Sun Care Hospice Inc.

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

Rule L0547. Standard-level.

Level of activity (42 CFR 418.78(e))

“Upon observation, there was not evidence that the annual report documented the use of Volunteers, providing day to day administrative and/or direct patient care services, in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid Hospice employees and contract personnel.”

Rule L0647. Standard-level.

Inpatient care provided under arrangements (42 CFR 418.108(c)(3))

“Upon Inpatient contract review, 1 of 1 (Hampden Hills) did not contain evidence that a copy of the Discharge Summary shall be provided to the Hospice at the time of a patient’s discharge from the inpatient facility.”

Rule L0713. Standard-level.

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.

Core services (42 CFR 418.64)

“Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all core services which includes medical social services and counseling services. The agency does not have evidence of medical social services or counseling employee(s).”

Rule L0587. Condition-level.

Furnishing of non-core services (42 CFR 418.70)

“Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all non-core services which includes volunteers, physical therapy, occupational therapy and speech-language pathology.”

Rule L0601. Condition-level.

Volunteers (42 CFR 418.78)

“Upon personnel record review, the agency did not have evidence the of an individual who supervises volunteers is qualified by meeting the hospice’s policies and procedures and/or job description criteria and is a designated hospice employee as agency did not have evidence of Volunteer Coordinator.”

Rule L0641. Condition-level.

Organizational environment (42 CFR 418.100)

“Condition of Participation: Organization and Administration of Services.”

Rule L0648. Condition-level.

Personnel qualification (42 CFR 418.114)

“Condition of Participation: Personnel Qualifications.”

Rule L0783. Condition-level.

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

Rule L0530. Standard-level.

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

“Upon patient record review, 1 of 15 (Patient #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 initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care.”

Rule L0531. Standard-level.

Approach to service delivery (42 CFR 418.56(a))

“Upon observation, there was no evidence the hospice has an interdisciplinary group (IDG) or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Interdisciplinary group members must provide the care and services offered by the hospice, and the group, in its entirety, must supervise the care and services. The agency does not employ a medical social worker or pastoral or other counselor to participate in IDG and for patient/family needs.”

Rule L0539. Standard-level.

Content of plan of care (42 CFR 418.56(c)(4))

“Upon patient record review, 3 of 15 (Patient #3,7,15) 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 treatments. Patient #3 has oxygen use in place with no evidence of the oxygen order. Patient #7 has Triamcinolone cream ordered, however no evidence of indication of where to apply cream. Patient #15 has Calmoseptine ordered, however no evidence of indication of where to apply cream.”

Rule L0549. Standard-level.

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

Rule L0555. Standard-level.

Medical social services (42 CFR 418.64(c))

“Upon observation, there was no evidence the hospice provides medical social services as a core service.”

Rule L0594. Standard-level.

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

“Upon personnel record review, 1 of 19 (Personnel #13) did not have evidence that all bereavement services are provided by a qualified counselor in accordance with applicable laws and regulations, professional practice standards, the hospice’s policies and procedures and/or job descriptions which includes experience or education in grief or loss counseling. No evidence of counselor.”

Rule L0596. Standard-level.

Hospice aide assignments and duties (42 CFR 418.76(g)(2))

“Upon patient record review 1 of 15 (Patient #14) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #14 on 4/1/24 orders in place for aide2x/week with an active care plan on 4/9/24, no evidence of any aide visits made.”

Rule L0626. Standard-level.

Role (42 CFR 418.78(b))

“Upon observation, there was no evidence volunteers are used in day to day administrative and/or direct patient care roles. The agency did not have volunteers”

Rule L0644. Standard-level.

Recruiting and retaining (42 CFR 418.78(c))

“Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers.”

Rule L0645. Standard-level.

Cost saving (42 CFR 418.78(d))

“Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78”

Rule L0646. Standard-level.

Level of activity (42 CFR 418.78(e))

“Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel.”

Rule L0647. Standard-level.

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

Rule L0651. Standard-level.

Services (42 CFR 418.100(c))

“Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Medical social services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Volunteer • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care • Medical supplies (including drugs and biologicals) and medical appliance”

Rule L0652. Standard-level.

Training (42 CFR 418.100(g)(3))

“Upon personnel record review, 8 of 19 (Personnel #2,3,4,5,6,7,8,9) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation.”

Rule L0663. Standard-level.

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

“Upon patient client record review, 3 of 15 (Patient #3,7,8) did not have evidence that each patient record contains Advance Directives. All patients had DNR however, this was not signed by the physician.”

Rule L0677. Standard-level.

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

“Upon client record review, 1 of 15 (Patient #13) did not have evidence that the discharge summary includes all required information.”

Rule L0684. Standard-level.

Personnel qualification (42 CFR 418.114(a))

“Upon personnel record review, 1 of 19 (Personnel #15 ) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements. No evidence of social worker for license verification.”

Rule L0784. Standard-level.

Personnel qualification (42 CFR 418.114(b)(4))

“Upon personnel record review, 1 of 19 (Personnel #19) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state’s Speech-Language Pathology Practice Act and the hospice’s policies and procedures and/or job descriptions. No evidence of SLP file.”

Rule L0788. Standard-level.

Personnel qualification (42 CFR 418.114(b)(5))

“Upon personnel record review, 1 of 19 (Personnel #18) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state’s Occupational Therapy Practice Act and the hospice’s policies and procedures and/or job descriptions. No evidence of OT file.”

Rule L0789. Standard-level.

Personnel qualification (42 CFR 418.114(b)(7))

“Upon personnel record review, 1 of 19 (Personnel #17) did not have evidence all Physical Therapy Services are provided by a qualified licensed Physical Therapist (PT) in accordance with the state’s Physical Therapy Practice Act and the hospice’s policies and procedures and/or job descriptions. No evidence of PT file”

Rule L0791. Standard-level.

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

“Upon personnel record review, 3 of 19 (Personnel #17,18,19) 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. Agency does not employ nor contract for PT/OT/SLP”

Rule L0795. Standard-level.

Criminal background checks (42 CFR 418.114(d)(2))

“Upon personnel record review, 5 of 19 (Personnel #12,13,14,15,16) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Agency does not employ social work, counseling, volunteer, or volunteer coordinator.”

Rule L0796. Standard-level.