Every finding on record at Hospice of the Chesapeake Inc

is required that 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 clinical record review, interview and observation. In 2 of 19 (11%) clinical records reviewed revealed that the agency did not ensure that the drug profile was updated at the time of each comprehensive assessment. CLINICAL RECORD 2: The patient elected the hospice benefit 01/23/2024 with a diagnosis of hypertensive heart disease. The patient resides in a skilled nursing facility. During the home visit (Home Visit 2) with the Social Worker (Personnel Record 8) a review of the medication profile provided by the skilled nursing facility revealed the patient was receiving spironolactone 25mg one time a day. Spironolactone was not listed on the hospice agencies medication profile. CLINICAL RECORD 3: The patient elected the hospice benefit on 08/19/2024. During the home visit on 01/14/2025 with the RN it was discovered that the patient was prescribed Morphine concentrate 100mg/5ml every 3 hours as needed for pain and Lorazepam 0.5mg every 6 hours as needed for anxiety and agitation. This was confirmed by the RN and the patient's caregiver. The medications were not listed on medication profile. During further interview with the RN, it was found that the medication was not in the home. The RN stated that the patient's daughter kept the medication at her home, but the RN had never seen them. This was information passed from the patient's previous RN. This information was not listed in the patient's clinical record including the plan of care. Further discussion with the clinical manager resulted in a phone call to the patient's daughter and she confirmed the medication was in her home and there was no plan how the medications would get to the patient in the case of a crisis. During joint review of the clinical record and interview with the clinical manager on 01/15/2025, it was discovered that spironolactone was placed on hold by the hospice doctor on 01/29/2024. The clinical manager confirmed that the hospice agency had not done a medication reconciliation to ensure that the hospice agency and the skilled nursing facility medication profiles matched.

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes reassessment of the patient’s response to care. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 19 (5%) clinical records reviewed revealed that the agency did not ensure that the comprehensive assessment included reassessment of the patient's response to care. CLINICAL RECORD 3: The patient elected the hospice benefit on 08/19/2024 with diagnosis of Traumatic subdural Hematoma w/o loss of consciousness. During a home visit with the registered nurse (RN) (Personnel Record 9)on 01/14/2024 it was observed that the patient was bedbound and mainly on her back during the day as confirmed by the patient's caregiver. During the skin assessment by the RN, it was observed that the patient had an extensive rash that was very red with small open areas across the patient's entire back. During interview with the RN (Personnel Record 9),she stated that the patient has had this rash for several months and they have been treating it with miconazole topical cream and clotrimazole-betamethasone topical cream. The RN stated that the rash has been better and recently gotten much worse. During joint review of the clinical record and interview with the clinical manager(Personnel Record 5), it was revealed that there was no documented evidence of the status of the patient's rash in comprehensive assessments reviewed during the months of 12/2024 and 01/2025. This was confirmed by the clinical manager (Personnel Record 5).

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 1of 19 (5%) clinical home care records reviewed revealed that the agency did not ensure that the written plan of care reflected the patient and family goals or identified planned interventions based on problems identified in the comprehensive assessment. CLINICAL RECORD 4: The patient elected the hospice benefit on 02/27/2023. The patient had documented wounds on the leg, heel, and back. During joint review of the clinical record and interview with clinical manager (Personnel Record 5) it was discovered that there was no documented evidence on the plan of care of planned interventions for documented wounds. During review of certification period 10/14/2024 -12/17/2024 and 12/18/2024-02/12/2025 there was no consistent documentation of the status of the wounds or if the wounds were responding to treatment. The clinical manager (Personnel Record 5) confirmed this information was missing. Further discussion with the clinical manager (Personnel Record 5) resulted in a phone call to the patient's daughter and she confirmed the medication was in her home and there was no plan how the medications would get to the patient in the case of a crisis. According to the clinical manager the information about the location of the patient's medications should be listed on the plan of care.

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. A revised plan of care includes Information from the patient’s updated comprehensive assessment; Record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed that were receiving homecare services revealed that the agency did not ensure that the individualized plan of care was not reviewed and revised as frequently as the patient's condition required. CLINICAL RECORD 7: The patient elected the hospice benefit on 12/27/2024. On 01/01/2025 the RN documented that the patient had an ostomy placed on the last hospitalization. The RN was providing care to the ostomy according to documentation made by the RN on 01/03/2025. It was also documented by the RN that the patient had a gastrostomy tube. It was documented on 01/09/2025 that the patient had pain on multiple visits by the RN and on 01/12/2025 it was documented that the patient had a wound. During joint review and interview with the clinical manager on 01/14/2025 it was discovered and confirmed by the clinical manager (Clinical Manager 5) that there had been no updates made to the plan of care since 01/01/2025.

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 2 of 17 (12%) clinical records reviewed that accepted aide services revealed that the agency did not ensure that there were specific written patient care instructions for the hospice aide. CLINICAL RECORD 4: The patient elected the hospice benefit on 02/27/2023. Aide services were accepted by the patient on admission. During review of the clinical record, it was documented that the patient had a foley catheter. During joint review of the clinical record and interview with the Clinical Manager (Clinical Manager 5) on 01/13/2025 it was revealed that there was no documented evidence the RN ensured there were specific written instructions to care for the foley on the aide plan of care. CLINICAL RECORD 7: The patient elected the hospice benefit on 12/27/2024. The patient elected accepted aide services on admission. On the clinical record it was documented that the patient had an ostomy and a gastrostomy tube. During interview and joint review of the clinical record with the clinical manager (Personnel Record 5) on 01/14/2025, it was revealed that there was no documented evidence that the RN ensured there were specific written instructions on the aide plan of care related to the gastrostomy tube or the ostomy.

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. Each patient’s record includes, at a minimum physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 21 (5%) clinical records reviewed revealed that the agency did not ensure that the patient's record included physician orders. CLINICAL RECORD 4: The patient elected the hospice benefit on 02/21/2023. A joint review of the clinical record and interview with the clinical manager (Personnel Record 5) was done on 01/15/2025. During the review it was documented on the RN assessment dated 06/18/2023, 06/21/2023, 06/28/2023 that the patient had an indwelling foley catheter. There was no physician order identified for a foley catheter until 03/27/2024. This was confirmed by the clinical manager (Personnel Record 5).

It is required that the hospice inpatient facility provides meals to each patient that are palatable, attractive, and served at the proper temperature. This standard was not met as evidenced by interview and observation. A tour of the inpatient unit (IPU) on 01/14/2025 revealed that the agency did not ensure that meals were served at the proper temperature. During a tour of the IPU on 01/14/2025, there was no documented evidence of food temperature checks. During an interview, on 01/14/2025, with the ICC Clinical Manager (Personnel Record 6), she stated that the staff that serves meals to patients use a meat thermometer to check the temperature of hot portions of meals. She also stated that there was no process in place to record the temperatures, in any log or other means, to verify that meals were served at the proper temperatures. A tour of the inpatient unit (IPU) on 01/14/2025 revealed that the agency did not ensure that meals were served at the proper temperature.

It is required that the hospice inpatient facility provides meals to each patient that are obtained, stored, prepared, distributed, and served under sanitary conditions. This standard was not met as evidenced by document review, interview, and observation. A tour of the inpatient unit (IPU) on 01/14/2025 revealed that the agency did not ensure that a proper dishwashing process was followed to ensure sanitary preparation, distribution, and serving of food to patients. The CMS regulation 483.60(i)(2) (F812) pertaining to the manual washing and sanitizing of dishes and utensils in a healthcare facility kitchen stated, in part, that "A 3-step process is used to manually wash, rinse, and sanitize dishware correctly. The first step is thorough washing using hot water and detergent after food particles have been scraped off. The second is rinsing with hot water to remove all soap residues. The third step is sanitizing with either hot water or a chemical solution" and "After washing and rinsing, dishes and utensils are sanitized by immersion in either hot water (at least 171 degrees F) for 30 seconds or a chemical sanitizing solution used according to manufacturer’s instructions." IPU TOUR: During the IPU tour on 01/14/2025, examination of the kitchen revealed that dishes and utensils used in the preparation and serving of meals for patients were cleaned by hand washing. The cleaning process involved scraping of dishes, washing the dishes in hot, soapy water, rinsing the dishes in clean, hot water, and allowing the dishes to air dry. Testing of the water by thermometer revealed that the temperature of the water at the sink within a patient room read 103.1 Fahrenheit. During an interview on 01/14/2025 with the ICC Clinical Manager (Personnel Record 6), she stated they did not have a policy or procedure, but the process for cleaning dishes was to scape the dishes and utensils, wash them by hand in hot, soapy water, rinse them by hand in hot water, and to let the dishes and utensils air dry. She also stated that a sanitization process was not undertaken. She also reported that the IPU had one water heater (for the kitchen and patient rooms) and that the water heater does not heat the water past 120 degrees Fahrenheit. This was confirmed through observation of the agency's water temperature-check logs and measurement of water from the tap in a patient's room. A tour of the inpatient unit (IPU) on 01/14/2025 revealed that the agency did not ensure that a proper dishwashing process was followed to ensure sanitary preparation, distribution, and serving of food to patients.