Emunah Hospice LLC

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. No evidence of Emergency Preparedness Program”

Rule E0001. Condition-level.

IDG, care planning, coordination of services (42 CFR 418.56)

“Upon patient record review, 1 of 16 (Patient #5) did not have evidence in the patient record that the written plan of care is developed by the IDG, in consultation with the patient’s attending physician, which specifies the services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as it relates to the terminal illness and related conditions. Patient #5-No POC from SOC 5/7/25 and no evidence of collaboration with attending”

Rule L0536. Condition-level.

Coordination of services (42 CFR 418.60)

“Condition of Participation: Infection Control.”

Rule L0557. Condition-level.

Quality assessment & performance improvement (42 CFR 418.58)

“Upon observation, there was no evidence the organization develops, implements, and maintains an effective, on-going, organization wide Quality Assessment and Performance Improvement (QAPI) program.”

Rule L0559. Condition-level.

Core services (42 CFR 418.64)

“Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all core services which includes nursing services, medical social services and counseling services. No evidence of counseling services for spiritual and bereavement services.”

Rule L0587. Condition-level.

Furnishing of non-core services (42 CFR 418.70)

“Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all non-core services which includes physical therapy, occupational therapy and speech-language pathology. No evidence of volunteers.”

Rule L0601. Condition-level.

Volunteers (42 CFR 418.78)

“Upon personnel record review, 1 of 14 (Personnel #9) did not have evidence the individual who supervises volunteers is qualified by meeting the hospice’s policies and procedures and/or job description criteria and is a designated hospice employee. The agency does not have a volunteer coordinator.”

Rule L0641. Condition-level.

Organizational environment (42 CFR 418.100)

“Condition of Participation: Organization and Administration of Services.”

Rule L0648. Condition-level.

Clinical records (42 CFR 418.104)

“Condition of Participation: Clinical Records.”

Rule L0670. Condition-level.

Personnel qualification (42 CFR 418.114)

“Condition of Participation: Personnel Qualifications.”

Rule L0783. Condition-level.

Develop EP Plan, Review and Update Annually (42 CFR 418.113(a))

“Upon observation, there was no evidence the hospice has developed and maintained an emergency preparedness plan that must be reviewed, and updated at least every two years. No evidence of Emergency Preparedness Program”

Rule E0004. Standard-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 No evidence of Emergency Preparedness Program”

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 No evidence of Emergency Preparedness Program”

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. No evidence of Emergency Preparedness Program”

Rule E0009. 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. No evidence of Emergency Preparedness Program plan.”

Rule E0029. Standard-level.

EP Training and Testing (42 CFR 418.113(d))

“Upon observation, there was no evidence of emergency preparedness training and testing program that is based on the emergency plan, policies and procedures and the communication plan. No evidence of Emergency Preparedness Program”

Rule E0036. Standard-level.

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

Rule E0037. 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. No evidence of Emergency Preparedness Program”

Rule E0039. Standard-level.

EP Testing Requirements (42 CFR 418.113(d)(3))

Rule E0039. Standard-level.

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

Rule L0530. 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))

Rule L0549. Standard-level.

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

“Upon client record review, 1 of 16 (Patient #12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #12 SC visit frequency is ordered 2x/month, a visit was made 5/12/25 and no evidence of a 2nd visit completed or attempted that month.”

Rule L0555. Standard-level.

Program scope (42 CFR 418.58(a)(1))

“Upon observation, there was no evidence the program shows measurable improvement in indicators related to improved palliative outcomes and hospice services. No evidence of QAPI Program”

Rule L0561. Standard-level.

Program scope (42 CFR 418.58(a)(2))

“Upon observation, there was no evidence the hospice measures, analyzes, and tracks quality indicators, including adverse patient events and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations. No evidence of QAPI Program”

Rule L0562. Standard-level.

Program data (42 CFR 418.58(b)(1))

“Upon observation, there was no evidence the program must use quality indicator data, including patient care, and other relevant data, in the design of the program.”

Rule L0563. Standard-level.

Program data (42 CFR 418.58(b)(2))

“Upon observation, there was no evidence the QAPI program uses quality indicator data, including patient care and other relevant data in the design of its program. The hospice must use the data collected to: • Monitor the effectiveness and safety of services and quality of care • Identify opportunities and priorities for improvement No evidence of QAPI Program”

Rule L0564. Standard-level.

Program data (42 CFR 418.58(b)(3))

“Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection. No evidence of Governing Body”

Rule L0565. Standard-level.

Program activities (42 CFR 418.58(c)(1)(i))

“Upon observation, there was no evidence QAPI activities focus on high risk ,high volume, or problem prone areas. No evidence of QAPI program”

Rule L0566. Standard-level.

Program activities (42 CFR 418.58(c)(1)(ii))

“Upon observation, there was no evidence Quality Assessment and Performance Improvement activities focus on high risk, high volume or problem-prone areas by considering incidence, prevalence, and the severity of problems. No evidence of QAPI program”

Rule L0567. Standard-level.

Program activities (42 CFR 418.58(c)(1)(iii))

“Upon observation, there was no evidence Quality Assessment and Performance Improvement activities focus on high risk, high volume or problem-prone areas by understanding how they affect palliative outcomes, patient safety and quality of care. No evidence of QAPI program”

Rule L0568. Standard-level.

Performance improvement projects (42 CFR 418.58(d)(1))

“Upon observation, there was no evidence the number and scope of distinct QAPI projects conducted annually is based on the needs of the hospice’s population and internal organizational needs and must reflect the scope, complexity, and past performance of the hospice’s services and operations.”

Rule L0572. Standard-level.

Performance improvement projects (42 CFR 418.58(d)(2))

“Upon observation, there was no evidence the hospice documents what QAPI projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.”

Rule L0573. Standard-level.

Executive responsibilities (42 CFR 418.58(e)(1))

“Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program.”

Rule L0574. Standard-level.

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

“Upon observation, there was no evidence the hospice’s governing body is responsible for ensuring that the hospice-wide Quality Assessment and Performance Improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness. No evidence of QAPI Program, No evidence of Governing Body”

Rule L0575. Standard-level.

Executive responsibilities (42 CFR 418.58(e)(3))

“Upon observation, there was no evidence the hospice ensures the implementation of a hospice wide Quality Assessment/Performance Improvement (QAPI) program by the designation of a person responsible for coordinating QAPI activities.”

Rule L0576. Standard-level.

Infection control (42 CFR 418.60)

“Upon observation, there was no evidence the hospice maintains and documents an effective infection control program that protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases. No evidence of Infection Control Program”

Rule L0577. Standard-level.

Control (42 CFR 418.60(b)(1))

“Upon observation, there was no evidence in QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the hospice’s Quality Assessment and Performance Improvement program. No evidence of QAPI program”

Rule L0580. Standard-level.

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

“Upon observation, there was no evidence in the QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. No evidence of QAPI program, No evidence of Infection Control Program”

Rule L0581. Standard-level.

Education (42 CFR 418.60(c))

“Upon observation, there was no evidence the hospice provides infection control education regarding basic and high-risk infection control procedures as appropriate to the care/services provided that is consistent with OSHA and CDC recommendations. No evidence of Infection Control Program”

Rule L0582. Standard-level.

Licensed professional services (42 CFR 418.62(c))

“Upon observation, there was no evidence licensed professionals participate in the hospice’s QAPI program. No evidence of QAPI program”

Rule L0586. Standard-level.

Counseling services (42 CFR 418.64(d))

“Upon observation, there was no evidence Spiritual counseling services must be available to the patient and family to assist in minimizing the stress and problems that arise from the terminal illness, related conditions and the dying process.”

Rule L0595. Standard-level.

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

“Upon personnel record review, 1 of 14 (Personnel #8) 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. The agency does not have an individual to provide bereavement services.”

Rule L0596. Standard-level.

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

Rule L0626. Standard-level.

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

“Upon patient record review 1 of 16 (Patient #11) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient #11 5/30/25, 6/3/25 and 6/10/25 SN notes for aide supervisory visit state “Please refer to intervention documentation”, no evidence of supervisory visits completed.”

Rule L0629. Standard-level.

Training (42 CFR 418.78(a))

“Upon observation, there was no evidence the hospice maintains, documents and provides volunteer orientation and training that is consistent with hospice industry standards.”

Rule L0643. Standard-level.

Role (42 CFR 418.78(b))

“Upon observation, there was no evidence volunteers are used in day to day administrative and/or direct patient care roles.”

Rule L0644. Standard-level.

Recruiting and retaining (42 CFR 418.78(c))

“Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers.”

Rule L0645. Standard-level.

Cost saving (42 CFR 418.78(d))

“Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include 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.

Level of activity (42 CFR 418.78(e))

“Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel.”

Rule L0647. Standard-level.

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

“Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. The agency did not have evidence of a governing body, ethics committee, QAPI or EPP program, volunteer, volunteer coordinator, counseling services-bereavement or spiritual care for patients. In addition, human resource management was not evidenced based on the lack of missing HR requirements.”

Rule L0651. Standard-level.

Services (42 CFR 418.100(c))

“Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services • Medical social services • Physician services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Hospice aide, volunteer, homemaker services • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care • Medical supplies (including drugs and biologicals) and medical appliance No evidence of counseling services for spiritual and bereavement and no evidence of volunteer coordinator or volunteers.”

Rule L0652. Standard-level.

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

“Upon personnel record review, 2 of 14 (Personnel #2,3) did not have evidence that the hospice employees have received orientation on their specific job requirements.”

Rule L0662. Standard-level.

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

“Upon patient client record review, 3 of 16 (Patient #4,6,11) 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”

Rule L0673. Standard-level.

Content (42 CFR 418.104(a)(6))

“Upon patient client record review, 1 of 16 (Patient #10) did not have evidence that each patient record contains Advance Directives.”

Rule L0677. Standard-level.

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

“Upon personnel record review, 1 of 14 (Personnel #5) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records.”

Rule L0795. Standard-level.

Criminal background checks (42 CFR 418.114(d)(2))

“Upon personnel record review, 8 of 14 (Personnel #1,2,3,4,5,6,7,11) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years.”

Rule L0796. Standard-level.

N/a (42 CFR 418.110(c)(1))

“Upon observation, there was noo evidence the hospice has a safety management plan that addresses real or potential threats to the health and safety of the patients, others and property.”

Rule L0825. Standard-level.

N/a (42 CFR 418.110(j))

“Upon observation, there was no evidence that the Hospice’s inpatient facility maintains and documents an effective infection control program that protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases. No evidence of Infection Control Program”

Rule L0833. Standard-level.

N/a (42 CFR 418.110(l))

“Upon observation, there was no evidence the hospice inpatient facility provides suitable linens for the care of the patient. Linens are provided in sufficient quantity for patient care and comfort. Linens are handled, stored, processed and transported in a manner that prevents the spread of infection. Shelf in Laundry room did not have a shelf liner on the bottom shelf to protect the linens. COS”

Rule L0835. Standard-level.