St Camillus Hospice

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

“Observed in Record Review. In 3 of 14 patient records reviewed, The organization failed to include all services needed in the plan of care for the palliation and management of the terminal illness and related conditions as evidenced in HOSRRHV#3: No volunteer interventions or frequency was in care plan. HOSRRNHV#9: Patient had massage and music therapy with no orders. HOSRRNHV#8: Patient had massage therapy with no orders, this was observed and validated by Hospice Clinical Manager”

Rule L0536. Condition-level.

Quality assessment & performance improvement (42 CFR 418.58)

“Observed in Data Session. The organization failed to evaluate contracts annually as evidenced the organization did not eval pharmacy or DME program, this was validated by the Administrator”

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 418.100,: 418.56 and 418.58”

Rule L0651. Condition-level.

Rights of the patient (42 CFR 418.52(c)(1))

“Observed in Record Review. In 1 of 14 patient records reviewed, The organization failed to assess and reassess the patients pain as per pain assessment policy as evidenced in HOSRRHV#2: No pain assessment completed during nursing visits, notes states staff used observation scale but unable to find it in documentation, this was observed and validated by the Hospice Clinical Manager”

Rule L0512. Standard-level.

Content of comprehensive assessment (42 CFR 418.54(c)(8))

Rule L0532. Standard-level.

Plan of care (42 CFR 418.56(b ))

“Observed in Record Review. In 1 of 14 patient records reviewed, The organization failed to provide a written plan of care based on the patient’s goals and time frames as most of the time frames were end of cert as evidenced by in HOSRRHV#1: Patient/caregiver will verbalize understanding of falls prevention, home safety measures: target date end of cert, this was observed and validated by the Hospice Clinical Manager”

Rule L0543. Standard-level.

Content of plan of care (42 CFR 418.56(c)(3))

Rule L0548. Standard-level.

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

Rule L0549. Standard-level.

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

Rule L0553. Standard-level.

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

Rule L0555. Standard-level.

Program scope (42 CFR 418.58(a)(1))

“Observed in Data Session. The quality assessment and performance improvement program failed to demonstrate improvement in the indicators related to improved palliative outcomes and hospice services, this was validated by the Administrator”

Rule L0561. Standard-level.

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

“Observed in Record Review. In 3 of 3 patient records reviewed, The hospice failed to develop a bereavement plan of care that specifies the type of bereavement services to be offered and the frequency of service delivery as evidenced in HOSRRBR#1, HOSRRBR#2 and HOSRRBR#3, this was observed and validated by Hospice Clinical Manager”

Rule L0596. Standard-level.

Competency evaluation (42 CFR 418.76(c)(5))

“Observed in HR File Review. In 1 of 9 HR files reviewed, The organization failed to assess and document staff competency once every three years as evidenced in HR#1: HHA competency was not done for the last 3 years, this was observed and validated by the Administrator”

Rule L0619. Standard-level.

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

“Observed in Record Review. In 6 of 14 patient records reviewed, The organization failed to provide an accurate written patient care instructions for the hospice aide as evidenced by in HOSRRHV#2: HHA care plan had assist with meal planning and also meal preparation, RN should HOSRRHV#4: HOSRRNHV#2, HOSRRNHV#3, HOSRRNHV#4 & HOSRRNHV#9: patient is on anticoagulant therapy and no special bleeding precautions identified in care plan. this was observed and validated by the Hospice Clinical Manager.”

Rule L0625. Standard-level.

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

“Observed in Record Review. In 2 of 14 patient records reviewed, The organization failed to provide services that are ordered by the physician or allowed practitioner in the plan of care as per policy Hospice Aide- Care Plan as evidenced in HOSRRHV#1:the patient declined shower since SOC during HHA visit and no communication to RN. HOSRRHV#2: HHA did not provide shower or bath and did not document reason , this was observed and validated by the Hospice Clinical Manager”

Rule L0626. Standard-level.

Supervision of hospice aides (42 CFR 418.76(h)(2))

“Observed in HR File Review. In 1 of 9 HR files reviewed, A registered nurse failed to make an annual on-site visit to the location where the patient is receiving care in order to observe and assess each aide while the aide is providing care as evidenced in HR #1, there is no record for on-site observation and assessment, this was observed and validated by the Administrator”

Rule L0632. Standard-level.

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

Rule L0663. Standard-level.

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

“Observed in Tracer Activities. Leaders failed to monitor contracted services by communicating the expectations in writing to the provider of the contracted services as evidenced by the DME and therapy contract did not include criminal background checks on employees who provide direct patient care or have access to patient records. There was no key performance indicators identified in pharmacy contract, this was observed and validated by the Administrator”

Rule L0716. Standard-level.

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

“Observed in Record Review. In 1 of 14 patient records reviewed, The organization failed to identify the care and services that are needed and identify which provider is responsible for performing the functions that have been agreed upon and include in the plan of care as evidenced in HOSRRHV#4: Patient is being seen by SNF wound care RN and there is no coordination of care in the hospice plan of care, this is observed and validated by the Hospice Clinical Manager”

Rule L0774. Standard-level.

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

“Observed in Record Review. In 1 of 14 patient records reviewed, The organization failed to provide the SNF in HOSRRHV#4: hospice election form as required, this was validated by the Hospice Clinical Manager”

Rule L0781. Standard-level.