Deficiency #1: Plan of Care

All hospice care and services furnished to patients and their families must follow an individualized, written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient’s needs if any of them so desire.

Deficiency #2: Drug Profile

A review of all of the patient's prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. This includes, but is not limited to, identification of the following: (i) Effectiveness of drug therapy (ii) Drug side effects (iii) Actual or potential drug interactions (iv) Duplicate drug therapy Drug therapy currently associated with laboratory monitoring.

Deficiency #3: Supervision of Hospice Aides

A registered nurse must make an on-site visit to the patient’s home: No less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. The hospice aide does not have to be present during this visit.

Deficiency #4: Content of the plan of care: The hospice must develop an individualized written plan of care for each patient

The plan of care must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions.

Deficiency #5: Content Plan of Care: A detailed statement of the scope and frequency of services necessary to meet specific patient and family needs.

The plan of care may include a range of visits and PRN orders for visit frequencies to ensure the most appropriate level of service is provided to the patient. A range of visits is acceptable as long as it continues to meet the identified needs of the patient/family. Visit ranges with small intervals are acceptable (i.e., 1‐3 visits/week; 2‐4 visits/week) but ranges that include “0” as a frequency are not allowed. The IDG may exceed the number of visits in the range to address patient/family’s needs. There should be documentation in the record to support the need for the extra visit(s). If the patient requires frequent use of PRN visits, the plan of care should be updated to include the need for additional visits. Standing orders or routine orders must be individualized to address the specific patient’s needs and signed by the patient’s physician. The IDG should be proactive in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis.

Deficiency #6: Standard: Prevention The hospice must follow accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions.

Standard Precautions are based on the principle that all blood, body fluids, secretions, excretions (except sweat), non‐intact skin, and mucous membranes may contain transmissible infectious agents. Standard Precautions include a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered. These include: hand hygiene; use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure; and safe injection practices. Any deficiency cited as a violation of accepted standards of practice must have a copy of the applicable standard of practice provided to the hospice along with the statement of deficiencies. A hospice may also be surveyed for compliance with State practice acts for each relevant discipline. Any deficiency cited as a violation of a State practice act must reference the applicable section of the State practice act allegedly violated, and a copy of that section of the act must be provided to the hospice along with the statement of deficiencies.

Deficiency #7: Level of activity. L-Tag: L647

Volunteers must provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5% of the total patient care hours of all paid hospice employees and contract staff. The hospice must maintain records on the use of volunteers for patient care and administrative services, including the type of services and time worked.

Deficiency #8: Bereavement

An initial bereavement assessment of the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment must be incorporated into the plan of care and considered in the bereavement plan of care.

Deficiency #9: Timeframe for Completion of the Comprehensive Assessment

Hummingbird's interdisciplinary approach allows for every discipline to contribute to the comprehensive assessment. Tracking of documentation of each discipline improves compliance on your IDG notes and Sfax allows you to share documents quickly and easily with outside physicians.

Deficiency #10: Coordination of Services Ensure that the care and services are provided in accordance with the plan of care.