Healing Hands Hospice

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

Rule L0531. Standard-level.

Approach to service delivery (42 CFR 418.56(a)(1))

Rule L0540. Standard-level.

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

Rule L0550. Standard-level.

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

“Upon patient record review, 1 of 7 records reviewed (Patient #2) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #2: The record indicated the patients start of hospice care was on 03/22/24. There was no evidence of the effective date on the election form.”

Rule L0673. Standard-level.

Establishment of the Emergency Program (EP) (42 CFR 418.113)

“Upon observation, there was no evidence the hospice complies with all applicable federal, state, and local emergency preparedness requirements by establishing and maintaining an emergency preparedness program that meets the requirements of 42 CFR 418.113. COS.”

Rule E0001. Condition-level.

Plan Based on All Hazards Risk Assessment (42 CFR 418.113(a)(1))

“Upon observation, there was no evidence the Emergency Preparedness plan: • Is based on and includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach • Includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. COS.”

Rule E0006. Standard-level.

EP Program Patient Population (42 CFR 418.113(a)(3))

“Upon observation, there was no evidence the The Emergency Preparedness plan addresses patient population, including, but not limited to: • The type of services the hospice has • The ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans COS.”

Rule E0007. Standard-level.

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 local, tribal, regional, state, and federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. COS.”

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. COS.”

Rule E0025. Standard-level.

Names and Contact Information (42 CFR 418.113(c)(1))

“Upon observation, there was no evidence the Emergency Plan communication plan includes all of the following: • Names and contact information for the following: • Hospice employees • Entities providing services under arrangement • Patients’ physicians • Other hospices COS.”

Rule E0030. Standard-level.

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

“Upon observation, there was no evidence the Emergency Plan communication plan must include a primary and alternate means for communicating with hospice’s employees; in addition, it must include contact information for Federal, state, tribal, regional, or local emergency preparedness staff. COS.”

Rule E0031. 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) COS.”

Rule E0033. Standard-level.

EP Training Program (42 CFR 418.113(d)(1))

Rule E0037. Standard-level.

Content of plan of care (42 CFR 418.56(c)(2))

“Upon patient record review, 5 of 5 (Patients #1,2,3,4,5) did not have evidence the plan of care (POC) must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs Patients #1,2,3,4,5: The POC indicated Bereavement Coordinator (BC) frequency “one as needed”. There was no baseline visit frequency for the BC. Agency provided late entry clarification orders. COS.”

Rule L0547. Standard-level.

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

Rule L0625. Standard-level.

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

Rule L0626. Standard-level.

Professional management responsibility (42 CFR 418.100(e))

“Upon contract review, 3 of 6 (contract PT/OT/ST) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Delivered in accordance with the patient’s plan of care not included in contract.”

Rule L0655. Standard-level.

Discharge or transfer of care (42 CFR 418.104(e)(3))

“Upon patient record review, 2 of 5 (Patients #4, 5) did not have evidence that the discharge summary (DC) includes all required information. Patients #4, 5: Did not include that the patients current plan of care was included in DC Summary”

Rule L0684. Standard-level.