Every finding on record at Capital Hospice - Maryland

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 clinical record review, document review and interview. In 2 of 3 (67%) clinical records reviewed, it was revealed that the agency did not implement written policies and procedures for the disposal of controlled drugs. Policy PC.M60 stated in part, "The medication collection and disposal will be documented in the patients record, on the Prescription Medication Reconciliation form including: the date and time; prescription medication name, dosage and quantity; the name of the individual and relationship who authorized the collection and disposal; the name of the (company) employee who collected and disposed of the prescription medications. Clinical Record 16: The start of care was 08/13/2024. The patient expired on 01/23/2024. There was no documentation of the disposal of the controlled drugs used by the patient, as required by agency policy. Clinical Record 15: The start of care was 06/06/2024. The patient expired on 01/17/2024. There was no documentation of the disposal of the controlled drugs used by the patient, as required by agency policy. During a joint record review and interview, the Administrator confirmed that the policy for disposition of controlled medications at the time of death was not followed.

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. 4 of 15 (27%) clinical records reviewed did not reveal any documented evidence that an initial bereavement risk assessment was completed on admission. Record #28293-Patient admitted on 10/30/2021. The Social Worker completed an initial psychosocial assessment on 11/01/2021. No documented evidence of an initial bereavement risk assessment at admission. No further social worker visits or documentation about bereavement services. Record #50806-Patient admitted on 10/05/2021. The Social Worker completed an initial psychosocial assessment on 10/06/2021. No documented evidence of an initial bereavement risk assessment at admission. The Social Worker visited on 10/15/2021 no documentation about bereavement services. Record #42866-Patient admitted on 08/11/2021. Social Worker completed an initial psychosocial assessment on 8/16/2021. No documented evidence of an initial bereavement risk assessment at admission. No documented evidence of a bereavement risk assessment on 10/15/2021 when social worker visited or during IDG on 10/14/2021 and 10/28/2021. Record #64297-Patient admitted on 03/19/2021. The Social Worker completed an initial psychosocial assessment on 03/23/2021. No documented evidence of an initial bereavement risk assessment at admission. No documented evidence of a bereavement risk assessment on 03/24/2021 when Social Worker visited or during IDG on 03/31/2021. During an interview on 11/10/2021 with the Area Director of Clinical excellence verified and confirmed that the records did not have initial bereavement risk assessments.

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 a review of clinical records and interview. 5 of 14 (36%) applicable records of patients receiving aide services revealed that the aide care plan by the RN failed to provide clear specific instructions regarding the aide services in the aide plan of care. Thus leaving the aide to make decisions outside of the aide scope of practice. Record # 42866 admitted on 08/11/2021. The Aide plan of care initiated on 08/15/2021 instructed the aide to shampoo patient's hair, file nails PRN. Record # 97273 Patient admitted on 07/06/2021. The Aide plan of care initiated on 07/25/2021 instructed the aide to shampoo patient's hair PRN. Record # 28587 Patient admitted on 04/13/2021. The Aide plan of care initiated on 04/13/2021 instructed the aide to transfer patient as tolerated. Record # 85878 Patient admitted on 04/10/2021. The Aide plan of care initiated on 04/19/2021 instructed the aide to shampoo patient's hair PRN. Record # 19290 Patient admitted on 10/19/2021. The Aide plan of care initiated on 10/19/2021 instructed the aide to shampoo patient's hair and clean fingernails PRN. During an interview on 11/10/2021 and 11/11 2021 with the Area Director of Clinical Excellence, stated that the records did not have clear specific instructions regarding the aide services.

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 and the patient’s record, if requested. This standard was not met as evidenced by review of clinical records and interview. 1of 1 (100%) applicable record of a patient reviewed who revoked their hospice benefit, there was no documented evidence that a copy of the patient's discharge summary was sent to the receiving agency. Record # 33431 admitted 06/08/2021 revoked his hospice benefit on 11/03/2021 to seek aggressive treatment at another agency. During an interview on 11/10/2021 and 11/11 2021 with the Area Director of Clinical Excellence, stated that the discharge summary and patient's record was not sent to the receiving facility.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician, a copy of the hospice discharge summary, and the patient's record, if requested. This standard was not met as evidenced by review of clinical records and interview. 1of 1 (100%) applicable record of a patient reviewed that revoked their hospice benefit, there was no documented evidence that a copy of the patient's discharge summary was sent to the attending physician. Record # 33431 admitted 06/08/2021 revoked his hospice benefit on 11/03/2021 to seek aggressive treatment at a hospital. The nurse documented that she did not forward a discharge summary to the attending physician. During an interview on 11/10/2021 and 11/11 2021 with the Area Director of Clinical Excellence, stated that the discharge summary and patient's record was not sent to the attending physician.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following, a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care,the patient’s latest physician orders, or any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by review of clinical records and interview. 1of 1 (100% ) applicable record of a patient reviewed revoked the discharge summary was not completed to include a summary of the patient's treatments, symptoms, and pain management, the patient's plan of care and physician orders. Record # 33431 admitted 06/08/2021 revoked his hospice benefit on 11/03/2021 to seek aggressive treatment at a hospital. During an interview on 11/10/2021 and 11/11 2021 with the Area Director of Clinical Excellence stated that the discharge summary was not completed.