A & S Hospice and Palliative Care LLC

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

“Upon patient record review, 6 of 14 (Patient #1,3,4,6,7,9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. #1-Patient record indicated patient utilizing oxygen. Oxygen order not included on the medication profile. Corrected on-site. #3,4,6,7,9-Patient record indicated patient receiving medications. Medication profile did not contain any patient medications. Corrected on-site #4-Upon observation at home visit, patient taking tizanidine 2mg tablets 1po daily for neck pain. Medication not included on medication profile. Corrected on-site.”

Rule L0530. Standard-level.

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

Rule L0549. Standard-level.

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

“Upon patient record review, 6 of 14 (Patient #3,4,6,7,8,9) 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 equipment and supply needs. #3,4,6,8,9-Patient record indicated patient using DME and supplies. No DME or supplies included on plan of care. Corrected on-site. #7-Patient record indicated patient using DME. No DME included on plan of care. Corrected on-site.”

Rule L0550. Standard-level.

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

Rule L0555. Standard-level.

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

“Upon patient record review 5 of 14(Patient #4,5,7,8,9) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care #4,5,7,8,9-Plan of care indicated patient a fall risk. Aide Care plan did not include fall precautions. All corrected on-site.”

Rule L0626. Standard-level.

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

“Upon patient record review, 2 of 14 (Patient #6,10) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient’s clinical information and provide written documentation that it is anticipated that the patient’s life expectancy is 6 months or less. #6-Certification dates are incorrect on CTI for 2nd benefit period. #10-Certification dates are incorrect on CTI for 3rd benefit period.”

Rule L0668. Standard-level.

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

“Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) 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 #1,2,3,4,5,6,7,8,9,10 -patient record did not have clear evidence of patient choice for hospice election statement addendum. Incomplete election addendum form provided to all patients at time of admission.”

Rule L0673. Standard-level.

Authentication (42 CFR 418.104(b))

“Upon patient record review, 2 of 14 (Patient #4,6) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. #4,6-Patient listed as full code in EMR. Patient paper chart contains DNR dated on date of admission. Corrected on-site.”

Rule L0679. Standard-level.

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

“Upon patient record review, 2 of 14 (Patient #11, 12) did not have evidence that the discharge summary includes all required information. #11-there was not evidence of a discharge summary. #12-there was not evidence of a discharge summary.”

Rule L0684. Standard-level.

Personnel qualification (42 CFR 418.114(b)(3))

“Upon personnel record review, 1 of 11 (Personnel #9) did not have evidence that all Medical Social Services are provided by a qualified Medical Social Worker in accordance with the state’s Social Work Practice Act, the hospice’s policies and procedures and/or job descriptions. #9-Employee is a BSW with hire date of 4-14-22 practicing without documented supervision by a qualified MSW.”

Rule L0787. Standard-level.

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

“Upon personnel record review, 2 of 11 (Personnel #3,5) 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. #3,5-no evidence of state required background checks. Corrected on-site.”

Rule L0796. Standard-level.