Comfort Hospice and Palliative Care

Local, State, Tribal Collaboration Process (42 CFR 418.113(a)(4))

“Upon observation, there was no evidence the Emergency Preparedness plan includes a process for cooperation and collaboration with any tribal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation.”

Rule E0009. 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.

Emergency Officials Contact Information (42 CFR 418.113(c)(2))

“Upon observation, there was no evidence the Emergency Plan communication plan includes a primary and alternate contact information for tribal emergency preparedness staff.”

Rule E0031. Standard-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 14 (Patient #1) 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.

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

Rule L0549. 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))

Rule L0555. Standard-level.

Competency evaluation (42 CFR 418.76(c))

Rule L0615. Standard-level.

Cost saving (42 CFR 418.78(d))

“Upon observation, there was no evidence that documented the cost savings achieved by agency through the use of volunteers. The Documentation must have included 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.

Training (42 CFR 418.100(g)(1))

“Upon personnel record review, 3 of 14 (Personnel #8, 9 &10) did not have evidence these hospice personnel have received orientation on the hospice philosophy.”

Rule L0661. Standard-level.

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

“Upon personnel record review, 3 of 14 (Personnel #8, 9 &10) did not have evidence that these hospice personnel have received orientation on their specific job requirements.”

Rule L0662. Standard-level.

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

“Upon personnel record review, 3 of 14 (Personnel #8, 9 &10) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for these personnel and volunteer during orientation.”

Rule L0663. Standard-level.

Medical director (42 CFR 418.102)

“Upon observation, there was no evidence the hospice designated a physician to serve as Medical Director. This was corrected on Day 3 of survey with an appointment of personnel #10 as the Medical Director.”

Rule L0664. Standard-level.

Medical director contract (42 CFR 418.102(a))

“Upon contract review, 1 of 4 (Alok Saxena) did not have evidence of a contract to fulfill the role of medical director. There was not an evidence in the contract identifying the role of a Medical Director, contract identified the role as Alt MD. This was corrected on Day3 of survey, agency appointed one of the 2 associate medical directors as the Medical Director.”

Rule L0666. Standard-level.

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

“Upon patient client record review, 1 of 14 (Patient #12) did not have evidence in the election statement of the effective date of election, which may be the first day of hospice care or a later date, but may be no earlier than the date of the election statement in accordance with 418.24”

Rule L0673. Standard-level.

Authentication (42 CFR 418.104(b))

“Upon patient client record review, 1 of 14 (Patient #1) did not have evidence that all entries were clear, complete, and appropriately authenticated. SN visit 5-13-23 documented that patient was still being provided care in the facility, when patient was discharged from the facility on 5-11-23 and was back to home during the 5-13-23 visit.”

Rule L0679. Standard-level.

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

“Upon client record review, 1 of 14 (Patient #12) did not have evidence that the hospice forwarded a summary to the admitting facility and a copy of the patient record, if requested, to a facility when patient was transferred on 11-22-22.”

Rule L0682. Standard-level.

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

“Upon client record review, 1 of 14 (Patient #11) did not have evidence that when the patient revoked the election of hospice care and was discharged from hospice on 1-13-23, the hospice forwarded the discharge summary and a copy of the patient records(if requested) to the patient’s attending physician in accordance with §418.26”

Rule L0683. Standard-level.

Multiple locations (42 CFR 418.116(a))

“Upon observation, there was no evidence the organizational chart did match the hospice’s information submitted to CMS and/or State licensing agencies management personnel. The current DPCS was not listed for the position she is holding as DPCS and the Alt DPCS was not listed for the position he is holding as Alt DPCS.”

Rule L0799. Standard-level.