Every finding on record at Capitol Healthcare Inc.

It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address informing local and state emergency officials about patients in need of evacuation from their residence at any time due to the emergency based on the patient’s medical or psychiatric condition, or home environment, the minimum information provided to facilitate patient evacuation and transportation including if the patient is mobile or not, if the patient has life-dependent equipment, and if so, is it able to be transported (e.g., battery operated, size, condition, etc.), and any patient special needs including cognitive disorders, intellectual disabilities, or communication issues (e.g., deaf, non-English speaking, etc.). This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure an individualized plan for emergency preparedness was developed for the patient. Clinical Record 7: The patient elected the hospice benefit on 11/16/2022. Clinical record review revealed the "Patient Evacuation Plan," and the "Home Environment Safety Checklist" were blank. The clinical record contained no documented evidence of an individualized emergency preparedness plan for the patient. During a joint clinical record review on 10/4/23, the Director of Patient Care Services confirmed that Clinical Record 7 lacked information about hospice patient's medical, physical, and psychosocial needs for safe evacuation including transportation and equipment needs during an emergency situation based on the patient’s home safety assessment needs.

It is required that the written Patient Bill of Rights includes the right to receive information about the services covered under the hospice benefit. This standard was not met as evidenced by document review, clinical record review, and interview. In 7 of 14 (50%) clinical records reviewed, the agency did not ensure the patient received information about the services covered under the hospice benefit. Clinical Record 5: The patient elected the hospice benefit on 6/16/2023. Clinical record review revealed the Consent for Election of Medicare/Medicaid Hospice Benefit form included the statement "I elect to receive the Patient Notification of Hospice Non-Covered Items, Services, and Drugs." The statement was followed by check boxes "yes" or "no" to indicate the patient’s choice. The yes and no boxes were left blank and did not indicate if the patient chose to receive information about the services covered under the hospice benefit. Clinical Record 6: The patient elected the hospice benefit on 11/13/2022. Clinical record review revealed the Admission Consent form with a revision date of 3/2020 did not include information that the patient had the right to receive written Patient Notification of Hospice Non-Covered Items, Services, and Drugs. Clinical Record 7: The patient elected the hospice benefit on 11/16/2022. Clinical record review revealed the Admission Consent form with a revision date of 3/2020 did not include information that the patient had the right to receive written Patient Notification of Hospice Non-Covered Items, Services, and Drugs. Clinical Record 8: The patient elected the hospice benefit on 9/26/2022. Clinical record review revealed the Admission Consent form with a revision date of 3/2020 did not include information that the patient had the right to receive written Patient Notification of Hospice Non-Covered Items, Services, and Drugs. Clinical Record 9: The patient elected the hospice benefit on 3/2/2023. Clinical record review revealed the Consent for Election of Medicare/Medicaid Hospice Benefit form included the statement "I elect to receive the Patient Notification of Hospice Non-Covered Items, Services, and Drugs." The statement was followed by check boxes "yes" or "no" to indicate the patient’s choice. The yes and no boxes were left blank and did not indicate if the patient chose to receive information about the services covered under the hospice benefit. Clinical Record 11: The patient elected the hospice benefit on 9/30/2022. Clinical record review revealed the Admission Consent form with a revision date of 3/2020 did not include information that the patient had the right to receive written Patient Notification of Hospice Non-Covered Items, Services, and Drugs. Clinical Record 14: The patient elected the hospice benefit on 11/14/2022. Clinical record review revealed the Admission Consent form with a revision date of 3/2020 did not include information that the patient had the right to receive written Patient Notification of Hospice Non-Covered Items, Services, and Drugs. During a joint clinical record review on 10/3/2023, the Director of Patient Care Services confirmed that Clinical Records 5, 6, 7, 8, 9, 11, and 14 lacked evidence that patients and families were provided with the right to choose an addendum containing any items, services, or drugs that would not be covered by the hospice. The DPCS stated, "We got new patient handbooks in 2023. We must still have some old ones in trunks if patients are still receiving a consent form that is not current with the addendum information."

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the organization did not ensure that all interventions based on problems identified in the initial and updated comprehensive assessments were identified in the patient's individualized written plan of care. Clinical Record 2: The patient elected the hospice benefit on 9/10/2023 with a terminal diagnosis of acute and chronic respiratory failure, other diagnoses included chronic obstructive respiratory failure, pneumonia, sepsis, stage 4 pressure ulcer to sacrum and gastrotomy [PEG] tube. The patient resided in a Skilled Nursing Facility. Clinical record review revealed the initial and updated comprehensive assessments included documentation that the patient had a Peg Tube with tube feedings and a tracheostomy with oxygen administered at 3-6 liters per minute that required "frequent suctioning" by the skilled nursing facility staff. The individualized plan of care dated 9/10/2023 and the updated plan of care dated 9/22/2023 contained no documented evidence of interventions for tracheostomy site care, how often the tracheostomy tube should be changed, the frequency of suctioning for the tracheostomy, and did not include interventions for the PEG tube site care or the frequency of the PEG tube site care. During a clinical record review and interview on 10/4/2023, the Director of Patient Care Services stated that interventions for care if the tracheostomy and PEG tube should have been included in the patient’s individualized plan of care.

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 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 9 of 14 (64%) clinical records reviewed, the agency did not ensure the patient’s individualized plan of care (POC) included measurable outcomes anticipated form implementing and coordinating the POC. Clinical Record 1: The patient elected the hospice benefit on 3/14/2023 with a terminal diagnosis of Alzheimer's disease. The individualized POC included a goal that stated, "Patient anxiety/agitation will be controlled/managed to an acceptable level for this patient.” The goal did not include a description of what the patient would consider an acceptable level of anxiety or agitation and was not measurable. Clinical Record 2: The patient elected the hospice benefit on 9/10/2023 with a terminal diagnosis of acute and chronic respiratory failure, other diagnoses included chronic obstructive respiratory failure, pneumonia, sepsis, stage 4 pressure ulcer to sacrum, tracheostomy, and gastrotomy [PEG] tube. The individualized POC included a goal that stated, “Caregivers will maintain adequate suctioning of trach [tracheostomy] for optimal breathing." The goal did not include a description of what would be considered optimal breathing for the patient and was not measurable. Clinical Record 3: The patient elected the hospice benefit on 7/14/2023 with a terminal diagnosis of chronic obstructive pulmonary disease, acute exacerbation of atrial fibrillation and dementia. The individualized POC included a goal that stated, "Patient anxiety/agitation will be controlled/managed to an acceptable level for this patient.” The goal did not include a description of what the patient would consider an acceptable level of anxiety or agitation and was not measurable. Clinical Record 5: The patient elected the hospice benefit on 6/16/2023. The individualized POC included a goal that stated, "Patient anxiety/agitation will be controlled/managed to an acceptable level for this patient.” The goal did not include a description of what the patient would consider an acceptable level of anxiety or agitation and was not measurable. The POC also included a goal that stated, “Blood pressure will be maintained at an acceptable level.” The goal did not include a description or parameters of what an acceptable blood pressure level would be for the patient and was not measurable. Clinical Record 8: The patient elected the hospice benefit on 9/26/2022 with a terminal diagnosis of acute systolic congestive heart failure. The individualized POC included a goal that stated, "Patient anxiety/agitation will be controlled/managed to an acceptable level for this patient.” The goal did not include a description of what the patient would consider an acceptable level of anxiety or agitation and was not measurable. Clinical Record 10: The patient elected the hospice benefit on 12/4/2022 with a terminal diagnosis of malignant neoplasm of the bladder wall. The individualized POC included a goal that stated, "Patient anxiety/agitation will be controlled/managed to an acceptable level for this patient.” The goal did not include a description of what the patient would consider an acceptable level of anxiety or agitation and was not measurable. Clinical Record 12: The patient elected the hospice benefit on 4/17/2023 with a terminal diagnosis of cerebral infarct. The individualized POC included a goal that stated, "Patient anxiety/agitation will be controlled/managed to an acceptable level for this patient.” The goal did not include a description of what the patient would consider an acceptable level of anxiety or agitation and was not measurable. Clinical Record 13: The patient elected the hospice benefit on 6/6/2023 with a terminal diagnosis of cerebral infarct. The individualized POC included a goal that stated, "Patient anxiety/agitation will be controlled/managed to an acceptable level for this patient.” The goal did not include a description of what the patient would consider an acceptable level of anxiety or agitation and was not measurable. Clinical Record 14: The patient elected the hospice benefit on 11/14/2022 with a terminal diagnosis of small cell carcinoma of the left lung. The individualized POC included a goal that stated, "Patient anxiety/agitation will be controlled/managed to an acceptable level for this patient.” The goal did not include a description of what the patient would consider an acceptable level of anxiety or agitation and was not measurable. During a joint clinical record review on 10/4/2023, the Director of Patient Care Services stated that patient plans of care lacked measurable criteria and specificity by not defining how anxiety/agitation would be measured or what constitutes an "acceptable level."

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review and observation. In 1 of 3 (33%) home visit observations, the agency did not ensure staff performed hand hygiene according to organizational policy. Agency policy Hand Hygiene [no date] stated in part, "Apply alcohol-based hand rub product to palm of one (1) hand and rub hands together, covering all surfaces of hands and finger (including under nails) until hands are dry. The volume of product needed to reduce the number of bacteria on hands will vary by product, so product directions must be followed. Hand decontamination using an alcohol-based hand rub should be performed: Before having direct contact with patients; after contact with a patient's intact skin (when taking a pulse, blood pressure or lifting a patient); after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings; when moving from a contaminated body site to a clean body site during patient care; after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; and after removing gloves." Home Visit 1: During the home visit observation on 10/2/2023, the Registered Nurse was observed to remove exam gloves and reapply new exam gloves without sanitizing each time gloves were removed, and new gloves applied. The RN was observed to apply A&D ointment to the patient's sacrum with gloved hands and then did not remove the soiled gloves before touching the patient's clothing, bedding, bed rails, and bed controls.

It is required that bereavement services are supervised by a qualified professional with experience or education in grief or loss counseling. This standard was not met as evidenced by document review, personnel record review, and interview. In 1 of 1 (100%) personnel record reviewed for the Bereavement Coordinator, the agency did not ensure bereavement services were supervised by a qualified professional with experience or education in grief or loss counseling. The Job Description for Bereavement Coordinator listed position qualifications in part, "bachelor's degree or equivalent theological degree from college or university. Experience with families/caregivers and patients through death/dying issues - OR - master's degree in social work with qualifications of experienced clinical grief counseling. Personnel Record 4: Bereavement Coordinator with date of hire 1/6/2023. Review of the personnel file and signed job description revealed the Bereavement Coordinator lacked the qualifications for the position listed in agency policy. During joint interview and document review on 10/4/2023 with the Bereavement Coordinator it was discussed and confirmed that the qualifications listed on the job description were not met by current personnel. The Bereavement Coordinator stated, "I did not notice those requirements before. Our Chaplain was a Bereavement Coordinator in a previous organization. We'll have him take over that role."

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation (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 clinical record review and interview. In 1 of 2 (50%) clinical records reviewed for patients that revoked hospice care, the agency did not ensure the patient’s attending physician was sent a copy of the hospice discharge summary. Clinical Record 14: The patient elected the hospice benefit on 11/14/22 and chose to revoke hospice services on 11/21/22 to pursue aggressive treatment. A communication note dated 11/22/22 documented that the attending physician’s office was notified of the patient’s revocation, but there was no documented evidence in the clinical record that the discharge summary was forwarded to the attending physician. During an interview and joint record review on 10/4/2023, the Director of Patient Care Services confirmed that the discharge summary was not forwarded 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, 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 clinical record review and interview. In 2 of 3 (67%) clinical records reviewed where patients were discharged from hospice care, the agency did not ensure the discharge summary provided to a facility receiving a hospice patient for care or to the patient's community attending physician upon hospice discharge included all required elements. Clinical Record 10: The patient elected the hospice benefit on 12/4/2022 and was discharged on 12/27/2022 due to moving out of the service area. Clinical record review revealed no documented evidence of a discharge summary that included 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, any other documentation that would assist in the post-discharge continuity of care or that was requested by the receiving facility or the attending physician. Clinical Record 11: The patient elected the hospice benefit on 9/3/2022 and was discharged on 12/16/2022 per patient request. Clinical record review revealed no documented evidence of a discharge summary that included 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, any other documentation that would assist in the post-discharge continuity of care or that was requested by the receiving facility or the attending physician. During an interview and joint record review on 10/4/2023, the Director of Patient Care Services confirmed that a complete discharge summary was not generated for records 10 and 11.