New Century Hospice of San Antonio

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

“Upon patient record review, 2 of 19 (Patients #11,#14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 11: The medication profile contained duplicative listings of acetaminophen. Patient 14: The medication profile contained a topical menthol ointment with no area defined for administration.”

Rule L0530. 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)(4))

“Upon patient record review, 1 of 19 (Patient #14) 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 14: The medical record contained an order for topical menthol ointment with no area defined for administration.”

Rule L0549. Standard-level.

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

Rule L0550. Standard-level.

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

“Upon client record review, 1 of 19 (Patient #11) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient’s condition requires but no less frequently then every 15 calendar days. Patient 11: The current plan of care update contained conflicting information identifying patient as both full code and DNR.”

Rule L0553. Standard-level.

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

“Upon client record review, 1 of 19 (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 4: The medical record contained nursing documentation 7/30/26 of cleansing and applying Optifoam to a wound. There was no evidence of an order for wound care.”

Rule L0555. Standard-level.

Coordination of services (42 CFR 418.56(e)(4))

Rule L0557. Standard-level.

Prevention (42 CFR 418.60(a))

Rule L0579. Standard-level.

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

“Upon patient record review, 1 of 19 (Patient #15) did not have evidence the hospice offers bereavement counseling that includes: • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 15: The medical record contained bereavement phone calls to bereaved at 3 and 9 months. There was no evidence of the phone call tasks included in the bereavement care plan.”

Rule L0596. Standard-level.

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

“Upon patient record review, 1 of 19 (Patient #6) did not have evidence in the patient record that hospice aide assignments and duties are specific to the patient’s needs. Patient 6: The aide care plan contained instructions for a wound dressing to be left in place during bathing. The patient did not have a wound dressing.”

Rule L0625. Standard-level.

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

Rule L0626. 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. The provider annual volunteer utilization rate is at 4.82% for rolling calendar August 2025 to July 2026. 2025 rate was 4.69%.”

Rule L0647. Standard-level.

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

“Upon patient client record review, 1 of 19 (Patient #17) did not have evidence that each patient record contains Advance Directives. Patient 17: The plan of care identified patient as DNR. There was no evidence of an out of hospital DNR order.”

Rule L0677. Standard-level.

Hospice plan of care (42 CFR 418.112(d)(1))

“Upon client record review, 1 of 19 (Patient #1) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 1: The medical record contained an order 7/15/26 for a urinalysis with culture and sensitivity. There was no evidence the order specified facility or hospice responsibility for performing the task.”

Rule L0774. Standard-level.

Coordination of services (42 CFR 418.112(e)(3))

“Upon patient record review, 1 of 19 (Patient #10) did not have evidence that the hospice provided the following information: • Physician certification and recertification of the terminal illness specific to each patient Patient 10: There was no evidence of a certification of terminal illness with physician narrative of eligibility in the hospice binder at the facility.”

Rule L0781. Standard-level.