Every finding on record at Capital Hospice

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. THIS IS A CONTINUED REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. In 2 of 3 (67%) clinical records reviewed for patients receiving hospice aide services, it was revealed that the agency did not ensure the registered nurse (RN) prepared a hospice aide plan of care that documented clear and specific instructions for the patient's care. Clinical Record 2: The hospice aide was ordered on 11/11/2024 with a frequency of 3 times a week. The aide plan of care (POC) included an assigned task for catheter care per visit. However, the patient had no catheter and wore incontinence briefs only. This task continued to be assigned as of the review dated 11/25/2024. The aide did document the catheter care task as N/A (not applicable) for each visit. Clinical Record 3: The hospice aide plan of care (POC) was documented on 11/09/2024 with an ordered visit frequency of 3 times a week. The POC was not updated as of 11/25/2024. The following assigned tasks had no documented frequency: assist with dressing; peri care; skin care; oral care; and bed bath. A review of all aide notes revealed that all tasks were provided at each visit, which occurred three times a week. During an interview, the Director of Clinical Services and the Executive Director confirmed the findings and stated the hospice aide plans of care were not accurate.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 2 of 11 (18%) clinical records reviewed, in which chaplain services were accepted, it was revealed that the agency did not ensure that a spiritual initial assessment was completed no later than five calendar days after the election of hospice care. Clinical Record 2: The patient elected the hospice benefit on 05/27/2024. On the initial plan of care dated 05/27/2024 the chaplain was ordered 1 time a month for 3 months effective 06/01/2024. The chaplain made a phone call on 05/31/2024 with no answer from the patient. The chaplain documented that he would "follow up appropriately." There was no follow up documented until 06/28/2024 which was an initial assessment via phone call. In an interview and joint review of the clinical record with the compliance director she confirmed the clinical record lacked documented evidence the chaplain followed up with the patient/family between 05/31/2024 and 06/28/2024. Clinical Record 8: The patient elected the hospice benefit on 04/23/2024. On the initial plan of care dated 04/23/2024 there was an order for the chaplain for 1 time for 1 month. The chaplain made a call to the patient with no answer on 04/26/2024 and left a message for patient and family. There was no documented evidence of any contact made by the chaplain again until 06/25/2024 in this note he documented that he family refused chaplain services. There was no spiritual assessment found in the RN initial assessment dated 04/23/2024. In an interview and joint review of the clinical record with the compliance director she confirmed that the initial assessment was not completed by the chaplain in a timely manner.

It is required that the comprehensive assessment includes 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 is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 22 (14%) clinical records reviewed it was revealed that the records did not include evidence of an initial bereavement assessment. Clinical Record 6: The patient elected the hospice benefit on 10/03/2024. During review of the clinical record there was no documented evidence that an initial bereavement risk assessment was completed. There was no bereavement risk assessment in the initial RN assessment made on 10/03/2024, it was not found in the social work assessment made on 10/07/2024 or in the chaplain visit made on 10/07/2024. Clinical Record 8: The patient elected the hospice benefit on 04/23/32024. During review of the clinical record there was no documented evidence that an initial bereavement risk assessment was completed by the interdisciplinary team. Clinical Record 9: The patient elected the hospice benefit on 07/16/2024. During review of the clinical record there was no documented evidence that an initial bereavement risk assessment was completed by the interdisciplinary team. During joint review of the clinical record and interview with the compliance director, she confirmed these clinical records did not include evidence that an initial bereavement risk assessment had been completed.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 22 (9%) clinical records reviewed it was revealed that the agency did not ensure that the plan of care included measurable outcomes to problems identified in the comprehensive assessment. Clinical Record 4: The patient elected the hospice benefit on 04/07/2024. The RN documented on the initial assessment that the patient had a feeding tube that was being used for enteral feedings and medication administration. On the face-to-face assessment completed by the nurse partitioner (NP) for certification period 07/30/2024 -09/27/2024 the NP documented that the patient was receiving Nepro 3 cans per day. The plans of care, effective from 04/07/2024 to current, included the problem of “Diet/Hydration: Diet as tolerated effective 04/07/2024 (no changes since last certification period); Nutritional supplement: Regular; Enteral/Parenteral: Enteral feeding of ________amount of_____ formula every ______effective date 04/07/2024.” Durning an interview and joint review of the clinical record with the compliance director she confirmed that the plan of care was lacking measurable outcomes required to meet the patient's needs. Clinical Record 5: The patient elected the hospice benefit on 08/29/2024 with a diagnosis of malignant neoplasm of the esophagus. The initial RN assessment dated 08/29/2024 documented throat pain and intermittent esophagus pain as a problem, rated by patient as “intermittent pain, characteristic unbearable, worsened by movement, relieved by medication, effects on activities.” Initial plan of care dated 08/29/2024 and updated plan of care dated 09/05/2024 did not include measurable outcomes for pain, the pain goal read "patient/caregiver goals: pain rating of _____/10 will be maintained by: ____Achieve by date: 09/19/2024 start effective date 08/29/2024" During joint clinical record review and interview with the compliance director she confirmed that the documentation for the goal was incomplete as it lacked measurable outcomes.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires; but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed in which wounds were documented revealed that the agency did not ensure that individualized plan of care was reviewed and revised as frequently as the patient's condition required. Clinical Record 3: The patient elected the hospice benefit on 01/13/2022 with a diagnosis of Alzheimer's Disease. Per the clinical record the patient was bedbound and had a long history of wounds. An order was documented on the plan of care effective 03/25/2024, “cleanse sacral wound with wound cleanser. Apply zinc to peri wound area, apply calcium alginate to wound bed, apply 4x4 gauze and cover with Opti foam dressing reinforce with pink zinc tape every 3 to 5 days as needed.” On 09/09/2024 the RN documented a wound assessment and the wound care done was cleansed with wound cleanser zinc paste, adhesive dressing and reinforced with pink zinc tape (this did not follow the order on the plan of care). The same wound care was performed on 09/16/2024, 09/23/2024, and 09/30/2024. There was no wound care discussed or updated during IDT meetings dated 09/05/2024, 09/20/2024, and 10/03/2024. In an interview and joint review with the compliance director she agreed and confirmed that the wound care was not updated as frequently as the patient care needs were changing according to wound documentation by the RN.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 4 of 11 (36%) clinical record reviewed, in which hospice aide services were accepted, it was revealed that the agency did not ensure the RN provided clear and specific written instructions for the aide assignments. Clinical Record 2: The patient elected the hospice benefit on 05/27/2024 with a diagnosis of Senile Degeneration of the Brain. The Aide plan of care initiated on admission instructed the aide to perform hair care as needed every visit. The aide plan of care did not provide instructions to define “as needed” and the patient was unable to direct their own care. Clinical Record 3: The patient elected the hospice benefit on 01/13/2022 with a diagnosis of Alzheimer's Disease. The plan of care for certification period 08/30/2024 – 10/28/2024 documented that the patient was on Oxygen, had a foley in place (effective since 03/28/2024), and wounds to the sacral area that were being covered with dressings. The aide plan of care (08/30/2024 – 10/28/2024) did not specific instructions for foley care, what the aide should for dislodged or soiled wound dressings, or if the aide could or could not remove oxygen for cares, and the patient was unable to direct their own care. Clinical Record 4: The patient elected the hospice benefit on 04/07/2023 with a diagnosis of Parkinson's disease. The clinical record documentation revealed the patient had a feeding tube and foley catheter in place. The aide plan of care, dated 09/30/2024, included the following tasks: range of motion exercises for right and left arms and legs “as needed” and shave with electric razor “as needed.” On the visits reviewed the aide had marked that these tasks had been completed. The aide plan of care (effective as of 09/30/2024) did not provide additional instructions for the “as needed” tasks, nor did it include specific instructions on RN notification for malfunctioning of the feeding tube or if the aide was to provide foley catheter care, and it did not state the patient could direct the cares. Clinical Record 9: The patient elected the hospice benefit on 07/16/2024 with a diagnosis of acute respiratory failure with hypoxia. The aide plan of care dated 07/23/2024 ordered “assist with toileting bathroom, raised toilet seat, beside commode as needed when toileting.” The aide care plan did not provide specific instructions for when the patient would use the bedside commode versus the bathroom toilet, and it did not state the patient could direct the cares. In an interview and joint record review with the compliance director she agreed and confirmed that these aide care plans were not specific.

It is required that a hospice aide provides services are ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 1 of 11 (9%) clinical records reviewed, in which hospice aide services were accepted, it was revealed that the agency did not ensure that the aide provided services as ordered by the interdisciplinary group. Clinical Record 8: The patient elected the hospice benefit on 04/23/2024. For the certification period 04/23/2024 - 07/21/2024 the plan of care ordered aide visits 1 time per week for 8 weeks starting on 05/01/2024. The week of 05/12/2024 the clinical record lacked evidence that an aide visit was completed nor was there evidence of why the visit was not provided. In an interview and joint review of the clinical record with the compliance officer she stated that there was no evidence of a visit made the week of 05/12/2024.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are noted in the plan of care, and documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed, in which volunteer services were requested, it was revealed that the agency did not ensure that a volunteer request was followed through. Clinical Record 1: The patient elected the hospice benefit on 09/01/2024. During the social worker's visit dated 09/19/2024 it was documented that the patient requested volunteer services 2 times a week for companionship. During further review of the clinical record there was no documented evidence that a volunteer had been provided for this patient. As of 10/15/2024 when the clinical record was reviewed there was still no follow up for volunteer services. During joint review of the clinical record and interview with the compliance director she stated that this happened during a time when the volunteer coordinator was in transition, and she confirmed there was no follow up with volunteer services.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, personnel record review and interview. In 2 of 7 (29%) personnel records of staff who provided direct care, it was revealed that the agency did not ensure that competency testing was performed annually. The agency's Staff Competency Assessment policy, with a date of 04/22/2024, stated, in part, that "Annual skills for direct care staff, and other staff members whose work directly affects patient care, are assessed by observation, simulated demonstration, or other knowledge-based evaluation methods. Staff includes...Certified Nursing Assistants." Per the Public Health Emergency (PHE) waiver: Condition of participation 418.103(g)(3) hospice’s requirement for hospices to annually assess the skills and competence of all staff furnishing care and provide in-service training and education programs where required. The PHE ended on 05/11/2023 and the guidance stated, “All postpones assessments must be completed by the end of the first full quarter after the expiration of the PHE (09/30/2023).” Personnel Record 8: The personnel record for this certified nursing assistant (CNA), who was hired on 10/05/2015 and who provided care in the home, contained a field review checklist that was completed on 10/15/2024 and stated that it covered the year of 2022. There was no other documented evidence that the annual competency assessment was completed for 2023. Personnel Record 12: The personnel record for this CNA, who was hired on 03/07/2016 and who provided care in the inpatient unit, contained a field review checklist that was completed on 01/09/2023 and stated that it covered the year of 2022. There was no other documented evidence that the annual competency assessment was completed for 2023. During an interview with the Corporate Compliance Manager on 10/16/2024, it was confirmed after following up with the human resources staff that they were unable to locate evidence of skills competency testing for these two personnel records for year of 2023.

The Condition of Participation requires that a hospice that provides inpatient care directly in its own facility is responsible to ensure the level of intensity of services needed to ensure that the patient's plan of care outcomes are achieved and negative outcomes avoided. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This Condition of Participation was not met as evidenced by observation, document review and interview, which revealed the hospice's inability to ensure the avoidance of negative outcomes for patients in the inpatient care facility. The hospice failed to maintain a safe physical environment free of hazards for patients, staff and visitors [L824/418.110(c)]. The hospice failed to address real or potential threats to the health and safety of the patients, others and property [L825/418.110(c)(1)]. The cumulative effect of this deficiency has resulted in the hospice's inability to ensure the provision of quality care for the Condition of Participation CFR 418.110, Hospices that provide inpatient care directly. The collective deficient practice illustrated a systemic process failure that had the potential to affect all patients receiving hospice inpatient care.

It is required that the inpatient hospice facility physical environment maintains a safe environment free of hazards and addresses real or potential threats to the health and safety of patients, hospice staff, visitors, others, and property. This standard was not met as evidenced by observation, document review and interview. Observation revealed that the inpatient hospice facility did not maintain a safe environment free of hazards and did not address real or potential threats to the health and safety of patients, hospice staff, visitors and others. 418.110(i) stated in part, "The intent of this regulation is that the temperature of water at fixtures and in showers and tubs used by patients shall be automatically regulated by control valves and delivered for use at the appropriate temperature. There is a risk that patients or staff may be scalded by excessively hot water discharged by plumbing fixtures. Water that is too hot may scald individuals who are exposed to it. This danger is particularly significant for patients who may have circulatory or other neurological deficits that prevent the instantaneous recoil from water that is too hot...The recommended water temperatures at the plumbing fixtures should be maintained at or below 110 degrees." During the IPU observation, conducted on 10/15/2024, a test of the hot water in the patient room that was furthest from the source of hot water resulted in a temperature reading of 112.4 degrees Fahrenheit. This was 2.4 degrees higher than the 110 degrees required by regulation. During an interview on 10/15/2024, the IPU Clinical Director confirmed the water temperature of 112.4 and stated that he was unaware of the requirement to monitor water temperatures. Agency policy, Patient Restraints, dated 11/04/2022, stated in part, "It is the policy of the above organization(s) to maintain a restraint free patient environment." This policy defined physical restraint in part as, "Any manual method, physical or mechanical device...that involve[s] the physical holding of a patient from falling out of bed...[and] devices with multiple purposes such as side-rails...when they cannot be easily removed by the patient and restrict the patient's movement, constitute a restraint." During a tour of the inpatient unit (IPU) on 10/15/2024, all 5 patients currently admitted to the IPU were observed to be in hospital beds with bed rails in the extended position and blocking egress to and from the bed. Three patients were in beds with all 4 beds rails up (2 upper and 2 lower), and 2 patients were in beds with 3 of the 4 bed rails up (1 lower rail down). There were 2 models of hospital beds in use. Both models were inspected. It was observed that the bed rails could not be moved or retracted by the patient. Both models had 4 bed rails attached to the bed (2 upper and 2 lower). During an interview on 10/15/2024, the Regional Executive Director and IPU Clinical Director confirmed the IPU had a no restraint policy and stated that bed rails were routinely used for patients to prevent them from falling from the bed and for repositioning. The Regional Executive Director and Clinical Director confirmed that staff immediately discontinued the use of the lower bed rails for all patients, and all staff were educated on the agency Patient Restraints policy. The cumulative effect of this deficiency has revealed that the hospice in-patient facility did not maintain a safe environment free of hazards and did not address real or potential threats to the health and safety of patients, hospice staff, visitors and others.

It is required that each patient in the hospice inpatient facility always has an adequate supply of hot water and has plumbing fixtures with control valves that automatically regulate the temperature of the hot water used by patients. This standard was not met as evidenced by document review, interview and observation. During observation of the inpatient unit (IPU) on 10/15/2024, it was revealed that the agency did not regulate the temperature of the hot water used by patients. 418.110(i) stated in part, "The intent of this regulation is that the temperature of water at fixtures and in showers and tubs used by patients shall be automatically regulated by control valves and delivered for use at the appropriate temperature. There is a risk that patients or staff may be scalded by excessively hot water discharged by plumbing fixtures. Water that is too hot may scald individuals who are exposed to it. This danger is particularly significant for patients who may have circulatory or other neurological deficits that prevent the instantaneous recoil from water that is too hot...The recommended water temperatures at the plumbing fixtures should be maintained at or below 110 degrees." During the IPU observation, conducted on 10/15/2024, a test of the hot water in the patient room that was furthest from the source of hot water resulted in a temperature reading of 112.4 degrees Fahrenheit. This was 2.4 degrees higher than the 110 degrees required by regulation. During an interview on 10/15/2024, the IPU Clinical Director confirmed the water temperature of 112.4 and stated that he was unaware of the requirement to monitor water temperatures. A review of the water temperature testing logs for the inpatient unit (IPU) revealed that the agency did not ensure that tests of the hot water temperature in the patients' rooms were completed and documented on a regular basis.

It is required that the use of restraint or seclusion in the hospice inpatient facility is in accordance with safe and appropriate restraint and seclusion techniques, as determined by hospice policy in accordance with state law. This standard was not met as evidenced by document review, interview and observation. Observation revealed that the hospice did not ensure the use of restraint in the hospice inpatient facility in accordance with safe and appropriate restraint and seclusion techniques, as determined by hospice policy. Agency policy, Patient Restraints, dated 11/04/2022, stated in part, "It is the policy of the above organization(s) to maintain a restraint free patient environment." This policy defined physical restraint in part as, "Any manual method, physical or mechanical device...that involve[s] the physical holding of a patient from falling out of bed...[and] devices with multiple purposes such as side-rails...when they cannot be easily removed by the patient and restrict the patient's movement, constitute a restraint." During a tour of the inpatient unit (IPU) on 10/15/2024, all 5 patients currently admitted to the IPU were observed to be in hospital beds with bed rails in the extended position and blocking egress to and from the bed. Three patients were in beds with all 4 beds rails up (2 upper and 2 lower), and 2 patients were in beds with 3 of the 4 bed rails up (1 lower rail down). There were 2 models of hospital beds in use. Both models were inspected. It was observed that the bed rails could not be moved or retracted by the patient. Both models had 4 bed rails attached to the bed (2 upper and 2 lower). During an interview on 10/15/2024, the Regional Executive Director and IPU Clinical Director confirmed the IPU had a no restraint policy and stated that bed rails were routinely used for patients to prevent them from falling from the bed and for repositioning. The Regional Executive Director and Clinical Director confirmed that staff immediately discontinued the use of the lower bed rails for all patients, and all staff were educated on the agency Patient Restraints policy. A tour of the inpatient unit (IPU) and interviews with the IPU leadership on 10/15/2024 revealed that the agency did not ensure that patients remained without restraint in accordance with their policy.

Based on clinical record review, policy review, and staff interviews, the Hospice Agency staff failed to ensure the coordination and supervision of care and services were implemented to ensure adequate supplies were provided to patients for management of illness in one (1) of one (1) patient. (Patient #1) Findings included ... A review of the facility's policy titled, "Coordination of Services," dated 7/2013, showed the agency Interdisciplinary Group (IDG) is responsible for coordinating care and services provided to their patients. A review of Patient #1's clinical record on 01/13/2022, showed an 89-year-old male, was admitted to Hospice care (Home) on 04/15/2021 with a Hospice benefit Period 12/11/2021 to 02/04/2022 with diagnoses of Parkinson's Disease, Seizures, and Cerebellar Stroke Syndrome. Also, Patient #1 has complete urinary retention and requires catheterization three (3) times a day by caregivers. Further review of the clinical record Hospice Nursing Initial Comprehensive Assessment dated 04/16/2021 showed Patient #1 with a history of Bladder Cancer, Hypertension, Seizures, and Stroke. Patient #1 and the Power of Attorney (POA) declined Indwelling Foley Catheter placement. A review of the clinical record, Hospice Social Services Clinical Note dated 11/17/2021, showed POA expressed concern over the lack of catheters for Patient #1. In addition, a review of the clinical record, Hospice Nursing Clinical Note dated 11/17/2021, showed the caregiver requested supply catheters as she only has about 7-10 days' supply. Employee #4 informed the caregiver it was discussed today and expected delivery soon. A review of the clinical record, IDG Meeting Review dated 11/18/2021 showed the social worker documented the POA expressed concern over the lack of catheters for Patient #1. The clinical record, Hospice Nursing Clinical Note dated 11/23/2021, showed the caregiver reported that Patient #1 has no catheters remaining. Employee #4 sent an email to the Hospice supervisor for a refill. Further review of the clinical record, Hospice Nursing Clinical Note dated 12/09/2021, showed the POA and Hospice Interdisciplinary Team (IDT) would proceed with the discharge process. Patient #1 has all the needed supplies for the next three (3) weeks. The surveyor conducted a virtual interview with Employee #1 on 01/14/2022 at approximately 2:45 PM. When queried about ordering supplies for patients, she stated the nurse requested the supplies, and if the order meets the requirements, the supplies are delivered within 24-48 hours to the patient's home. If the order does not meet the requirements, the system notifies the clinical manager for approval. The Regional Executive Director receives the notification as well. The clinical manager approves the order, and the order is delivered to the patient. The surveyor conducted a virtual interview with Employee#2, the Clinical Manager, on 01/14/2022 at approximately 3:11 PM. Employee #2 has been employed with the agency since 11/15/2021. When queried about ordering supplies for patients, she stated there is a supply company portal where employees have an account and can order supplies. Some supplies are on-site at the hospice health agency, including gloves, diapers, chux pads, 4x4s, and foley catheters. The surveyor conducted a virtual interview with Employee #4 on 01/18/2022 at approximately 3:15 PM. When queried about the process of ordering supplies for Patient #1, Employee #4 stated that the family members and private caregivers will inform the nurse when the patient needs supplies. Employee #4 stated he could not just order the catheters. Employee #4 also stated that once a request is made online, an email was sent to the supervisor to let the agency know the patient had a supply of catheters for about a week. Employee #4 stated he can order basic supplies such as diapers, chux pads, and gloves. Employee #4 did not order the catheters, and a request was sent by email to the supervisor to order the catheters. There are catheters in the online system we can order, but Patient# 1 used another type of catheter. The order should arrive at the patient's home within 24-48 hours. Family members will inform the nurse when supplies arrive at the house. If there are any problems, a separate email and follow-up phone calls to the supervisor by the nurse. Employee #4 stated that the supervisor he notified is no longer in the office. The hospice agency lacked documented evidence of coordination of care and services were implemented to ensure adequate supplies were provided to all patients identified. The surveyor conducted a face-to-face interview (virtual) with Employees #1 (Regional Executive Director) and #2 (Clinical Manager) on 01/18/2022 at approximately 3:30 PM. Both employees acknowledged the findings.

Based on personnel record review, policy review, District of Columbia Municipal Regulations review, and staff interviews, the Hospice Agency failed to ensure that the personnel record of the Licensed Graduate Social Worker and the Director of Family Services included current information relative to qualifications and the need to practice under the supervision of a Licensed Independent Clinical Social Worker in the District of Columbia (Employees #6 and 12). The findings include: According to the DC Department of Health, Health Regulation and Licensing Administration (HRLA), Board of Social Work Policy Statement titled, "Scope of Social Work Practice and Licensed Graduate Social Workers (LGSWs) in Private Practice," date amended 03/23/20, showed "LGSW may receive supervision for non-clinical practice from either a Licensed Independent Social Worker (LISW) or a Licensed Independent Clinical Social Worker (LICSW). However, LGSW may perform clinical practice only under the supervision of a LICSW. The LICSW is authorized to practice both clinical and non-clinical social work independently. Additionally, the LICSWs are authorized to supervise social work practice, both clinical and non-clinical, in the District." A review of the Hospice Agency's personnel records on 01/14/22 at approximately 11:30 AM showed Employee #6 (Director, Family Servies) is licensed as a Licensed Clinical Social Worker (LCSW) and has an active Virginia License, with an expiration date of 06/30/22. Employee #12 (Social Worker) is licensed as a Licensed Medical Social Worker-Masters, (LMSW) and has an active Maryland license with an expiration date of 10/31/23. A review of the District of Columbia Municipal Regulations (DCMR), titled DCMR for Social Work", dated 04/05/19, showed that "only an Independent Social Worker or Independent Clinical Social Worker licensed are authorized to supervise the practice of a Licensed Graduate Social Worker." During the record review, the surveyor conducted a face-to-face interview with Employee # 18 (Human Resources Generalist) on 01/14/22 at approximately 11:30 AM. Employee #18 informed the surveyor, "Employee #6 oversees all float pool and counselors and does not oversee the home care, social workers." The personnel record lacked documented evidence that Employee #6 (Director, Family Services) provided supervision as a DC Licensed Independent Clinical Social Worker (DC License) and Employee #12 practiced with a current DC license per the District of Columbia Municipal Regulations for Social Workers. The surveyor conducted a face-to-face interview with Employee #18 (Human Resource Generalist) on 01/14/22 at approximately 11:30 AM. Employee #18 acknowledged the findings during the personnel record review.

It is required that the patient’s pain is assessed as part of a comprehensive assessment. Assessment of pain in children and adolescents is conducted with consideration of age and neurocognitive development. The documented assessment of the patient’s pain includes: 1. History of pain and its treatment, both pharmacological and non-pharmacological; 2. Use of a standardized pain assessment tool appropriate to the patient’s developmental and cognitive status; 3. Characteristics of the pain, including: a) Location, frequency, and intensity; b) How pain impacts the patient’s ability to engage in usual activities and function (e.g., appetite, sleeping); 4. The patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. This standard was not met as evidenced by interview and document review. 1 of 5 (20%) records reviewed revealed the pain assessment did not address all aspects of pain. Record #19816 was reviewed and identified that the pain assessment did not address all aspects of pain. The following items were not completed in the pain assessment: worst pain level experienced, best pain level experienced, and acceptable level of pain. The Quality Nurse was interviewed on 12/23/2021, and stated the pain assessment tool was not completed nor was there any additional information to provide.

It is required that Medical social services are provided: Based on a psychosocial assessment; According to the patient’s and family’s needs and acceptance of these services; Per the plan of care; Under the direction of a physician. The psychosocial assessment addresses: The patient’s and the family’s adjustment to the terminal illness; The social and emotional factors related to the terminal illness; The presence or absence of adequate coping mechanisms; Family dynamics and communication patterns; Financial resources and any constraints; The caregiver’s ability to function effectively; Obstacles and risk factors that may affect compliance with the plan of care; and Family support systems to facilitate coping with end-of-life issues. The psychosocial assessment is revised as new information is acquired and as progress toward goals is made. Continuing Previous Required Action This standard was not met as evidenced by review of records and interview. 1 of 5 (20%) records reviewed revealed the hospice did not provide psycho-social frequencies in the POC according to the patient's and family's acceptance of these services. Record #42641 was reviewed and identified a RN comprehensive assessment was completed 12/3/2021. The documentation revealed the patient accepted psycho-social services. The POC dated 12/3/2021 was missing documentation of psycho-social visit frequencies. An order was written on 12/8/2021 for "SW services to resume". There was no evidence of psycho-social visit frequencies with this order. The Quality Nurse was interviewed on 12/23/2021 and stated that no SW frequencies could be found nor was there any additional information to provide.

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group and included in the plan of care. Continuing Previous Required Action This standard was not met as evidenced by review of clinical record and interview. 1 of 4 (25%) records in which a hospice aide was accepted for care, the hospice aide failed to follow the frequency order for visits written in the POC. Record #53679 was reviewed and identified the hospice aide care plan was written 12/9/2021 for 3XW. For the week of 12/12/2021 -12/18/2021 there were visits performed on 12/15/2021 and 12/16/2021. This did not meet the frequency order of 3XW. There was no evidence of documentation to explain the missed visit. An Interview was conducted with the Quality Nurse who indicated there was no evidence that the hospice aide visit was performed nor was there evidence of further explanation of the reason for the missed visit.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: The effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by review of clinical record, document review and interview that in 5 of 16 (31%) records fail to document all current medications, specifically oxygen; and fail to update the medication profile and review medications with changed medication. Agency Policy PC.M50 Medication Management stated in part, "A Medication Profile is maintained for every patient and includes a listing of the current medication orders for each patient ...." Record #61644: Admitted 07/23/2021 with Oxygen 3 L (liters) per nasal cannula. Oxygen is not on the medication profile as of review 11/10/2021. Record #41529: Admitted 09/24/2021 with Oxygen 2 -4 L per nasal cannula. Oxygen is not on the medication profile as of review 11/10/2021. Record #39860: Admitted 05/23/2021 with Oxygen 2-4 L per nasal cannula. Oxygen is not on the medication profile as of review 11/10/2021. Record #52058: Admitted 12/08/2020 with Oxygen ordered and continues to use Oxygen as of review 11/11/2021. Oxygen is not on the medication profile. Record #35940: Nursing visit note on 11/04/2021 documents physician ordered Remeron (a medication to help with sleep), 15mg at night. The medication profile reviewed 11/11/2021 is not updated for this changed medication. Interview 11/11/2021 with the Quality assurance utilization management nurse confirmed this finding and stated that "oxygen is not on the medication profile and the Remeron is not updated as of review."

It is required that the comprehensive assessment includes 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 is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by review of clinical records, policy review and interview. In 2 of 16 (13%) records reviewed it was revealed that the records did not include evidence of an initial bereavement assessment. Agency Policy PC.B25 (revised 09/2019) Bereavement Risk Assessment stated in part, "During the comprehensive assessment of the patient, an initial bereavement assessment is conducted by the interdisciplinary group (IDG) to determine the cultural, social and spiritual factors that may impact the ability of family members or other involved individuals to cope with the patients death." Record #61644: Hospice benefit of election date 07/23/2021. No evidence of documented initial bereavement assessment as of review date 11/11/2021. Record #60169: Hospice benefit of election date 09/07/2021. No evidence of documented initial bereavement assessment as of review date 11/10/2021. Interview with the Quality assurance utilization management nurse on 11/11/2021 stated that the assessments should be in the record.

It is required that the hospice designates a registered nurse member of the IDG to: Provide coordination of care; Ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by: The hospice IDG in collaboration with the attending physician (if any); The patient or patient representative; The primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by review of clinical records and interview. In 2 of 16 (50%) clinical records reviewed it was revealed the records fail to document registered nurse following ordered visit frequency. Record #35940: Nursing frequency order beginning 07/13/2021 and each updated plan of care for 1 x weekly visits. The weeks of 08/08/2021, 08/15/2021, and 08/22/2021 failed to document a nursing visit or the reason for the visit not provided. Record #46259: Nursing frequency order beginning 09/24/2021 and each updated plan of care for 1 x week visits. The week of 10/17/2021 failed to document a nursing visit or the reason for the visit not provided. Interview on 11/11/2021 with the quality assurance utilization management nurse and the Clinical Director stated that documentation and the change in the electronic health record with the pandemic have been a challenge.

It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by review of clinical records, document review and interview that in 2 of 3 (66%) records which included infusions fail to document interventions for the infusion therapy. Agency Policy PC.40 Plan of Care (Revised 07/2013) stated in part, "A [name of agency] patient plan of care may include, but not be limited to individualized interventions to assist with end of life care." Record #73869: Admitted 06/25/2020 with a port in the right chest and a pain control infusion. The plans of care through review 11/10/2021, fail to document interventions for port access to include type of needle, gauge of needle and length of needle, port site care, frequency of tubing change, and safety and infection control interventions specific to port care. On 11/04/2021 the patient presented with a PICC (peripherally inserted central line catheter). The plan of care failed to document interventions specific to PICC line care, site care, tubing change, safety and infection control for PICC line Record #59114: Admitted 10/31/2021 with orders for a subcutaneous hydration for 3 days. The plan of care failed to document interventions for subcutaneous site care, access with size and gauge of subcutaneous needle, tubing change, dressing change and length of therapy. Safety and infection control intervention documented are not specific to the subcutaneous infusion., Interview with the quality assurance utilization management nurse stated the detailed interventions are not documented.

It is required that each patient’s individualized written plan of care: Measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by review of clinical records, document review and interview that in 2 of 3 (66%) of infusion records fail to document measurable outcomes in the plan of care. Agency Policy PC.40 Plan of Care (Revised 07/2013) stated in part, "Revisions to the hospice plan of care are based on information from the components of the patient updated comprehensive assessment tools and the patient progress toward outcomes specified in the plan." Record #73869: Admitted 06/25/2020 with a port in the right chest and a pain control infusion. The goals for pain control state to use PCA pump. There are no specific goals or outcomes to include the goals for the port care, safety, infection control and patency. On 11/04/2021 the patient presented with a PICC (peripherally inserted central line catheter). The updated plan of care, 11/04/2021, failed to included to include goals for patency, safety and infection control for the PICC line. Record #59114: Admitted 10/31/2021 with ordered subcutaneous hydration for 3 days. The plan of care provided goals and outcomes for hydration and nutrition. There is no documentation on the plan of care for goals for safety and infection control and patency for the subcutaneous infusion. Interview with 11/11/2021 with the quality assurance utilization management nurse stated that staff should use the infusion addendum for documentation and to build the goals for the plan of care.

It is required that Medical social services are provided: Based on a psychosocial assessment; According to the patient’s and family’s needs and acceptance of these services; Per the plan of care; Under the direction of a physician. The psychosocial assessment addresses: The patient’s and the family’s adjustment to the terminal illness; The social and emotional factors related to the terminal illness; The presence or absence of adequate coping mechanisms; Family dynamics and communication patterns; Financial resources and any constraints; The caregiver’s ability to function effectively; Obstacles and risk factors that may affect compliance with the plan of care; and Family support systems to facilitate coping with end-of-life issues. The psychosocial assessment is revised as new information is acquired and as progress toward goals is made. This standard was not met as evidenced by review of clinical records, policy review and interview. In 1 of 16 (06%) clinical records reviewed it was revealed that there was no documented evidence that a psychosocial assessment was completed. Agency Policy PC.A80 Assessment Comprehensive stated in part, "Each member of the IDG (interdisciplinary group) provides input into the comprehensive assessment through the use of discipline specific assessment forms, within the scope of his/her practice and in accordance with the needs and desires of the patient." Record #61644: Admitted 07/23/2021 with end stage lung disease and accepted SW (social work) on admission. No social work visit until 09/08/2021 in which an agency clinical note is completed. The clinical note did not include all areas of a comprehensive psychosocial assessment that include: coping, family dynamics, financial, caregiver ability, family support and assessment of social and emotional factors for terminal illness. Interview with quality assurance utilization management nurse on 11/11/2021 confirmed this finding and she stated that "the comprehensive psychosocial assessment was not in the record and it should be."

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and is consistent with the hospice aide training. THIS IS A CMS CONDITION-LEVEL DEFICIENCY This CONDITION was not met as evidenced by a review of clinical records and interview which revealed that the registered nurse failed to provide written patient care instructions for a hospice aide [HCDT.15.I/418.76(g)(1)/L625] and the hospice aide failed to follow the established plan of care [HCDT.16.I/418.76(g)(2)/L626]. The cumulative effect of these deficiencies could place the patient in jeopardy for a safety risk or a lack of quality care.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by review of clinical records and interview that 3 of 8 (38%) records in which a hospice aide was accepted revealed a lack of clear and specific written instruction for the aide assignment, thus leaving the aide to make decisions outside of the aide scope of practice. Record #90396: Admitted 10/07/2021. The Aide plan of care, initiated on 10/12/2021, instructed the aide to shampoo hair as needed, transfer as needed (this is a bedbound patient with no direction of safety in transfer), and date of last BM (bowel movement) as requested (this is not clear). Record #35940: Admitted 07/13/2021. The Aide plan of care initiated on 08/25/2021, instructed the aide to shampoo hair prn (as needed), and dressing prn. This patient is admitted with malignant brain cancer and is not a decision-maker. Record #39860: Admitted 05/13/2021. The Aide plan of care initiated on 05/14/2021 instructed aide to provide complete bed bath, skin care, hair care, peri care, foot care, however, no frequency was provided for any of these duties. Interview on 11/11/2021 with the Quality Assurance Utilization Management Nurse stated that these plans are not correct for the way staff have been instructed and more education is needed.

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by review of clinical record and interview that in 4 of 8 (50%) records in which a hospice aide was accepted for care, fail to document aide compliancy with the plan of care. Agency Policy PC.H20 (Reviewed 07/2019) Hospice Aide Assignments and Duties, stated in part, "Hospice aides must complete accurate and legible documentation of services provided to the patient." Record #90396: Aide assigned duties each visit include bed bath, oral care, check pressure area, assist with dressing, change linens and check temperature. Aide visit note 10/12/2021, the area to document task completed was blank for bath, oral care, pressure area, linen change, and temperature. Aide visit note 10/19/2021, the area to document task completed was blank for temperature and linen change. Record #60169: Aide assigned duties each visit include peri care and oral care. Aide visit note 09/10/2021, the area to document task completed was blank for peri care and oral care. Additionally, aide ordered services beginning 09/07/2021 for 2 week 1, then 3 times a week. The week of 09/19/2021 only 2 visits provided, no evidence for why the third visit was not provided. Week 10/24/2021 with continued plan of care documented aide visit for 3 times a week, only 2 visits provided. Record #93650: Aide assigned duties each visit for date of last BM. Aide visit note 05/17/2021, 05/18/2021 and 05/21/2021 was blank for date of last BM. Record #35940: Aide ordered frequency beginning 08/22/2021 for 1 times a week visits. The week of 09/19/2021 no visits were provided. No evidence documented in the record for why the visit was not provided. Interview with the Quality Assurance Utilization Management Nurse stated that the documentation is not correct.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by clinical record review , policy review and interview that in 2 of 15 (13%) records which documented additional orders, did not include documentation of all required physician orders. Agency Policy PC.C15, Clinical Records (Reviewed 09/2012), stated in part, "Each patients clinical record includes, at a minimum, the following: signed physician orders." Record #73869: Admitted 06/25/2020 with a right chest port and infusion of pain medication through the port. No documented physician order for huber need gauge and length to access port, frequency of port access, dressing change procedure or frequency, or flushing frequency for port. Additionally, 11/04/2021 a PICC (peripherally inserted central catheter) is started. The record failed to document orders for dressing change frequency and securement device for the catheter. Record #93650: Nursing note on 05/10/2021 stated dressing changed with normal saline, dry with 4 x 4 gauze, calcium alginate and border dressing. There was no order in the record for this dressing. On 05/13/2021 there are orders for a different dressing change and this change was documented in the nursing notes and on the plan of care. Interview on 11/11/2021 with the quality assurance utilization management nurse stated we should have orders for all of these.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid/MediCal-certified facility, the hospice forwards to the receiving facility a copy of: The hospice discharge summary described in HCDT 41.I; and the patient’s record, if requested.. This standard was not met as evidenced by review of clinical records, document review and interview that in 1 of 4 (25%) of records in which a patient was admitted/transferred to a facility, failed to document sending the discharge summary or any part of the patients record to the facility. Record #67467: Nursing note on 09/17/2021 documents uncontrolled pain and sent to hospital and discharged. The discharge summary was documented 09/17/2021, but no evidence of documentation that the summary or record was sent to the hospital as of review 11/11/2021. Interview with the quality assurance utilization management nurse stated that the sending of the documentation is not in the record.

It is required that medical supplies and appliances related to the palliation and management of the patient’s terminal illness and related conditions are: Checked for expiration dates. This standard was not met as evidenced by tour of inpatient unit on 11/10/2021, 9:30am - 12:30pm. Tour of supply room revealed 10 expired subcutaneous infusion kits that had expired 01/26/2021. Interview with the In patient Clinical Manager stated that the kits are expired and should not be on the shelf.

It is required that the hospice has written policies and procedures for the management and disposal of controlled drugs in the patient’s home. The policies and procedures address the circumstances under which controlled drugs are disposed of (e.g., the patient’s death, a change in drug regimen, etc.) and the method to be used in accordance with the state and federal law and regulation. This standard was not met as evidenced by review of clinical records, document review and interview that 1 of 5 (20%) of records in which the agency drug disposal policy was required to be implemented, failed to provide evidence that staff followed the policy. Agency Policy PC.M60 (Revised 08/2019) Medication Disposal At Home, stated in part, "The medication collection and disposal will be documented in the patient record, on the prescription Medication Reconciliation form including the date and time; prescription medication names, dosage and quantity;.." Record #81446: Patient deceased at home on 05/02/2021 with medications in the home to include a morphine PCA (patient-controlled analgesia) and lorazepam. Death visit note stated that the pump was retrieved. There is no evidence of medication disposal to include prescription medication name, dosage or quantity as of review 11/1//2021. Interview the Quality Assurance Utilization Management Nurse stated that the documentation should be in the record but that it is not there.

It is required that the hospice inpatient facility provides meals to each patient that are: Palatable, attractive, and served at the proper temperature. Food is available 24/7 to respond to patient’s needs or requests. The Interdisciplinary Group (IDG) is kept informed of the patient’s response to their prescribed diet. This standard was not met as evidenced by tour of inpatient unit on 11/10/2021. Interview with the Clinical Manager of the inpatient unit during the tour for patient meals included refrigerated meals which were labeled with expiration dates. Interview with inpatient staff and Clinical Manager included that meals are heated in the microwave and brought to the patient. The meal container is monitored for temperature by feeling with hand touching it. No internal temperature of the meal served is conducted. This process risks potential for under-heated and/or over-heated meals to be delivered to patients.