Lighthouse Hospice LLC

Federal, state, local laws & regulations (42 CFR 418.116)

“Upon observation, there was no evidence the hospice has the appropriate licenses/permits required by state or local rules and regulations. During selection of home visits, it was observed that the agency had 7 of the 41 current patients located in the state of Oregon. Upon inquiry, the agency verified they do not have a hospice licensure in Oregon.”

Rule L0797. Condition-level.

Develop EP Plan, Review and Update Annually (42 CFR 418.113(a))

“Upon observation, there was no evidence the hospice has developed and maintained an emergency preparedness plan that must be reviewed, and updated at least every two years. The agency provided last revision dated 11/16/2020.”

Rule E0004. Standard-level.

Arrangement with Other Facilities (42 CFR 418.113(b)(5))

“Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.”

Rule E0025. Standard-level.

Methods for Sharing Information (42 CFR 418.113(c)(4))

“Upon observation, there was no evidence the Emergency Plan communication plan includes: • A method for sharing information and medical documentation for patients under the hospice’s care, as necessary, with other health care providers to maintain the continuity of care • A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii) • A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4)”

Rule E0033. Standard-level.

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

“Upon patient record review, 2 of 14 (Patients #6,#8) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. • Drug therapy currently associated with laboratory monitoring Patient 6: The medication profile contained diclofenac and lidocaine topicals with no area defined for administration. Corrected on site. Patient 8: The medication profile contained multiple pain medications including hydromorphone, morphine and oxycodone without instructions to differentiate appropriate indications for use. Corrected on site.”

Rule L0530. Standard-level.

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

Rule L0531. 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)(2))

Rule L0547. Standard-level.

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

“Upon patient record review, 2 of 14 (Patients #6,#8) 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 6: The medical record contained orders for diclofenac and lidocaine topical medications with no area defined for administration. Corrected on site. Patient 8: The medical record contained orders for multiple pain medications including hydromorphone, morphine, and oxycodone without instructions to differentiate appropriate use. Corrected on site.”

Rule L0549. Standard-level.

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

“Upon patient record review, 1 of 14 (Patient #8) 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 equipment and supply needs. Patient 8: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair. There was no evidence of the wheelchair included as DME in the plan of care. Corrected on site.”

Rule L0550. Standard-level.

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

“Upon client record review, 1 of 14 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The medical record contained a social work visit 10/25/23. There was no evidence of an order for social work util 11/1/23.”

Rule L0555. Standard-level.

Program activities (42 CFR 418.58(c)(2))

“Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient 10: The medical record contained nursing documentation identifying a patient fall 10/23/23. There was no evidence of an investigation and prevention of reoccurrence.”

Rule L0569. Standard-level.

Executive responsibilities (42 CFR 418.58(e)(2))

“Upon observation, there was no evidence the hospice’s governing body is responsible for ensuring that the hospice-wide Quality Assessment and Performance Improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness. No evidence in governing body minutes of updates for QAPI.”

Rule L0575. Standard-level.

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

“Upon patient record review 1 of 14 (Patients #2) 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 2: There was no evidence of an order for aide visits. The medical record contained aide visits completed twice weekly since admission.”

Rule L0626. 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.

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

“Upon patient client record review, 1 of 14 (Patient #8) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient 8: The medical record contained an election statement identifying the patient elected to receive the Notification of Hospice Non-Covered Items upon admission 10/23/23. The patient did not receive the addendum until 10/30/23.”

Rule L0673. Standard-level.

Inpatient care provided under arrangements (42 CFR 418.108(c)(4))

“Upon inpatient contract review, 1 of 5 (Karcher Estates contract) did not have evidence that the inpatient facility has identified an individual within the facility who is responsible for the implementation of the provisions of the agreement.”

Rule L0714. Standard-level.

Inpatient care provided under arrangements (42 CFR 418.108(c)(5))

“Upon inpatient contract review, 2 of 5 (Saint Alphonsus and Karcher Estates contracts) did not have evidence that the hospice retains responsibility for ensuring that the training of personnel who will be providing the patient’s care in the inpatient facility has been provided and that a description of the training and the names of those giving the training are documented.”

Rule L0715. Standard-level.

Written agreement (42 CFR 418.112(c)(2))

Rule L0765. Standard-level.

Written agreement (42 CFR 418.112(c)(3))

“Upon SNF/NF contract review, 1 of 5 (Karcher Estates contract) did not have evidence of a provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.”

Rule L0766. Standard-level.

Written agreement (42 CFR 418.112(c)(8))

“Upon SNF/NF contract review, 1 of 5 (Karcher Estates contract) did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation.”

Rule L0771. Standard-level.

Written agreement (42 CFR 418.112(c)(9))

“Upon SNF/NF contract review, 1 of 5 (Karcher Estates contract) did not have a delineation of the responsibilities of the hospice and the SNF/NF to provide bereavement services to SNF/NF personnel.”

Rule L0772. Standard-level.