Address
426 NORTH 44TH STREET, SUITE 405, PHOENIX, AZ 85008
Phone
(602)476-2047
License
HSPC8279 (Active)
License Owner
SACRED HEART HOSPICE, LLC
Administrator
Leslie Cooper
Capacity
N/A
License Effective
5/1/2025 - 4/30/2026
CCN (Medicare)
031588
Services:
No services listed
1
Total Inspections
6
Total Deficiencies
1
Complaint Inspections
Inspection History
INSP-0043904
Complete
Date: 5/13/2024
Type: Complaint
Worksheet: Hospice Service Agency
SOD Sent: 2024-06-12
Summary:
Deficiencies were found during the unannounced on-site State Complaint survey conducted on May 13, 2024. Megan Foster, LCSW
Deficiencies Found: 6
Deficiency #1
Rule/Regulation Violated:
R9-10-607. Admission B. At the time of admission, a physician or registered nurse shall: 1. Assess a patient's medical, social, nutritional, and psychological needs; and
Evidence/Findings:
Based on medical records review, review of policies and procedures and interview, the Department has determined the administrator failed to ensure that a physician or registered nurse ensured a patient's psychological needs were appropriately assessed at the time of admission for 5 out of 13 patients reviewed, Patients #1, #4, #8, #9 and #13. Failure to appropriately assess the psychological needs of patients can result in patients being inappropriately admitted to programs that cannot service them and patients not receiving the services they need. Findings include:
Deficiency #2
Rule/Regulation Violated:
R9-10-608. Care Plan C. An administrator shall ensure that: 3. A patient ' s physician authenticates the care plan with a signature within 14 calendar days after the care plan is initially developed and whenever the care plan is reviewed or updated.
Evidence/Findings:
Based on review of medical records, review of policy and procedure and interview, the Department has determined the administrator failed to ensure that care plans were authenticated with physician signatures within fourteen (14) days of the care plan development both upon initial development and whenever a care plan was reviewed or updated for 6 out of 13 patients reviewed, Patient #2, #3, Patient #4, Patient #7, Patient #10, or Patient #11. Failure to ensure physicians authenticate care plans can result in physicians not being fully included in the care planning of patients, leading to substandard patient care. Findings include:
Deficiency #3
Rule/Regulation Violated:
R9-10-611. Medical Records C. An administrator shall ensure that a patient ' s medical record contains: 9. Orders;
Evidence/Findings:
Based on review of medical records, review of facility policy and procedures and interview, the Department has determined the administrator failed to ensure that discharge orders were written by a physician and entered into the medical record for 8 out of 13 patients reviewed, Patient #1, #3, #4, #5, #6, #8, #9 and #13. Failure to ensure a discharge order is written by a physician can result in a patient's physician not being consulted regarding the discharge of a patient and the needs of a patient not being fully met upon discharge. Findings include:
Deficiency #4
Rule/Regulation Violated:
R9-10-607. Admission B. At the time of admission, a physician or registered nurse shall: 1. Assess a patient's medical, social, nutritional, and psychological needs; and
Evidence/Findings:
Deficiency #5
Rule/Regulation Violated:
R9-10-608. Care Plan C. An administrator shall ensure that: 3. A patient ' s physician authenticates the care plan with a signature within 14 calendar days after the care plan is initially developed and whenever the care plan is reviewed or updated.
Evidence/Findings:
Deficiency #6
Rule/Regulation Violated:
R9-10-611. Medical Records C. An administrator shall ensure that a patient ' s medical record contains: 9. Orders;
Summary:
Deficiencies were found during the unannounced on-site State Complaint survey conducted on May 13, 2024. Megan Foster, LCSW