L0533. 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))

“Upon patient record review, 1 of 11 (Patient #4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatment. Patient 4: The POC 1/28/23 contains a Foley order with no size and the order is written to “irrigate 1-2” no frequency. The pt has a G tube and there are no orders for site care.”

Rule L0549. Standard-level.

Content of plan of care (42 CFR 418.56(c)(5))

Rule L0550. Standard-level.

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

“Upon client record review, 3 of 11 (Patient 9,10,11) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient’s condition requires but no less frequently then every 15 calendar days. Patients 9,10,11: The medical records do not contain evidence of the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient’s condition requires but no less frequently then every 15 calendar days.”

Rule L0552. Standard-level.

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

“Upon patient record review, 3 of 11 (Patient 9,10,11) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patients 9,10,11: There is no evidence in the patient record that a revised plan of care includes information from the patient’s updated comprehensive assessment or note the patient’s progress towards outcome/goals from the plan of care.”

Rule L0553. Standard-level.

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

Rule L0555. Standard-level.

Content (42 CFR 418.104(a)(1))

“Upon patient client record review, 3 of 11 (Patient 9,10,11) did not have evidence that each patient record contains:(this references that the documentation is part of the patient record. Patients 9,10,11: The medical records did not have evidence of any signed and dated progress notes, updated comprehensive assessments, updated POC.”

Rule L0672. Standard-level.

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

“Upon patient client record review, 3 of 11 (Patient 1,5,6) did not have evidence that each patient record contains: Patient 1: The EOB has multiple blank spaces not filled in and has patient’s signature. Patient 5: The EOB has a blank line where the pt is informed of the Medicare coverage. Patient 6: The EOB has a blank line where the pt is informed of the Medicare coverage.”

Rule L0673. Standard-level.

Content (42 CFR 418.104(a)(7))

“Upon patient client record review, 3 of 14 (Patient #9. 10, 11) did not evidence that each patient record contains physician orders. Patient 9,10,11: There were no further visits past admission on these patients despite having visit orders for all disciplines. There was no discharge orders written on any of these patients.”

Rule L0678. Standard-level.

Authentication (42 CFR 418.104(b))

“Upon patient client record review, 1 of 11 (Patient 1) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1: The SN documented “F/C” for foley catheter. This is not an approved abbreviation.”

Rule L0679. Standard-level.

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

“Upon client record review, 3 of 11 (Patient 9,10,11) did not have evidence that the discharge summary includes all required information. Patients 9,10,11: There were no further visits performed on these patients and no discharge summaries documented.”

Rule L0684. Standard-level.

Written agreement (42 CFR 418.112(c)(5))

“Upon SNF/NF contract review, 1 of 3 (Heritage Manor) did not have evidence that it is the hospice’s responsibility to provide services at the same level and to the same extent as those services would be provided if the SNF/NF resident were in his or her own home.”

Rule L0768. Standard-level.

Hospice plan of care (42 CFR 418.112(d)(1))

“Upon client record review, 1 of 11 (Patient 2) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 2: The POC 1/5/23 contains wound care orders but does not state who is to perform the wound care.”

Rule L0774. Standard-level.

Orientation and training of staff (42 CFR 418.112(f))

“Upon observation, there was no evidence the hospice provides orientation to personnel of a SNF/NF or ICF/IID regarding the policies and procedures of the provision of care/service including all required content.”

Rule L0782. Standard-level.