HCA Houston Hospice & Family Care

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

“Observed in HR File Review. In 2 of 11 HR files reviewed, ongoing education in emergency management training was not provided every 2 years in personnel file records HR#5 MSW, and HR#9 NP. This RFI was reviewed with and verified by the Hospice Director and Clinical Director.”

Rule E0037. Standard-level.

Exercise of rights/respect for proprty/person (42 CFR 418.52(b)(1)(i))

“Observed in Record Review. In 1 of 2 live discharge records reiviewed, the organization failed to provide services in accordance with licensure requirements, laws, and rules and regulations. In record RRDC#2 the patient was discharged for cause, but was not notified of the discharge in writing. This RFI was reviewed with and verified by the Hospice Director and Clinical Director.”

Rule L0505. Standard-level.

Initial & comprehensive assessment of patient (42 CFR 418.54)

“Observed in Record Review. In 7 of 10 active patient records reviewed where oxygen was present, safety risk was not assessed as part of the patient-specific comprehensive assessment as required by the Provision of Care, Treatment, Services policy. This RFI was found in records RRHV#1, RRHV#2, RRHV#3, RRNHV#1, RRNHV#2, RRNHV#3, and RRNHV#10 and was reviewed with and verified by the Hospice Director and Clinical Director.”

Rule L0520. Standard-level.

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

“Observed in Record Review. In 4 of 14 active patient records reviewed, the initial comprehensive assessment was not completed within five calendar days after the election of the hospice benefit. In record RRHV#2, RRHV#3, RRHV#4, RRNHV#5 bereavement, medical social work, and/or spiritual assessments were not done within this time frame. This RFI was reviewed with and verified by the Hospice Director and Clinical Director.”

Rule L0523. 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)(1))

Rule L0546. Standard-level.

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

“Observed in Record Review. In 14 of 14 active patient records reviewed, interdisciplinary group meeting notes by all core services did not document patient decline, progress towards desired outcomes and goals, and plans for the following two weeks. This RFI was reviewed with and verified by the Hospice Director and Clinical Director.”

Rule L0552. Standard-level.

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

Rule L0555. Standard-level.

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

“Observed in Record Review. In 1 of 14 active patient records reviewed, all disciplines did not collaborate in the care of the patient. In record RRNHV#3 the medical director was not notified at the time the hospice learned that the patient had gone to an emergency department. This RFI was reviewed with and verified by the Hospice Director and Clinical Director.”

Rule L0557. Standard-level.

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

“Observed in Record Review. In 4 of 13 active patient records reviewed where aide services were ordered, supervision was not always documented every 14 days in records RRHV#2, RRNHV#1, RRNHV#5, RRNHV#10. There were several instances of supervisory visits done every 15 days. This RFI was reviewed with and verified by the Hospice Director and Clinical Director.”

Rule L0629. Standard-level.

Initial certification of terminal illness (42 CFR 418.102(b)(3))

“Observed in Record Review. In 11 of 14 active patient records reviewed, the certificate of terminal illness did not include subjective and objective information to support a life expectancy of six months or less. In records RRHV#1, RRHV#2, RRHV#3, RRHV#4, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#6, RRNHV#7, RRNHV#9, and RRNHV#10 documentation lacked metrics or decline related to a terminal diagnosis. This RFI was reviewed with and verified by the Hospice Director and Clinical Director.”

Rule L0667. Standard-level.

Use and mintenance of equipment and supplies (42 CFR 418.106(f)(2))

“Observed in Patient Home. In 1 of 4 home visits where oxygen was present, cylinders were not stored safely. multiple secured and unsecured oxygen tanks were observed in the board and care home entry hallway. More secured and unsecured tanks were found in the patient’s closet along with 4 concentrators. All were covered with clothing and other items. The caregiver stated that she did not receive education on proper storage. This RFI was reviewed with and verified by the Hospice Director and Clinical Director.”

Rule L0702. Standard-level.