| Survey Date | Inspection Type | Track ID | Deficiency | Requirement Description | Correction Date |
| 01/25/2021 | Complaint | BZPU | None | NoneNone | None |
| 07/07/2020 | Standard | 8VMC | None | NoneNone | None |
| 03/09/2020 | Complaint | FGMU | None | NoneNone | None |
| 04/29/2019 | Complaint | 3HM1 | None | NoneNone | None |
| 09/19/2018 | Complaint | GVYL | L0543 | PLAN OF CAREAll 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.
| 11/09/2018 |
| 09/19/2018 | Complaint | GVYL | T0113 | COUNSELING AND SOCIAL SERVICES58A-2.016 Counseling and Social Services.
(4) The hospice shall ensure, by employment or contractual arrangement, that there are sufficient social workers and other mental health professionals to meet the social, emotional and mental health needs of the patients and families being served by the hospice.
| 11/09/2018 |
| 08/07/2018 | Complaint | NLZC | T0061 | PLAN OF CARE400.6095
(5) Each hospice, in collaboration with the patient and the patient's primary or attending physician, shall prepare and maintain a plan of care for each patient, and the care provided to a patient must be in accordance with the plan of care. The plan of care shall be made a part of the patient's medical record and shall include, at a minimum:
(a) Identification of the primary caregiver, or an alternative plan of care in the absence of a primary caregiver, to ensure that the patient's needs will be met.
(b) The patient's diagnosis, prognosis, and preferences for care.
(c) Assessment of patient and family needs, identification of the services required to meet those needs, and plans for providing those services through the hospice care team, volunteers, contractual providers, and community resources.
(d) Plans for instructing the patient and family in patient care.
(e) Identification of the nurse designated to coordinate the overall plan of care for each patient and family.
(f) A description of how needed care and services will be provided in the event of an emergency.
(6) The hospice shall provide an ongoing assessment of the patient and family needs, update the plan of care to meet changing needs, coordinate the care provided with the patient's primary or attending physician, and document the services provided.
| 08/26/2018 |
| 08/07/2018 | Complaint | NLZC | T0076 | QAUR(5) Activities undertaken by the QAUR/QAPI committee must demonstrate a systematic collection, review, and evaluation of information and must result in proposed actions to correct any identified problems. The information used by the QAUR/QAPI committee must include:
(a) Care provided in alternate settings and by contracted entities;
(b) Services provided by professional and volunteer staff;
(c) Evaluations by the patient and the patient's family of care provided by the hospice;
(d) Incident reports;
(e) Complaints received from patients and their families;
(f) High-risk, high-volume and problem-prone activities that would have a significant impact on patients, staff or the organization, even if adverse incidents occur infrequently. For example, high-risk activities may include review and evaluation of protocols for containment of communicable diseases, emergency evacuations and continuity of operations; high-volume activities might include collection of information regarding administration of medications; lastly, identifying problem-prone activities might include deterioration or malfunction of equipment, including security of information systems, disposal of contaminated materials or other bio-medical waste; and
(g) Appropriateness of team services and levels of care measured by whether:
1. The plan of care was directly related to the identified physical and psychosocial needs of the patient and the patient's family;
2. Services, medications and treatments prescribed were in accordance with the current hospice plan of care; and
3. The hospice care was primarily a home-care program that utilized inpatient hospice care on a short-term or respite basis only.
(6) The QAUR/QAPI committee shall periodically review the accessibility of hospice services and the quality of those services.
| 08/26/2018 |
| 08/07/2018 | Complaint | NLZC | T0130 | ADMINISTRATIVE POLICIES-DRUGS & BIOLOGICALS58A-2.005
(3) Administrative Policies and Practices.
(a) The administrator must be responsible for developing, documenting and implementing administrative policies and practices which are consistent with these rules, the bylaws, and the plans and decisions adopted by the governing body. These policies and practices must ensure the most efficient operation of the hospice program and the safe and adequate care of the patient and family units. These policies and practices must include:
5. Policies for administering drugs and biologicals in the home which must include:
a. All orders for medications shall be dated and signed by a physician licensed in the State of Florida pursuant to Chapter 458 or 459, F.S.
b. All orders for medications shall contain the name of the drug, dosage, frequency and route.
c. All verbal orders for medication or treatments, or changes in medication or treatment must be taken by a licensed health professional and recorded in the patient's record. Verbal orders must be signed by the physician within thirty (30) calendar days from the date of the order.
d. Experimental drugs shall not be administered without the written consent of the patient or the patient's legal representative, surrogate or proxy. The program administering such drugs must fully inform the patient or the patient's legal representative, surrogate or proxy of any risks, and be prepared to invoke remedial action should an adverse reaction occur. A copy of the signed consent must be kept in the patient's record.
| 08/26/2018 |
| 03/28/2018 | Standard | 1PQV | None | NoneNone | None |
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