Every finding on record at Central Washington Health Services Association

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; supplements; herbal remedies and other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review and interview. In 3 of 4 (75%) home visits, it was revealed that the agency did not ensure the drug profile contained the patient's current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. HOME VISIT 2: The patient elected the hospice benefit on 11/28/2025 for a diagnosis of acute myeloid leukemia. The patient resided in an assisted living facility (ALF). During Home Visit 2 with Personnel Record 5 (Social Worker) on 12/09/2025, the hospice medication profile (printed on 12/09/2025) was compared to the ALF medication profile (printed on 12/09/2025). The following medication discrepancies were noted: The hospice medication profile had Guaifenesin 100 mg/5ml oral liquid, 10 ml twice daily (ordered 11/28/2025) vs ALF Guaifenesin 600 mg tablet twice daily (ordered 11/28/2025). HOME VISIT 3: The patient elected the hospice benefit on 09/25/2024 for a diagnosis of unspecified lump in right breast. The patient resided in an assisted living facility (ALF). During Home Visit 3 with Personnel Record 6 (Spiritual Counselor) on 12/09/2025, the hospice medication profile (printed on 12/09/2025) was compared to the ALF medication profile (printed on 12/09/2025). The following medication discrepancies were noted: The hospice medication profiled had Miralax 17 grams twice daily as needed (ordered 02/07/2025) vs ALF Miralax 17 grams once daily (ordered 01/02/2025 and Miralax 17 grams daily as needed (ordered 04/2025). HOME VISIT 4: The patient elected the hospice benefit on 03/28/2025 for a diagnosis of malignant neoplasm of middle lobe. The patient resided in a skilled nursing facility (SNF). During Home Visit 4 with Personnel Record 4 (Registered Nurse) on 12/09/2025, the hospice medication profile (printed on 12/09/2025) was compared to the SNF medication profile (printed on 12/09/2025). The following medication discrepancies were noted: The hospice medication profile had sodium chloride flush 20 ml once monthly and as needed (ordered 03/28/2025); Heparin lock 100 ml flush once monthly and as needed (ordered 03/31/2025). A joint clinical record review and interview was conducted on 12/11/2025 with the Quality Specialist. She advised a Performance Improvement Project "was about to be opened after internal audits had revealed medications weren't being reconciled per policy and 91% were found to have discrepancies."

It is required that 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 3 of 15 (20%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the registered nurse provided specific written instructions for the hospice aide. CLINICAL RECORD 1: The hospice aide care plan dated 05/09/2025 included the following relevant tasks: "Assist to shower chair, bathing (shower), dressing, oral care, shampoo, skin care-apply lotion of patient's choice, transfer client to/from bed/chair." All tasks were to be completed every visit. Aide frequency of once weekly. A physician's order dated 09/02/2025 noted the following: "Right anterior shin skin tear. Apply steri strips to secure skin flap. Cover with nonstick film and foam." A physician's order dated 10/24/2025 noted the following: "Right shin skin tear cover with foam dressing." A physician's order dated 12/04/2025 noted the following: "RN (registered nurse) to provide wound care to right wrist from dermatologist freezing suspected neoplasm and cover with bandaid." The hospice aide care plan did not notify the aide of the wound(s), nor provide specific instructions to notify the nurse if the wound dressing(s) became soiled, dislodged, or wet. CLINICAL RECORD 4: The hospice aide care plan dated 03/28/2025 included the following relevant tasks: "Bathing (bed bath), dressing, hair care, perineal care, shampoo, skin care, turn and position in bed." All tasks were to be completed every visit. Aide frequency of twice weekly. A physician's order dated 08/05/2025 noted the following: "Cleanse left hand skin tear with normal saline, pat with gauze, and cover with foam." A physician order dated 11/19/2025 noted the following: "Left hand skin tear, pat dry with gauze, apply steri strips, cover with foam. Right upper forearm skin tear, pat dry with gauze, apply steri strips if needed." The hospice aide care plan did not notify the aide of the wound(s), nor provide specific instructions to notify the nurse if the wound dressing(s) became soiled, dislodged, or wet. CLINICAL RECORD 5: The hospice aide care plan dated 10/09/2025 included the following relevant tasks: "Bathing (bed bath)-weekly, bathing (partial sponge bath)-twice weekly, apply lotion of choice to extremities and trunk, apply barrier cream, shampoo-weekly, hair care, dressing-weekly, oral care." All tasks were to be completed every visit unless specified. Aide visit frequency of three times weekly. The hospice aide visits dated 10/20/2025 and 10/22/2025 had both bath types checked as completed. These were during the same week. The hospice aide visit dated 11/17/2025 had bed bath checked as Y, sponge bath N. The hospice aide visit dated 11/19/2025 had bed bath N, sponge bath Y. The hospice aide visit dated 11/21/2025 had bed bath checked Y, sponge bath N. The hospice aide care plan was not specific on which bath type should be provided per visit. A joint clinical record review and interview was conducted on 12/10/2025 with the clinical manager and quality specialist during which time they agreed the "aide should be notified if patients had wounds and bandages." During interview with leadership on 12/10/2025, it was stated "this is exactly why we discourage two bath types being placed on aide care plans. If for some reasons the patient must have two bath types, then it should specify, first visit of the week bed bath, second visit of week sponge bath." There was discussion that "two bath types should not be added to aide care plans to avoid any type of confusion."

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IID representatives. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (50%) clinical records reviewed in which patients resided in a facility revealed the agency did not ensure care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF. CLINICAL RECORD 1: A review of the clinical record on 12/10/2025 revealed the patient had a respite stay from 05/24/2025 to 05/27/2025. There was no evidence of a written plan of care established between the hospice and the facility. CLINICAL RECORD 5: A review of the clinical record on 12/10/2025 revealed the patient elected the hospice benefit on 10/09/2025 and was a resident of a skilled nursing facility (SNF). The clinical record did not contain documentation of a written plan of care established between the hospice and the facility. A joint clinical record review and interview was conducted with the Administrator and Clinical Manager on 12/11/2025 during which time they advised that "the hospice physicians normally wrote orders for patients in respite or GIP (general inpatient) but they didn't believe they had privileges at the hospital for Clinical Record 1 so they are not sure they wrote orders there." They were unable to find evidence the plan of care was faxed to the hospital during the respite stay. In regards to Clinical Record 5, the Plan of Care Intervention for "Facility Coordination" had not been added and they were unsure if the "written one had been left at the SNF."

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. This standard was not met as evidenced by a review of clinical records, documents and interviews. 1 of 13 (8%) clinical records reviewed revealed the hospice interdisciplinary group (IDG) failed to complete an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. Policy: Organizational Policy, #12774820, "Hospice Interdisciplinary Group (Revised: 12/6/22)", stated in part: "The hospice IDG, 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." Clinical Record 3: The patient was admitted to hospice on 11/23/22. The record lacked evidence of a Chaplain assessment or supporting documentation of the family requesting a later visit - no later than five (5) calendar days after the election of hospice care. The clinical record showed evidence that the Chaplain called the patient on 11/30/22 to schedule the initial Chaplain visit. Interview: In an interview on 2/8/23, the Administrator, Clinical Manager and Clinical Supervisor reviewed the findings and confirmed that the Chaplain did not complete an assessment within 5 days after the election of hospice care.

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 a review of clinical records, documents and interviews. 1 of 13 (8%) clinical records reviewed revealed the patient's individual written plan of care (POC) did not include goals and interventions based on problems identified in the initial and updated comprehensive assessments. Policy: Organizational Policy, #12774820, "Hospice Interdisciplinary Group (Revised: 12/6/22)", stated in part: "The Plan of Care: 5. Each patient's individualized written plan of care: a. Reflects patient and family goals; b. Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments." Clinical Record 3: The patient was admitted to hospice on 11/23/22. The initial nursing assessment dated 11/23/22 stated the patient had full bladder incontinence. The interdisciplinary group (IDG) POC dated 11/23/22 did not include a goal and interventions for bladder incontinence. Interview: In an interview on 2/8/23, the Administrator, Clinical Manager, and Clinical Supervisor reviewed the findings and confirmed that the POC did not include a goal and interventions related bladder incontinence.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid 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 a review of clinical records, documents, and interviews. 2 of 3 (67%) clinical records reviewed for patients that were transferred to another hospice or revoked and discharged from hospice services to pursue aggressive treatment at the hospital, revealed the agency did not ensure that a copy of the discharge summary was forwarded to the receiving facility. Policy: Organizational Policy, #12949986, "Discharge, Revocation or Transfer from Hospice Care (Revised: 1/10/23)", stated in part: “G. If a hospice patient is transferred to a facility, the hospice will provide the facility a copy of the discharge summary and patient's record, if requested." Clinical Record 7: The patient was admitted to hospice on 9/22/22. The family revoked hospice on 10/17/22 and the patient was transported to the hospital to pursue aggressive treatment. The clinical record lacked evidence that a copy of the hospice discharge summary was forwarded to the receiving facility (hospital). Clinical Record 6: The patient was admitted to hospice on 10/13/22. The family revoked hospice on 12/17/22 and the patient was transported to the hospital to pursue aggressive treatment. The clinical record lacked evidence that a copy of the hospice discharge summary was forwarded to the receiving facility (hospital). Interview: In an interview on 2/8/23, the Administrator, Clinical Manager, and Clinical Supervisor reviewed the findings and confirmed that copies of the discharge summary were not forwarded to the receiving facilities.