Hospice: Top 10 Deficiencies

Expert Presentation at NAHC’s 2012 March on Washington
April 8, 2013 07:18 PM

Brenda Blunt, MSN, RN, CHPPN, a nurse consultant who serves as the hospice lead within the Survey and Certification Group at the Centers for Medicare & Medicaid Services (CMS), presented at the National Association for Home Care & Hospice’s (NAHC) March on Washington last month.  Blunt focused on recent activity in the hospice survey and certification arena, with her primary focus on top survey deficiencies during calendar year (CY) 2012.

Blunt underscored that there is no statutory requirement relative to frequency of hospice surveys. As a result, CMS determines the frequency of hospice surveys based on its budget allotment.  Currently the budget allows CMS to conduct surveys for a targeted sample of five percent of hospice providers on an annual basis, all hospice providers are required to be surveyed every six and a half years and, on average, each hospice is surveyed every six years.  CMS also conducts validation surveys of providers that have been certified through private accrediting organizations.

Blunt indicated that the top 10 survey deficiencies, which are arranged in order of frequency during CY2012 below - along with the accompanying L-tag from the State Operations Manual. The survey deficiencies are accompanied by examples of the specific shortcoming(s) for which agencies were cited:

418.56(b) – Plan of Care (L543)

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.


  • While continuous oxygen was part of plan of care, discussed in interviews, and during a home visit, there was no indication of respiratory or airway assessment, no interdisciplinary team notes regarding the need for oxygen use or changes.  Patient was seen during visit sitting up in chair with no oxygen on - or in – the vicinity.
  • Widespread issue -- Plan of Care indicates hospice aide services but there were no indications in the form of visit orders or documentation that hospice aide services were being provided. 


418.56(c) - Content of the Plan of Care (L545)

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 plans of care must include all services necessary for the palliation and management of the terminal illness and related conditions.


  • Patient had an ileal conduit but care plan did not include related orders or stomal care for the patient.  Care plan had incontinence listed under functional assessment, but no mention of conduit. 
  • RN removed a patient’s Foley catheter based on his wife’s request, as she would rather change him and husband would find more comfortable, but care plan a month later reflected catheter care and goals related to patient having a catheter.
  • With some frequency plans of care indicated care - wound care, oxygen, or Foley care - per standing orders but no standing orders were present in chart.
  • Failure to have proper information in plan of care relative to wound care, either information was missing or not accurate, was also a frequent survey issue.  


418.64(b) – Nursing Services (L591)

The hospice must provide nursing care and services by or under the supervision of a registered nurse. Nursing services must ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and updated assessments.


  • Patient caregiver contacted agency that nurse had not come after two hours, and first documented RN visit was two days later after another late night call by caregiver.  Patient was found with a fever, tachycardia, abdominal pain and was sent to hospital and admitted.
  • Caregiver called at midnight concerned that patient was having difficulty breathing; caregiver was instructed to administer morphine and Ativan.  Caregiver called again 40 minutes later, was told that the nurse was coming and was instructed to give more medication.  The nurse called at 1:25 am, and told caregiver to give more medications and that she was on her way.  The nurse called again at 1:30 am to report that she was on the way and had spoken to the doctor. Caregiver reported to the nurse that the patient had stopped breathing.  The nurse did not arrive until 2:15 am.


418.76(h) -- Supervision of Hospice Aides (L629)

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.


  • Reviews indicated widespread problems of supervisory visits not being completed or documented. Reported time frames between supervisory visits ranged from 16 days to over 15 weeks.  Given the frequency of this problem, tracking of aide supervision was suggested as a good QAPI project.


418.56(d) - Review of the Plan of Care (L552)

The hospice IDG - with the patient’s attending physician, if any - must review, revise, and document the individualized plan of care as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days.


  • No documentation that the personal physician was involved with the plan of care reviews.
  • Patient admitted on 3lpm of oxygen, over a period of two weeks oxygen increased to 4.5lpm with no indication of a change in orders, no IDG info on the increase and SOB.
  • Chaplain-provided support was documented but no mention or discussion regarding this care was included in IDG meeting notes.
  • Progressing wounds with no indication of IDG addressing changing wound care, RN changing wound care and documenting.
  • No IDG notes mention of changes to plan of care was a frequent concern.
  • Hospice MD failed to attend some IDG meetings but no record of someone catching the physician up on what transpired as part of IDG discussions.


418.56(e)(4) - Coordination of Services (L557)

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.


  • Based on clinical record review, staff interviews, and patient/family interviews, a patient was admitted on a Monday with lung cancer, CHF, and COPD.  Caregiver called first night regarding respiratory distress of patient and was told that he was not a patient according to the computer system,  and therefore hospice staff could not assist.  Eventually the caregiver was advised to give Ativan and morphine, although the family was asking about administration of Lasix, which had been ordered by hospice.  No assistance or visits were provided.  The family took the patient to the hospital for the last two days of life. It was discovered that the admitting nurse had been unable to sync her computer and did not notify the on-call staff of the patient’s admission.
  • Plan of care indicated that patient requested a volunteer, but there was no communication documented between nurse, case manager, and volunteer coordinator about what family was requesting.


418.104 – Clinical Records (L671)

A clinical record containing past and current findings is maintained for each hospice patient. The clinical record must contain correct clinical information that is available to the patient’s attending physician and hospice staff. The clinical record may be maintained electronically.


  • Clinical records lacking signed revocation forms, discharge summary, or events leading to discharge.
  • Volunteer conducted bereavement counseling and kept records at her home.
  • Volunteer was out of town so agency could not provide records.


418.54(c)(6)-Drug Profile (L530)

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 including, but is not limited to, identification of the following:

  • Effectiveness of drug therapy
  • Drug side effects
  • Actual or potential drug interactions
  • Duplicate drug therapy
  • Drug therapy /lab monitoring


  • In signed physician orders, doctor wrote for Ferrous Gluconate. The order was not in the medication profile, nor was there any documentation about this addition or change.
  • Duplicate listings for acetaminophen (acetaminophen and Tylenol) and roxinol (roxinol and morphine). Reason given for duplicate listings was computer synchronization issues.
  • Medication orders failed to list oxygen orders (dose, frequency, route) – this was a frequent issue in surveys.


418.54(c)(7) – Bereavement (L531)

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.

  • No documented initial bereavement assessments – this was a widespread issue in surveys. This could be a good QAPI project – tracking bereavement assessments.


418.100(b) – Governing body and administrator (L651)

A governing body, or designated persons so functioning, assumes full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operations, and continuous quality assessment and performance improvement. A qualified administrator appointed by - and reporting to - the governing body is responsible for the day-to-day operation of the hospice. The administrator must be a hospice employee and possess education and experience required by the hospice’s governing body.


  • No documentation of overall operation of hospice, approval of policies and procedures.
  • Failure to meet as a hospice quality improvement committee (QAPI), no documentation of quality improvement projects or any quality assessment monitoring – meaning no data to support QAPI program.
  • Failure to clearly appoint an administrator.


Blunt concluded her remarks by reminding attendees that CMS conducts annual training for surveyors that runs three and half days. CMS also has four broadcast videos availableon the following topics:

  • Hospice CoPs Subpart C
  • Hospice CoPs Subpart D
  • Hospice QAPI: Part I
  • Hospice QAPI: Part II