Sacred Heart Hospice Care

Medical director (42 CFR 418.102)

“Condition of Participation: Medical Director.”

Rule L0664. Condition-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. The Administrator could not identify a contract/agreement with another facility to receive patients in the event the hospice could not provide care during an emergency”

Rule E0025. Standard-level.

Development of Communication Plan (42 CFR 418.113(c))

“Upon observation, there was no evidence the hospice develops and maintains an emergency preparedness communication plan that complies with federal, state, and local laws and must be reviewed and updated every two years.”

Rule E0029. Standard-level.

Primary/Alternate Means for Communication (42 CFR 418.113(c)(3))

“Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice’s employees and Federal, state, tribal, regional, and local emergency management agencies. The agency administrator could not find the communication plan.”

Rule E0032. Standard-level.

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

Rule E0033. Standard-level.

EP Testing Requirements (42 CFR 418.113(d)(2))

“Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years.”

Rule E0039. Standard-level.

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

“Upon patient record review, 5 of 14 (Patient #1,2,3,5,9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1,2,3,5,9: There is evidence of an order for oxygen, but oxygen is not on the medication record.”

Rule L0530. Standard-level.

Plan of care (42 CFR 418.56(b))

“Upon patient record review, 1 of 14 (Patient #6) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient #6: There is evidence in the medical record of an order for wound care. Under the order is a note: the “caregiver is validated to be competent in performing wound care maintenance during non-skilled nurse visits”. There is no evidence of education of the caregiver.”

Rule L0544. 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)(4))

“Upon patient record review, 1 of 14 (Patient #4) 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 #4: There is evidence in nurses note 12/5/25 the patient has a Foley catheter. There is no order for Foley catheter.”

Rule L0549. Standard-level.

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

Rule L0555. Standard-level.

Prevention (42 CFR 418.60(a))

Rule L0579. Standard-level.

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

“Upon personnel record review, 1 of 13 (Personnel #9) 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. Personnel #9: There is no evidence Bereavement Coordinator met the qualifications of bachelor’s degree or equivalent theological degree from college or university per the job description. There is only a Certificate of Ordination.”

Rule L0596. Standard-level.

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

Rule L0596. Standard-level.

Supervision of hospice aides (42 CFR 418.76(h)(3))

Rule L0633. Standard-level.

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

“Upon personnel record review, 1 of 14 (Personnel #2) did not have evidence the alternate administrator’s personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Personnel #2: There is no evidence the Alternate administrator was oriented to the role.”

Rule L0651. Standard-level.

Initial certification of terminal illness (42 CFR 418.102(b))

“Upon patient record review, 8 of 14 (Patient #1,2,4,5,6,8,9,10) did not have evidence that there is a physician’s brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification forms, or as an addendum to the certification forms. Patient #1,2,4,5,6,8,9,10: There is no evidence of a brief narrative that included the patients clinical circumstances to justify certification. Only the diagnosis and comorbidities and certification statement was documented.”

Rule L0667. Standard-level.

Recertification of the terminal illness (42 CFR 418.102(c))

“Upon client record review, 3 of 14 (Patient #1,2,6) did not have evidence that the physician provides a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the recertification form, or as an addendum to the recertification form. Patient #1,2,6: There is no evidence of a brief narrative that included the patients clinical circumstances to justify recertification. Only the diagnosis and comorbidities and certification statement was documented.”

Rule L0668. Standard-level.

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

“Upon patient client record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) did not have evidence that each patient record contains: •Diagnoses related to terminal illness and related conditions •Diagnoses unrelated to terminal illness and related conditions Patients #1-10: There is evidence during the admission, the patient signed a blank “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” form. On the election statement, there is a spot for the patient to check, “yes or no” that they wanted the form. However, neither box was checked.”

Rule L0673. Standard-level.

Written agreement (42 CFR 418.112(c)(7))

Rule L0770. Standard-level.

Orientation and training of staff (42 CFR 418.112(f))

“Upon observation, there was no evidence the hospice provides orientation to personnel of a SNF/NF or ICF/IID regarding the policies and procedures of the provision of care/service including all required content.”

Rule L0782. Standard-level.

Personnel qualification (42 CFR 418.114(b)(3))

“Upon personnel record review, 1 of 13 (Personnel #5) did not have evidence that all Medical Social Services are provided by a qualified Medical Social Worker in accordance with the state’s Social Work Practice Act, the hospice’s policies and procedures and/or job descriptions. Personnel #5: There was no documentation that the MSW serves as an active advisor, consulting with the BSW on assessing the needs of patients and families, developing and updating the social work portion of the plan of care. There is no evidence of supervision by an MSW.”

Rule L0787. Standard-level.

Multiple locations (42 CFR 418.116(a))

“Upon observation, there was no evidence the organizational chart matches the hospice’s information submitted to CMS and/or State licensing agencies, and ACHC for ownership and management personnel. The Medical Director was new last year and there is no evidence documentation submitted to CMS, state agencies and ACHC.”

Rule L0799. Standard-level.