Traditions Health

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

“Observed in Record Review. In 1 of 4 patient records reviewed, the update of the comprehensive assessment did not include changes occurring since the initial assessment. For example, in record RRNHV#2 a nurse documented that the patient had fallen, however the plan of care was not updated and this was not discussed in the following interdisciplinary meeting. This RFI was reviewed and validated with the Administrator and Branch Directors.”

Rule L0533. Standard-level.

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

“Observed in Record Review. In 2 of 4 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. For example, in records RRNHV#1 and RRNHV#4 the patient was provided with fungal cream or powder but there were no orders documented in the plan of care. This RFI was reviewed and validated with the Administrator and Branch Directors.”

Rule L0550. Standard-level.

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

“Observed in Leadership Session. Leaders did not manage implementation of patient care policies and procedures governing the provision of care as evidenced by condition level findings at §418.54 and §418.56. This RFI was reviewed with the Regional Clinical Specialist, Administrator and Branch Director.”

Rule L0651. Condition-level.

Notice of rights and responsibilities (42 CFR 418.52(a)(1))

“Observed in Patient Home. In 4 of 4 home visits conducted, the hospice did not inform patients of their rights both orally and in writing. The election of benefits and consent were signed at the start of care. The patient was given a blank template of these that was similar, but not exactly like the signed document. Also, the template did not contain the same patient specific information as the original document. This RFI was reviewed with the Regional Clinical Specialist, Administrator and Branch Director.”

Rule L0502. Standard-level.

Timeframe for completion of assessment (42 CFR 418.54(b))

“Observed in Record Review. In 2 of 19 patient records reviewed, the hospice did not assess patients according to defined timelines. For example, in record RRNHV#3 the initial bereavement risk assessment was not completed until 20 days after the admission date. And in record RRNHV#4 the initial bereavement risk assessment was not completed until 50 days after the admission date. This RFI was reviewed with the Regional Clinical Specialist, Administrator and Branch Director.”

Rule L0523. Standard-level.

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

Rule L0531. Standard-level.

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

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)(2))

Rule L0547. Standard-level.

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

Rule L0550. Standard-level.

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

“Observed in Record Review. In 2 of 19 patient records reviewed, hospice failed to provide the patient with care, treatment, or services according to their individualized plan of care. In record RRHV#1 an occupational therapy evaluation was ordered but was not completed. In the records of RRHV#1 and RRHV#4 oxygen and oral suction machines were ordered but not fulfilled. This RFI was reviewed with the Regional Clinical Specialist, Administrator and Branch Director.”

Rule L0555. Standard-level.

Supervision of hospice aides (42 CFR 418.76(h)(1)(i))

“Observed in Record Review. In 4 of 14 patient records reviewed, a registered nurse did not supervise the hospice aide every 14 days or less. In record RRHV#1 there was a span of 18 days. In record RRNHV#1 more than 14 days elapsed seven times in three and a half months. In record RRNHV#3 there were spans of 15 and 24 days. In record RRNHV#4 there were spans of 20 and 23 days. This RFI was reviewed with the Regional Clinical Specialist, Administrator and Branch Director.”

Rule L0629. Standard-level.

Training (42 CFR 418.100(g)(2))

“Observed in Competency Session. In 2 of 9 HR files reviewed, the hospice did not ensure that staff were oriented to their job duties. In file HR#2 RN and HR#9 MT staff did not receive a description of their job duties as part of orientation. This RFI was reviewed with the Regional Clinical Specialist, Administrator and Branch Director.”

Rule L0662. Standard-level.

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

“Observed in Competency Session. In 1 of 9 HR files reviewed, the hospice did not assess and document staff competence as part of orientation. There was no competence assessment completed by another physician during the orientation process in the file of HR#1 MD. This RFI was reviewed with the Regional Clinical Specialist, Administrator and Branch Director.”

Rule L0663. Standard-level.

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

Rule L0678. Standard-level.

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

“Observed in Record Review. In 1 of 2 discharge records reviewed, the hospice did not notify the patient’s physician of the availability of a discharge summary. This was found in record RRDC#2 where the patient was discharged for extended prognosis. This RFI was reviewed with the Regional Clinical Specialist, Administrator and Branch Director.”

Rule L0682. Standard-level.

Discharge or transfer of care (42 CFR 418.104(e)(2)(i))

“Observed in Record Review. In 1 of 2 discharge records reviewed, the hospice did not provide a discharge summary and provide a copy to the patient’s physician. In record RRDC#1 the patient revoked for aggressive care following a fall. This RFI was reviewed with the Regional Clinical Specialist, Administrator and Branch Director.”

Rule L0683. Standard-level.

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

Rule L0702. Standard-level.

Personnel qualification (42 CFR 418.114(a))

“Observed in Competency Session. In 1 of 9 HR files reviewed, the hospice did not verify and document staff credentials using the primary source when certification is required by law and regulation. In the file HR#9 MT there was a license for her role as a certified occupational therapy aide. However, there was no certification for her role as a massage therapist, which is what she was hired to do. This RFI was reviewed with the Regional Clinical Specialist, Administrator and Branch Director.”

Rule L0784. Standard-level.