Mennonite Hospice

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

“Observed in Record Review. In 1 of 2 patient records reviewed, where the patient had a high risk medication prescribed, the plan of care had not addressed any teaching, interventions or goals nor any safety precautions related to bleeding precautions. This was evident in RRNHV#3 where the patient had Eliquis prescribed. There is documentation that the education had been completed. This was validated with the DOPCS.”

Rule L0549. Standard-level.

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

“Observed in Record Review. In 3 of 3 patient records reviewed, of patient’s receiving Warfarin and Eliquis it was noted that the plan of care did not address any teaching, interventions, or goals nor any safety precautions related to bleeding precautions. This was noted in record review #2 and record review #1 and #5 and was confirmed by the hospice director.”

Rule L0536. Condition-level.

Quality assessment & performance improvement (42 CFR 418.58)

“Observed in Document Review. During document review, data review and discussion with quality nurse and hospice director it was determined that the hospice quality program was not organization wide and did not include any indicators from bereavement, volunteer or contracted services. Additionally there were no palliative outcomes being assessed other than pain however that indicator was a review of documentation in the record and did not demonstrate outcomes.”

Rule L0559. Condition-level.

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

“Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation and staff interviews: 418.58, 418.102, 418.52, 418.56 and 418.100,”

Rule L0651. Condition-level.

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

“Observed in Emergency Management Session. During review of Emergency Plan and Policies as well as review of documentation of drills and real events, it was noted that there had been no evaluation of the incidents. This was confirmed by the hospice director.”

Rule E0039. Standard-level.

Notice of rights and responsibilities (42 CFR 418.52(a)(1))

“Observed in Document Review. During review of patient information packet both in office and in patient homes it was noted that there was no documentation of charges or any patient responsibility for charges in the hospice program. This was discussed with the administrator and hospice director.”

Rule L0502. Standard-level.

Rights of the patient (42 CFR 418.52(c)(4))

“Observed in Record Review. In 12 of 12 patient records reviewed, it was noted that the form allowing the patient to elect an attending physician or the hospice medical director to manage their hospice care was not completed and placed in the record. This was noted in all records reviewed and was confirmed by the hospice director.”

Rule L0515. Standard-level.

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

“Observed in Record Review. In 1 of 13 patient records reviewed, it was noted that in record review for home visit #1 the initial bereavement risk assessment was not done until one month after the start of care. This was reviewed with the hospice director.”

Rule L0531. Standard-level.

Plan of care (42 CFR 418.56(b ))

“Observed in Record Review. In 12 of 12 patient records reviewed, it was noted that the goals stated on the plan of care were not measurable or timed. For example, pt will report that pain is at or below tolerance level, Pt,/CG will be knowledgeable of pain management throughout the course of care, Pt./Cg will receive support with grieving process, symptoms problematic to pt will be addressed to meet the goal of dying with dignity. These were noted on every record reviewed. This was discussed with administrator and hospice director.”

Rule L0543. Standard-level.

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

“Observed in Record Review. In 2 of 2 patient records reviewed, for live discharge it was noted in DCRR#1 that there was no order in the record for discharge from this hospice and to transfer to another hospice per patient request. In review of DCRR#2 there was no discharge order for the patient who elected to revoke hospice care. This was discussed with the hospice director.”

Rule L0547. Standard-level.

Review of the plan of care (42 CFR 418.56(d ))

Rule L0552. Standard-level.

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

Rule L0555. Standard-level.

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

“Observed in Data Session. During discussion with hospice leadership during the data session it was noted that there had been no Performance Improvement Projects in the past two years and therefore did not reflect the scope, complexity, and past performance of the hospice’s services and operations. The only initiative described was one related to supervisory visits being done every 14 days.”

Rule L0572. Standard-level.

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

“Observed in Data Session. During discussion with hospice leadership during the data session it was noted that there had been no Performance Improvement Projects in the past two years and therefore did not reflect the scope, complexity, and past performance of the hospice’s services and operations. There was no documentation of any projects.”

Rule L0573. Standard-level.

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

Rule L0629. Standard-level.

Cost saving (42 CFR 418.78(d))

“Observed in Data Session. During discussion with hospice director during the data session it was noted that there has been no active volunteers for the past two years since the pandemic.”

Rule L0646. Standard-level.

Level of activity (42 CFR 418.78(e))

“Observed in Data Session. During discussion with hospice director during the data session it was noted that there has been no active volunteers for the past two years since the pandemic.”

Rule L0647. Standard-level.

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

“Observed in Record Review. In 5 of 12 patient records reviewed, it was noted that the initial Certification of Terminal Illness did not include a narrative statement. In record review for home visit #1 the only statement on the certification was that the patient had a terminal diagnosis and less than 6 month life expectancy. This was also observed in record review for home visit #3 and record review #1 and #2 and #6. This was discussed with the hospice medical director and the hospice director.”

Rule L0667. Standard-level.

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

“Observed in Record Review. In 1 of 13 patient records reviewed, it was noted that the recertification Certificate of Terminal Illness was not documented in a narrative format by the physician. This was confirmed by the hospice director. This was noted in record review #2.”

Rule L0668. Standard-level.

Content (42 CFR 418.104(a)(3))

Rule L0674. Standard-level.

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

“Observed in Record Review. In 2 of 2 patient records reviewed, who were discharged it was noted that there was no documentation of a discharge summary. This was confirmed by the hospice director for DCRR#1 and #2.”

Rule L0683. Standard-level.

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

“Observed in Record Review. In 2 of 2 patient records reviewed, who were discharged it was noted that there was no documentation of a discharge summary. This was confirmed by the hospice director for DCRR#1 and #2.”

Rule L0684. Standard-level.

Label dispose storage drugs (42 CFR 418.106(e)(2)(i)(A))

“Observed in Document Review. During review of hospice admission packet both in office and in patient homes it was noted that the agency policy on the management and disposal of controlled drugs was not provided to the patient or patient family/representative. Specifically, in home visit #1 the patient was on controlled substances. This was discussed with the hospice director and medical director.”

Rule L0695. Standard-level.