Inspection Report
Re-Inspection
Deficiencies: 5
Mar 13, 2013
Visit Reason
The inspection was a recertification survey conducted on 03/13/2013 based on federal requirements for hospices, 42 CFR Part 418, Subparts A through E.
Findings
The survey identified multiple deficiencies related to patient rights, comprehensive drug therapy assessment, patient outcome measures, and content of plan of care. The agency failed to document patient or representative involvement in care plans, complete comprehensive drug profiles, collect data elements for quality assessment, and create measurable outcomes in plans of care.
Deficiencies (5)
| Description |
|---|
| Failure to document the patient's or patient representative's understanding, involvement, or agreement with their plan of care for 13 of 13 sampled patients. |
| Failure to complete a comprehensive drug profile including effectiveness, side effects, drug interactions, and duplicate therapy for 13 of 13 sampled patients. |
| Failure to collect data elements from each assessment for use in the facility's Quality Assessment/Performance Improvement (QAPI) program for 13 of 13 sampled patients. |
| Failure to create measurable outcomes for the plan of care for 13 of 13 sampled patients. |
| Failure to document the patient's or patient representative's understanding, involvement, or agreement with their plan of care for 13 of 13 sampled patients (repeated deficiency). |
Report Facts
Sampled patients: 13
Dates of corrective actions: Corrective actions scheduled between 03/25/13 and 04/25/13.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Clinical Services | Interviewed and confirmed lack of documentation and data collection related to patient understanding and drug therapy. | |
| QAPI Committee | Responsible party for compliance with quality assessment and performance improvement activities. | |
| Administrator | Responsible party for corrective actions and monitoring compliance. | |
| Contract pharmacist | Responsible for comprehensive drug review and patient education. | |
| QA Assistant | Responsible for monitoring audits and compliance. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 25, 2009
Visit Reason
The inspection was conducted as a complaint investigation (NM #27135) to assess compliance with 42 CFR Part 418, Subpart C, Federal Requirements for Hospice Agencies.
Findings
No deficiencies were cited as a result of the complaint investigation completed on 06/25/2009.
Complaint Details
Complaint investigation NM #27135 was completed with no deficiencies cited.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carly O'Neal | Administrator | Signed the statement of deficiencies and plan of correction. |
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