Cohesive Healthcare

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

Rule L0523. Standard-level.

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

Rule L0531. Standard-level.

Prevention (42 CFR 418.60(a))

“Upon observation during home visits, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. the RN used paper towel as barrier for nursing bag. Agency Policy for Bag Technique requires waterproof disposable barrier.”

Rule L0579. Standard-level.

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

“Upon personnel record review, 1 of 11 (Personnel #9 ) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #9 did not have evidence of orientation to job description, as indicated by no signed job description available.”

Rule L0662. Standard-level.

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

“Upon personnel record review, 1 of 11 (Personnel # 5) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #5: No evidence of competency for bereavement coordinator could be located during survey.”

Rule L0663. Standard-level.

Content (42 CFR 418.104(a)(5))

“Upon patient client record review, 2 of 11 (Patient #7, 10) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient #7: There is no CTI by attending. Patient #10. There is no CTI by attending.”

Rule L0676. Standard-level.

Inpatient care provided under arrangements (42 CFR 418.108(c)(3))

Rule L0713. Standard-level.

Inpatient care provided under arrangements (42 CFR 418.108(c)(4))

“Upon inpatient contract review, 2 of 5 (Prague Hospital and Parkland Manor contracts) did not have evidence that the inpatient facility has identified an individual within the facility who is responsible for the implementation of the provisions of the agreement. Prague Hospital: There is no reference to a designated individual responsible for the implementation.”

Rule L0714. Standard-level.

Inpatient care provided under arrangements (42 CFR 418.108(c)(5))

“Upon inpatient contract review, 2 of 5 (Prague Hospital and Parkland Manor contracts) did not have evidence that the hospice retains responsibility for ensuring that the training of personnel who will be providing the patient’s care in the inpatient facility has been provided and that a description of the training and the names of those giving the training are documented. There is no reference to training by hospice in either contract.”

Rule L0715. Standard-level.

Inpatient care provided under arrangements (42 CFR 418.108(c)(6))

“Upon inpatient contract review, 2 of 5 (Prague Hospital and Parkland Manor contracts) did not have evidence of a method for verifying that the requirements for ACHC standard HSP1-8B and CFR 418.108c (1)-418.108c(5)are met. There is no documented reference to review or verification process.”

Rule L0716. Standard-level.

Written agreement (42 CFR 418.112(c)(2))

Rule L0765. Standard-level.

Written agreement (42 CFR 418.112(c)(3))

“Upon SNF/NF contract review, 1 of 5 (Parkland Manor contract) did not have evidence of a provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided. The level of care is not specifically referenced in the contract, and therefore, it is not clearly stated that the hospice retains responsibility for determination”

Rule L0766. Standard-level.

Written agreement (42 CFR 418.112(c)(8))

“Upon SNF/NF contract review, 1 of 5 (Parkland Manor contract) did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation. There is no such provision for reporting included in contract.”

Rule L0771. 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. The agency has no documented evidence of facility training/orientation, although reportedly have communicated informally.”

Rule L0782. Standard-level.