Schneck Medical Center Hospice

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

“Observed in Record Review. In 7 of 14 patient records reviewed, the hospice goals were not individualized to meet the patients’ needs based on the assessments. All of the goals listed for Hosp RR#2, RR#3, #4, #5 #7, #8 and #10 included the following target dates- In Progress. This observation was discussed with the director.”

Rule L0545. Condition-level.

Quality assessment & performance improvement (42 CFR 418.58)

“Observed in Leadership Session. Based on a review of the available data there was no comprehensive QAPI plan for 2024. There were several projects however these projects did not reflect the complexity of the services provided by the hospice. For example, the data collection/analysis did not address volunteer services, bereavement services, contract oversight, and or the levels of care specifically continuous care. This was discussed with the director.”

Rule L0559. Condition-level.

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

“Observed in Leadership Session. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by condition level deficiencies - 418.100, 418.56, and 418.58.”

Rule L0651. Condition-level.

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

“Observed in Record Review. In 1 of 14 patient records reviewed, did not have all interventions included on the comprehensive care plan based on the assessment. Bereavement RR#1 had a Foley and the comprehensive hospice care plan did not include orders for the Foley related to the size of the catheter, balloon size, or frequency of change. This observation was discussed with the director.”

Rule L0546. Standard-level.

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

“Observed in Individual Tracer. In 1 of 14 patient records reviewed, the hospice plan of care goals were not revised based on the comprehensive assessment. Hosp RR#1 HV had 5 recertification periods. The initial certification period had the following goal-Patient will describe measures to protect skin/ wound care teach back within 48 hours. This goal remained on the current certification plan of care. This observation was discussed with the director.”

Rule L0553. Standard-level.

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

“Observed in Tracer Activities. There was no identification of the frequency of data collection/reporting/ and or analysis of required data points therefore limited opportunities to internally benchmark and reprioritize performance improvement initiatives as necessary in 2024 or 2025. This observation was discussed with the director.”

Rule L0575. Standard-level.

Control (42 CFR 418.60(b)(2)(ii))

“Observed in Data Session. Based on a review of the available data, the hospice and home care only collected hand hygiene data on the nursing staff. These programs provided therapy, chaplain, social work , and volunteer services to patients. This observation was discussed with the director.”

Rule L0581. Standard-level.

Hospice aide assignments and duties (42 CFR 418.76(g)(1))

“Observed in Individual Tracer. In 2 of 6 patient records reviewed, that had a hospice aide, the care plan did not reflect all of the written instructions required by on the assessment. RR#1 had a colostomy and this device was not reflected on the care plan. Hos RR#12 had multiple wounds and the aide care plan did not reflect wound precautions. This observation was discussed with the director.”

Rule L0625. Standard-level.

Services (42 CFR 418.100(c)(1)(i))

“Observed in Leadership Session. Based on a review of admission data provided to patients, there was no process in place to educate patients related to all levels of hospice care. While the policy specifically detailed continuous care as a option under the hospice benefit, this language did not appear in patient data given. Additionally, per the director, continuous care has not been provided within the past 3 years due to staffing. There was no discussion of continuous care in the QAPI minutes and or annual evaluation.”

Rule L0652. Standard-level.

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

“Observed in HR File Review. In 1 of 8 HR files reviewed, did not have discipline specific competencies. HR#5 was a hospice social worker and there were no competencies completed and or developed that addressed her specific duties. The competency completed was general. Additionally, this social worker also functioned as the bereavement coordinator and there was no specific competencies defined for this role. This observation was discussed with the director.”

Rule L0663. Standard-level.

Authentication (42 CFR 418.104(b))

“Observed in Individual Tracer. In 1 of 14 patient records reviewed, entries in the hospice record were not appropriately authenticated. Two consent forms in Hosp RR#1 were signed but not dated. This observation was discussed with the director.”

Rule L0679. Standard-level.

Discharge or transfer of care (42 CFR 418.104(e)(1)(ii))

“Observed in Record Review. In 1 of 2 patient records reviewed, that were live discharges, did not provide the discharge summary to the next provider. DC RR#1 was transferred to another hospice and there was no transfer/discharge summary or documentation in the record that this summary was provided to the receiving hospice. This observation was discussed with the director.”

Rule L0682. Standard-level.

Coordination of services (42 CFR 418.112(e)(3)(i))

“Observed in Patient Home. In 1 of 2 patient records reviewed, that resided in a nursing home, did not have updated hospice documents in the facility. Hosp RR#1 HV has been recerted 5 times and only the initial certification plan of care was located in the nursing home chart. This was discussed with the RN.”

Rule L0781. Standard-level.

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

“Observed in Tracer Activities. In 1 of 2 tracers conducted, did not have appropriate language in the contract. The nursing home contract did not have a stipulation that the criminal background checks would be obtained for all employees that have patient contact. This observation was discussed with the director.”

Rule L0795. Standard-level.