Every finding on record at Professional Healthcare Resources of Washington D.C., Inc.

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes the following: For all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles; Demonstration of staff knowledge of emergency procedures; EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years; More frequent training occurs if there is a significant update of EP policies and procedures; A periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others, and documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by interview and personnel record review. In 5 of 9 (56%) personnel records reviewed it was revealed that the agency did not ensure that all hospice employees and those providing services under arrangement received initial emergency preparedness training upon hire and every two years thereafter. PERSONNEL RECORD 1: The LPN was hired 01/31/2022. A review of the personnel record on 07/01/2025 revealed that the personnel record lacked evidence that emergency preparedness education was provided upon hire and every two years thereafter. PERSONNEL RECORD 2: The Registered Nurse was hired 01/29/2018. A review of the personnel record on 07/01/2025 revealed that the personnel record lacked evidence that emergency preparedness education was provided every two years. PERSONNEL RECORD 3: The Medical Social Worker was hired 03/21/2005. A review of the personnel record on 07/01/2025 revealed that the personnel record lacked evidence that emergency preparedness education was provided every two years. PERSONNEL RECORD 4: The Hospice Nurse was hired 05/14/2018. A review of the personnel record on 07/01/2025 revealed that the personnel record lacked evidence that emergency preparedness education was provided every two years. PERSONNEL RECORD 6: The Volunteer Coordinator/Volunteer was hired 01/20/2025. A review of the personnel record on 07/01/2025 revealed that the personnel record lacked evidence that emergency preparedness education was provided upon hire. The Senior Vice President of Analytics and Operations confirmed findings in a joint interview and personnel record review on 07/01/2025. The Human Resources Manager, in a joint interview and personnel record review on 07/01/2025 stated in part, "I don't see it here (Relias) or in the H drive, it could be in our old system."

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 4 of 14 (29%) clinical records reviewed it was revealed that the agency did not ensure that the initial comprehensive assessment was completed no later than five (5) calendar days after the election of hospice care. CLINICAL RECORD 1: The patient elected the hospice benefit on 03/18/2025. The record lacked documentation of a spiritual care assessment. CLINICAL RECORD 4: The patient elected the hospice benefit on 02/05/2025. The initial social work assessment was dated 02/12/2025, a total of 7 days later and 2 days outstanding. There was no documentation in the record to indicate why the social work assessment was late. CLINICAL RECORD 9: The patient elected the hospice benefit on 07/03/2024. The record lacked documentation of a psychosocial assessment. CLINICAL RECORD 13: The patient elected the hospice benefit on 04/23/2025. The initial social work assessment was dated 04/30/2025, a total of 7 days later and 2 days outstanding. There was no documentation in the record to indicate why the social work assessment was late. During a joint record review and interview with the Chief Nurse Executive of Clinical Operations on 07/01/2025, the Chief Nurse Executive of Clinical Operations confirmed the findings, stating "The social work and chaplain assessments that are late or missing do not have any coordination notes explaining why they were late or missing".

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IID (intermediate care facility/Individuals with Intellectual Disabilities) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered, and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 3 of 5 (60%) bereavement clinical records reviewed it was revealed that the agency did not ensure that bereavement services reflected the needs of the bereaved per a documented bereavement plan of care. CLINICAL RECORD 10: The patient elected hospice care on 06/24/2024 and passed away on 04/27/2025. The record lacked a bereavement plan of care and documentation of post-death bereavement activities. CLINICAL RECORD 11: The patient elected hospice care on 03/03/2024 and passed away on 07/14/2024. The record lacked a bereavement plan of care and documentation of post-death bereavement activities. CLINICAL RECORD 14: The patient elected hospice care on 10/27/2023 and passed away on 04/19/2024. The record lacked a bereavement plan of care and documentation of post-death bereavement activities. During a joint record review and interview with the Chief Nurse Executive of Clinical Operations on 07/02/2025, the Chief Nurse Executive of Clinical Operations confirmed the above findings, stating "I do not see any bereavement plans of care or notes regarding bereavement services after the death of these patients". During an interview with the Bereavement Coordinator on 07/02/2025, the Bereavement Coordinator stated, "There are no coordination notes in the system regarding if bereavement follow-up was accepted or declined. I am still trying to learn this system".

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 3 of 4 (75%) clinical records reviewed of patients with hospice aide services provided, it was revealed that the agency did not ensure that hospice aide supervisory visits were completed by a registered nurse no less frequently than every 14 days. CLINICAL RECORD 10: The patient elected the hospice benefit on 06/24/2024. A physician's order dated 07/03/2024 read in part "Start aide services three times weekly on 07/08/2024". The first hospice aide visit was dated 07/08/2024. The record lacked documentation of any hospice aide supervisory visits. CLINICAL RECORD 11: The patient elected the hospice benefit on 03/03/2024. A physician's order dated 04/21/2024 read in part "Aide services five times weekly". The first hospice aide visit was dated 04/22/2024. The record lacked documentation of any hospice aide supervisory visits. CLINICAL RECORD 14: The patient elected the hospice benefit on 03/03/2024. A physician's order dated 02/14/2025 read in part "Aide services two times weekly". The first hospice aide visit was dated 02/14/2025. The record lacked documentation of any hospice aide supervisory visits. During a joint record review with the Chief Nurse Executive of Clinical Operations on 07/01/2025, the Chief Nurse Executive of Clinical Operations confirmed the above findings that hospice aide supervisory visits were not documented in the clinical records.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. Review of agency volunteer documents revealed that the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that was at a minimum equal to five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. DOCUMENT 1: A joint review of the agency report titled, Hospice Volunteer Requirement Report, with the Senior Vice President of Analytics and Operations and Volunteer Coordinator on 07/01/2025 it was revealed that volunteer utilization was 0% for the time period 06/01/2024 through 06/30/2025. During an interview on 07/01/2025, the Volunteer Coordinator confirmed the finding and stated, "We have volunteers ready to visit patients but at this time there have been no requests." During an interview and joint review of the Volunteer Requirement Report on 07/01/2025, the Senior Vice President of Analytics and Operations confirmed the finding. Review of volunteer documents revealed the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that was equal to five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.

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. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by interview and personnel record review. In 1 of 9 (11%) personnel records reviewed it was revealed that the agency did not ensure that all individuals providing care had documentation that a competency assessment was completed. PERSONNEL RECORD 6: The Volunteer Coordinator was hired 01/20/2025. The personnel record lacked documentation of a competency assessment. During a joint record review on 07/01/2025, the Human Resources Manager confirmed that the competency assessment was not in the personnel record.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. This standard was not met as evidenced by interview and personnel record review. In 1 of 9 (11%) personnel records reviewed it was revealed that the agency did not ensure criminal background checks were completed on all hospice employees who had direct patient contact or access to patient records. PERSONNEL RECORD 7: The Medical Director was hired 05/31/2024. Review of the personnel record revealed there was no evidence that a criminal background check was obtained. The Human Resources Manager confirmed findings in a joint interview and personnel record review on 07/02/2025 and stated in part "I don't see it here or in the H drive."

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes the following: for all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles, demonstration of staff knowledge of emergency procedures, EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years. This standard was not met as evidenced by personnel records review and document review. 3 of 8 (38%) records reviewed revealed the agency did not ensure that emergency preparedness (EP) training was provided upon hire and every two years. Record # 3 (RN) was reviewed and identified the date of hire on 12/6/2021. The record lacked evidence of the initial (EP) training upon hire. Record # 4 (RN) was reviewed and identified the date of hire on 10/13/2014. The record lacked evidence of (EP) training in 2000 or 2021. Record # 8 (Aide) was reviewed and identified the date of hire on 8/30/2010. The record lacked evidence of (EP) training in 2020 or 2021.

It is required that the hospice has a written Patient Bill of Rights and Responsibilities (Bill of Rights). The patient has the right to be informed of his or her rights and responsibilities, and the hospice defines, protects, and promotes the exercise of these rights. This standard was not met as evidenced by observation and interview. 1 of 1 (100%) home visits, review of the written information provided at the time of admission revealed that the agency did not ensure the patients/family received the patient bill of rights. Record # 16 elected hospice care on 4/16/22. During an interview, the patient's daughter confirmed that the hospice had not provided the patient bill of rights. There was no evidence that the patient bill of rights was included in the written information provided to the patient. During an interview, the patient's daughter discussed the care her mother was receiving. She stated if she had the patient handbook that is given to all of the patients on admission and she stated, "I did not get the "Red Book", I was told that they would give me one, but I have not received it yet."

It is required that the hospice informs and distributes to the patient written information about its policies on advance directives, including a description of applicable state law. The hospice provides written information to patients about their rights under state law to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives at the individual’s option. This standard was not met as evidenced by document reveiw and observations. 1 of 1 (100%) home visits, review of the written documents on advanced directives provided to patients at the time of admission revealed that the agency did not ensure the patients/family received written information on advanced directives. Record # 16 elected hospice care on 4/16/22. During an interview, the patient's daughter confirmed that the hospice had not provided written information on the advanced directives. There was no evidence that advanced directives information was included in the written information provided to the patient.

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 records reviewed. 5 of 13 (38%) revealed that the agency did not ensure that the spiritual counselor and social worker completed a comprehensive assessment within 5 calendar days after the patient elected the hospice bennefit. Record #16 was reviewed and identified the patient elected hospice on 4/16/22. The record lacked evidence as to the reason the psychosocial assessment was not completed within the required 5 days. There was no documented evidence that the Social Worker attempted to contact the family within the mandated five days. Record # 5 was reviewed and identified the patient elected hospice on 8/9/22. The record lacked evidence as to the reason the spiritual assessent was not compmleted within the 5 required days. The Chaplain initial visit was completed on 8/26/22, 17 days after the election date. There was no documented explanation for the reason for the delay. Record # 2 was reviewed and identified the patient elected hospice on 7/29/22. The record lacked evidence as to the reason the psychosocial assessment was not completed within the required 5 days. There was no documented evidence that the Social Worker attempted to contact the family within the mandated five days. The record did not contain evidence that patient and/or family refused chaplain visit. Patient died on 8/4/22. Record 2- MR # 2311202): This patient was reviewed and elected hospice on 06/02/2022. The Chaplain saw the patient for the first time on 08/12/2022.The spiritual assessment was not completed or attempted to be completed within 5 calendar days after the election of hospice care. Record 1- MR # 2224102): was reviewed and identified the patient elected hospice care on 03/25/2022 and accepted Social Worker services. There was no documented evidence that the Social Worker attempted to complete an initial psychosocial assessment within 5 calendar days after the election of hospice services. The plan of care revealed the patient was to receive Social Worker Services initial assessment with frequencies to be determined. The Social Worker's notes were reviewed between 03/25/2022 and 04/30/2022 and there was no documented evidence of communication with the patient or caregiver or that a psychosocial assessment was completed. The Administrator (Staff # 5) was interviewed and stated that the Social Worker and the Chaplain did not complete and initial psychosocial assessment within 5 days of the election of Hospice Services. No further information was provided.

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; 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 clinical record review, document review, and interview. 1 of 1 (100%) visits with obsrevation revealed the hospice did not ensure that medication profiles were updated and drug reviews occurred when new medications were ordered for patients. [Record # 5] The patient admission packet did not contain the medication profile. During an interview, the patient's daughter explained that the hospice had medications delivered to the patient on admission. The daughter stated that she and the caregiver were provided education by the nurse, but the family had not received a current medication profile. 1 of 13 (8%) records reviewewd revealed the hospice did not ensure that medication profiles were updated and drug regimes occurred when new medications were obtained for patients. Record # 5 was reviewed and identified the patient elected hospice on 8/9/22. The RN admission note documented the comfort pack (Morphine, hyosyamine, tylenol suppositories, haldol, and lorazapam) was ordered. Review of the drug profile revealed the medications in the comfort pack were not a part of the medication profile and medication reconcilation.

It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program: reflects the complexity of the hospice and services; involves all hospice services, including those provided under contract; addresses efforts and sets priorities for improved quality of care and patient safety, and ensures all improvement actions are evaluated for effectiveness; focuses on indicators related to improved palliative outcomes; includes investigation and analysis of sentinel and adverse events; includes defined data detail and frequency of collection, and approves such; has evidence of action taken that results in improvement in hospice performance; and is evaluated annually. THIS IS A CMS CONDITION LEVEL DEFICENCY This CONDITION was not met as evidenced by review of Governing Body documents, policies and procedures, Quality Improvement documents, which revealed issues with the organization's Quality Assessment Performance Improvement (QAPI) program in the following areas: Failure of the organization to implement quality improvement activities that are capable of showing measurable improvement [HQPI 3.I/L561]; Failure of the organization's performance improvement activities to track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospice [HQPI 7.I/L569]; and, Failure to develop.implement and mainntain an ongoing QAPI program [HQPI.1.D/L560]. The cumulative effect of these deficiencies could impact the organization's ability to assess care and services provided by hospice and ensure the provision of high quality care and services.

It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program' reflects the complexity of the hospice and services; involves all hospice services, including those provided under contract, addresses efforts and sets priorities for improved quality of care and patient safety, and ensures all improvement actions are evaluated for effectiveness; focuses on indicators related to improved palliative outcomes; includes investigation and analysis of sentinel and adverse events; includes defined data detail and frequency of collection, and approves such; has evidence of action taken that results in improvement in hospice performance; is evaluated annually. This standard was not met as evidenced by documentation reviews that revealed that the agency did not ensure a QAPI program was implemented. The Governing Body minutes on 6/27/2022 documented the approval of the QAPI program. However, the agency clinical leadership was unable to produce a QAPI plan, adverse events tracking, no monitoring, benchmarking, and performance improvement programs. In the Governing Body minutes on 6/27/2022, the QAPI program was approved. The agency did not have a QAPI plan, no adverse events tracked, no monitoring, no benchmarking, and performance improvement programs.

It is required that the QAPI program demonstrates measurable improvement among indicators related to improved palliative outcomes and hospice services. This standard was not met as evidenced by review of the agency’s QAPI program documents which revealed there was no documentation available for review related to measurable improvement among indicators related to improved hospice services. There was no documented evidence that the agency had collected data and tracked indicators to demonstrate measurable improvement. The agency's policy "CQI.1.-6/QAPI.1-9" stated in part "the program is capable of showing measurable improvement in indicators related to outcomes, patient safety and quality of care."

It is required that performance improvement activities: track adverse patient events; analyze the causes; implement preventive action and mechanisms that include feedback and learning throughout the hospice. This standard was not met as evidenced by document reviews. A review of the documents provided by the agency as QAPI revealed the agency was not tracking and analyzing patient adverse events. There was no evidence of activities involving adverse events and the implementation of preventive actions as part of a performance improvement plan. The agency policy "CQI.1.-6/QAPI.1-9" stated in part, "Based on the findings in the QAPI data review, clinical charts may be audited. Trends are identified by the team and performance improvement action items are chosen. the BA/CM develop and track the ongoing performance improvement plan and interventions. They monitor weekly and update and evaluate progress toward identified goals as appropriate. Agency utilizes the Performance Improvement plan of Actions as a means of identifying a target area that is measurable." Review of the documents provided by the agency as QAPI revealed the agency was not tracking and analyzing patient adverse events. There was no evidence of activities involving adverse events and the implementation of preventive actions as part of a performance improvement plan.

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases.The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by a review of interviews and personnel records. 3 of 8 (38%) records reviewed revealed that the agency did not ensure that employees participated in infection-control in-services. Records # 3 (RN), # 8, (Hospice Aide) and # 4 (RN) did not contain documented evidence of infection control training.

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group; 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 clinical record reviews. 4 of 6 (67%) applicable records receiving hospice aide services revealed the agency did not provide aide services that were consistent with the plan of care. Record # 16 was reviewed and identified that the patient elected hospice on 4/16/22. The ordered hospice aide visit frequency on 4/16/22 was 5 times a week. The week of 7/17/22, 3 visits were completed. There was no documentation stating the reason for the missed visit. Record # 11 was reviewed and identified that the patient elected hospice on 3/16/22. The ordered hospice aide visit frequency on 3/16/22 was 3 times a week.The week of 3/13/22, no visits were completed. There was no documentation stating the reason for the missed visits. Record # 2 was reviewed and identified that the patient elected hospice on 7/29/22. The ordered hospice aide visit frequency on 7/29/22 was 5 times a week. The week of 7/31/22, no visits were completed. There was no documentation stating the reason for the missed visits. Record 1 (MRN # 2224102): The ordered hospice aide task was to shampoo the patient's hair weekly. There was no documented evidence that shampoo was provided on 04/05/2022, 04/07/2022 and 04/11/2022. There was no documentation stating the reason fthe shampoo was not provided. During an interview, the Administrator (Staff # 5) stated that the aide did not follow the plan of care as ordered by the Interdisciplinary Group. No further information was provided.

It is required that Volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care and documented in the patient record, including the time spent. THIS IS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidence by an interviews and clinical record review, which revealed the hospice failed to document and demonstrate viable and ongoing efforts to recruit and retain volunteers [HSRM.30.I/L645; failure to provide volunteer services in administrative or direct patient care roles [HCDT.21.I/644]; and failure to provide and document appropriate orientation and training [HSRM.31.I/L643]. The cumulative effect of these deficiencies has resulted in the hospice agency's inability to provide quality care for the Condition of Participation CFR 418.78, Volunteers. The collective deficient practice illustrated not having a process to ensure the provision of Volunteer Services to all patients.

It is required that the hospice maintains, documents, and provides hospice volunteer orientation and training that is consistent with hospice industry standards; it includes: the volunteer’s duties and responsibilities, the person to whom they report, the person to contact if they need assistance and instruction, hospice goals, services, and philosophy, confidentiality and protection of the patient’s and family’s rights, family dynamics and psychological issues surrounding terminal illness, death, and bereavement, procedures to be followed in an emergency and/or following the death of a patient, and guidance specific to individual responsibilities. This standard was not met as evidenced by personnel record review and interview that revealed the hospice did not ensure that a volunteer orientation program was developed. Upon review of personnel records there was no evidence of volunteer records or an orientation program and training program. During an interview, the acting hospice Administrator confirmed this finding and stated that the volunteer orientation and training program had been inactive since the start of COVID, that a Volunteer Coordinatorwas recently hired to recruit, train and reestablish the orientation and training program. The Volunteer Coordinator, (Record # 6) was interviewed and reported that the agency did have any current volunteers. The program had been dormant since COVID.

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 a review of clinical records and interview which revealed that the agency did not ensure that volunteer services were offered to the patients and families. There was no evidence of an active volunteer. The records reviewed did not contain documentation that volunteer visits were completed in 2020 and 2021. A review of personnel records identified that there were no active volunteers. The Volunteer Coordinator, (Record # 6) was interviewed and reported that the agency did have any current volunteers. The program had been dormant since COVID.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by a review personnel records, and interview. There was no evidence of volunteer recruitment and retention activity. During an interview, the Volunteer Coodrinator (Record # 6) stated that the agency had not been recruiting for volunteers since Covid. interview with staff 6, revealed that the agency had not been recruiting for volunteers and had no current volunteers. The program had been dormant since COVID.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. Orientation includes the following, as appropriate to the employee’s specific job duties: the needs and concerns of patients and families coping with a terminal illness; and education regarding the hospice’s policies and procedures on advance directives. This standard was not met as evidenced by personnel record review. 8 of 8 (100%) revealed that agency did not ensure that orientation was provided to all staff upon hire. Record review revealed that the agency did not ensure that orientaiton was provided upon hire. [Record #1 (MSW) date of hire (DOH) on 8/23/2021; Record# 3 (RN) DOH 12/06/21; Record # 5 (Administrator), DOH 4/18/2022; Record # 2 (MSW) DOH 7/25/22; Record # 6 (Chaplain/Bereavement) DOH 8/15/2022; and Record# 4 (RN) DOH 10/13/14.]

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. The hospice has written policies and procedures describing the method(s) of assessing competency and: maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by personnel record review. 3 of 8 (38% ) revealed that the agency did not ensure that clinical competencies were assessed. Record # 3 (RN) was reviewed and identified the hire date on 12/06/21. There was no evidence that an initial competency assessent was completed. Record # 1 (MSW) was reviewed and identified the hire date on 8/23/2021.There was no evidence that an initial competency assessent was completed. Record # 2 was reviewed and identified the hire date on 7/25/2022. There was no evidence that an initial competency assessent was completed.

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: Signed copies of the notice of paptient rights and the hospice election statement; This standard was not met as evidenced by a review of clinical records and interviews. 1 of 13 (8%) records reviewed did not includue signed copied of the hospice election statement and a signed addendum for the non-covered items for the episode of care reviewed. Record 2- MR # 2311202: Patient elected hospice on 06/02/2022. The clinical record did not contain any signed admission documentation verifying the hospice election statement and the addendum for the non-covered items. During an interview, the Administrator (Staff # 5) stated that the signed Notice of Election and the Addendum for the Non-covered items was not in the patient's record. No further information was provided.

It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or patient’s legal representative(s). he Interdisciplinary Group: discusses the policies and procedures in a language and manner that the patient and family or patient’s legal representative understand; ensures that the safe use and disposal of controlled drugs is understood; documents in the patient record that the policies and procedures for managing and disposing of controlled medications is provided and discussed. This standard was not met as evidenced by clinical record review, observation and interview. 1 of 1 (100%) visits with observation reviewed revealed the agency did not ensure that the patient/family received a copy of the hospice’s written policies and procedures for the management and disposal of controlled medication. Record #16 was reviewed and identified the patient elected hospice on 4/16/22. The patient admission packet did not contain a copy of the hospice's written policies and procedures for the managment and disposal of controlled medications. There was no documented evidence that this information was provided to the patient or patient's legal representative. During an interview the patient's daughter stated that controlled medications were delivered to the patient but they had not received a copy of the policy on management and disposal of controlled medications. During the patient #6 visit the daughter stated that controlled medications were delivered to the patient but they had not received a copy of the policy on management and disposal of controlled medications.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. Criminal background checks are obtained in accordance with state requirements. This standard was not met as evidenced by personnel record review. 1 of 8 (13%) review of records reviewed revealed the hospice did not ensure that background checks were not in the personnel records. Record # 3 was reviewed and identified the date of hire for the employee was on 12/6/2021. The agency could not provide evidence of a completed background check for the employee.