Health and Human Services Commission (HHSC) is required to report survey and enforcement data every year. This data is captured in the Long-term Care Regulation Annual Report. This report provides data about licensed and certified hospice providers who fail to comply with applicable health and safety standards.
The report may be accessed online using the following link:
https://www.hhs.texas.gov/reports/2024/03/regulatory-services-annual-report-march-2024
This course specifically outlines the top 10 certification deficiencies for hospices in Fiscal Year 2023 (FY 2023) included in the annual report.
The goal of the hospice survey is to determine if the licensed and certified hospice provider is in compliance with applicable standards in the Conditions of Participation set forth in Title 42, Chapter IV, Part 418, of the Code of Federal Regulations (CFR) for certification.
Surveyors use observations, interviews and record reviews as evidence when citing noncompliance and determining if the provider is ensuring an individual's dignity is respected, and that their rights are being protected.
The Conditions of Participation regulations listed in this course can be found using the following links:
https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418
|
FY 2023 Ranking |
Tag Title |
L-Tag: CFR Reference |
FY 2022 Ranking |
|
1 |
Plan of Care |
42 CFR 418.56(b) TAG 0543 |
1 |
|
2 |
Coordination of Services |
42 CFR 418.56(e)(4) TAG 0557 |
NR* |
|
3 |
Review of the Plan of Care |
42 CFR 418.56(d) TAG 0552 |
7 [TIED] |
|
4 |
Update of Comprehensive Assessment |
42 CFR 418.54(d) TAG 0533 |
NR* |
|
5 |
Governing Body and Administrator |
42 CFR 418.100(b) TAG 0651 |
2 [TIED] |
|
6 [TIED] |
Condition of Participation: Interdisciplinary Group, Care Planning, Coordination of Services |
42 CFR 418.56 TAG 0536 |
NR* |
|
6 [TIED] |
Content of Plan of Care |
42 CFR 418.56(c)(4) TAG 0549 |
4 |
|
6 [TIED]
|
Supervision of Hospice Aides |
42 CFR 418.76(h)(1)(i) TAG 0629 |
NR* |
|
9 |
Content - Physician Orders |
2 CFR 418.104(a)(7) TAG 0678 |
7 [TIED] |
|
10 [TIED] |
Timeframe for Completion of Assessment |
42 CFR 418.54(b) TAG 0523 |
4 [TIED] |
|
10 [TIED] |
Content of Comprehensive Assessment
|
42 CFR 418.54(c)(7) TAG 0531 |
NR* |
|
10 [TIED] |
Content of Plan of Care |
42 CFR 418.56(c)(1) TAG 0546 |
NR* |
|
10 [TIED] |
Content of Plan of Care |
42 CFR 418.56(c)(2) TAG 0547 |
NR* |
|
10 [TIED] |
Coordination of Services |
42 CFR 418.56(e)(5) TAG 0558 |
NR* |
|
10 [TIED] |
Quality Assessment and Performance Improvement |
42 CFR 418.58 TAG 0560 |
NR* |
|
10 [TIED] |
Counseling Services |
42 CFR 418.64(d)(1) TAG 0596 |
NR* |
|
10 [TIED] |
Condition of Participation: Organizational Environment |
42 CFR 418.100 TAG 0648
|
NR* |
NR* - Not ranked in Fiscal Year 2023
All examples provided for this training are for illustrative purposes only. We acknowledge that examples may not contain all potential details but are meant to show basic non-compliance.
The hospice failed to ensure all hospice care and services furnished to patients and their families followed an individualized written plan of care established by the hospice interdisciplinary group (IDG) 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.
The hospice failed to ensure that chaplain services were provided to 6 of 10 patients and their families, as ordered in the plan of care.
The hospice failed to develop and maintain a system of communication and integration, in accordance with the hospice's own policies and procedures, to provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement.
The hospice failed to maintain communication and coordination of care between the hospice agency and the contracted physical therapist for 6 of 8 active patients, in accordance with the hospice's own policies and procedures.
The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) must review, revise, and document the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days.
The hospice IDG failed to revise and document the changes in the plan of care, for 3 of 6 patients, when clinical records documentation identified changes had occurred in the patient's condition within 15 calendar days.
The hospice failed to ensure that the update of the comprehensive assessment was accomplished by the hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) and must consider changes that have taken place since the initial assessment, including information on the patient's progress toward desired outcomes and/or a reassessment of the patient's response to care. The assessment update was not completed as frequently as the condition of the patient required, but no less frequently than every 15 days.
The hospice IDG failed to update the comprehensive assessments for 5 out of 10 patients with the changes to patient's progress every 15 days.
The hospice failed to ensure a governing body (or designated persons functioning as the governing body) assumes full legal authority and responsibility for the management of the hospice and the provision of all hospice services, its fiscal operations, and continuous quality assessment and performance improvement. The hospice failed to ensure a qualified administrator appointed by and reporting to the governing body was responsible for the day-to-day operation of the hospice. The hospice failed to ensure that the administrator is a hospice employee with the education and experience required by the hospice's governing body.
The hospice administrator failed to ensure the hospice physician took part in physical assessments to update the clinical diagnoses, medical plan of care, and prognosis for 4 of 5 patients.
The hospice failed to meet one or more requirements identified in this rule including: establishing an Interdisciplinary Group (IDG) to prepare written care plans for each patient in consultation with their attending physician; creating written care plans for five out of seven reviewed patient records; and ensuring that both patients and primary caregivers received education and training on their responsibilities regarding the care and services outlined in the care plans.
The hospice failed to ensure that the IDG prepared written care plans in collaboration with the patient's attending physician for 6 of 10 patients and failed to educate and train the patients and their primary care givers on their responsibilities for care and services as identified in the plan of care.
The hospice failed to include all services necessary for the palliation and management of the terminal illness and related conditions, including drugs and treatment necessary to meet the needs of the patient in the patient's plan of care.
The hospice failed to include the physician's orders in the patient's plan of care for pain management related to the patient's bone pain from metastasized cancer.
The hospice failed to ensure that the registered nurse 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 failed to ensure that the registered nurse conducted an on-site supervisory visit for 2 of 9 patients receiving hospice services at least every 14 days.
The hospice failed to ensure the patient's clinical record included the physician's orders.
The hospice failed to ensure physician's orders were included in the clinical records for 6 of 10 active clients and 2 of 3 discharged clients.
The Interdisciplinary Team (IDT) failed to complete the comprehensive assessment no later than 5 calendar days after the election of hospice care.
The hospice's IDT failed to ensure that all disciplines conduct an initial comprehensive assessment within the five days following the benefit election for 6 of 8 active and 2 of 3 discharged hospice patients.
The comprehensive assessment failed to include 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 and to be considered in the bereavement plan of care.
The hospice failed to ensure the comprehensive assessment included an initial bereavement assessment of the patient's daughter for coping with the patient's death.
The hospice's plan of care failed to include all services necessary for the palliation and management of the terminal illness and related conditions, including interventions to manage pain and symptoms.
The hospice failed to ensure the plan of care contained interventions to address pain discovered on the initial comprehensive assessment for one of seven active patients.
The hospice's plan of care failed to include all services necessary for the palliation and management of the terminal illness and related conditions, including a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.
The hospice failed to include the frequency of visits in the plan of care for 12 of 13 patients receiving skilled nursing services.
The hospice failed to develop and maintain a system of communication and integration, in accordance with the hospice's own policies and procedures, to provide for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions.
The hospice failed to maintain an open dialogue with the Personal Assistance Services agency servicing the client, resulting in the duplication of services such as bathing, toileting, and transfer.
The hospice failed to develop, implement, and maintain an effective, ongoing, hospice-wide data-driven quality assessment and performance improvement program. The hospice's governing body did not ensure that the program: reflects the complexity of its organization and services; involves all hospice services (including those services furnished under contract or arrangement); focuses on indicators related to improved palliative outcomes; and takes actions to demonstrate improvement in hospice performance. The hospice failed to maintain documentary evidence of its quality assessment and performance improvement program and be able to demonstrate its operation to the Centers for Medicare and Medicaid Services.
The hospice failed to maintain evidence of an on-going QAPI program. The QAPI plan was last revised on 08/01/2011 and the last QAPI meeting minutes were dated 11/05/2011.
The hospice failed to ensure that counseling services include bereavement counseling. The hospice did not have an organized program for the provision of bereavement services furnished under the supervision of a qualified professional with experience or education in grief or loss counseling. The hospice did not make bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. The hospice did not extend bereavement counseling residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care. The hospice did not ensure that bereavement services reflect the needs of the bereaved.
The hospice failed to ensure the bereavement services were provided under the supervision of a qualified professional when the administrator, who did not have the proper credentials, signed off as the bereavement coordinator during the IDT meeting.
The hospice must organize, manage, and administer its resources to provide the hospice care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness and related conditions.
The hospice failed to intervene when the IDT failed to plan for the safety of two patients who were at risk for harm to self and others.
Most of the top deficiencies reoccur year to year. Knowing the most commonly cited certification deficiencies may help you anticipate issues and resolve them to maintain in compliance and avoid citation.
Regardless of your position in the agency, you can learn important and valuable information to improve your agency's service to patients.
In preparation of future surveys, agencies should review and implement their Quality Assessment and Performance Improvement (QAPI) plan to make self-determination of compliance, particularly in accordance with the most-frequently cited certification deficiencies.
HHSC Long-Term Care Regulation
LTCRPolicy@hhs.texas.gov
https://hhs.texas.gov/