Calm Care, Inc.

Plan Based on All Hazards Risk Assessment (42 CFR 418.113(a)(1))

“Observed in Emergency Management Session. The organization’s hazard vulnerability analysis did not include technological hazards. This was confirmed by the QA Manager.”

Rule E0006. Standard-level.

EP Testing Requirements (42 CFR 418.113(d)(3)(iii))

“Observed in Emergency Management Session. The organization reviews and makes necessary updates based on after-action reports or opportunities for improvement every two years, or more frequently if necessary. Example: The HVA was not updated to include Hospice MD EMR outages, which had occurred twice in the last 12 months and resulted in the activation of the Emergency Plan. This was confirmed by the QA Manager.”

Rule E0039. Standard-level.

Content of comprehensive assessment (42 CFR 418.54(c)(5))

“Observed in Record Review. In 4 out of 5 wound record reviews, hospice did not conduct and document patient-specific reassessments that identified the patient’s need for hospice care and services. Example: In 3 out of 4 wound records, reassessments did not accurately reflect the patient’s wound status and were not updated per agency Ongoing Assessment Policy. Example: In RRHV#2 benefit period 8, RRHV#3 benefit period 4, RRNHV#4 benefit period 1, and RRHV#6 wound measurements were not obtained during bi-weekly RN Supervisory visits per policy. This was confirmed by the DCPS.”

Rule L0529. Standard-level.

Plan of care (42 CFR 418.56(b))

Rule L0544. Standard-level.

Content of plan of care (42 CFR 418.56(c))

Rule L0545. Standard-level.

Content of plan of care (42 CFR 418.56(c)(1))

“Observed in Tracer Visit. In 2 out of 5 records, oxygen range did not have defined parameters and indications for adjusting and/or changing the settings. Example: In RRHV#1 and RRNHV#1, oxygen order was for 2 LPM with ability to titrate to 5 LPM for SOB/comfort. However, there were no defined parameters and indications for adjusting and/or changing the settings. This was confirmed by the DCPS.”

Rule L0546. Standard-level.

Content of plan of care (42 CFR 418.56(c)(5))

“Observed in Tracer Visit. In 3 out of 3 home visit record reviews, medical supplies and appliances necessary to meet the patient’s needs were not included in the plan of care. Examples: In RRHV#1, NS and gauze wound supplies were not included in the plan of care. In RRHV#2, sacral wound supplies were not included int he plan of care. In RRHV#3, facial wound care supplies (wound cleanser and gauze) were not included in the plan of care. This was confirmed by the DCPS.”

Rule L0550. Standard-level.

Competency evaluation (42 CFR 418.76(c)(1))

“Observed in Tracer Visit. In 1 out of 1 observed hospice aide visits, staff were unable to verbally demonstrate competency related to aide care plan safety precautions. Example: During the RRHV#3 staff interview, the hospice aide was unable to identify safety precautions (bleeding precautions) identified on the aide plan of care. When informed by the Surveyor of the bleeding precautions listed, the hospice aide lacked knowledge related to what the precautions meant and how the precautions should be incorporated in the care they provide. This was confirmed by the DCPS.”

Rule L0615. Standard-level.

Content (42 CFR 418.104(a)(7))

“Observed in Tracer Activities. In 1 of 3 home visit records, the medication profile within the medical record was inaccurate. Example: In RRHV#1, the patient’s primary caregiver reported using albuterol and Benadryl as needed. Both medications were in the home but were not on the medical record medication profile. This was confirmed with the DCPS.”

Rule L0678. Standard-level.

Criminal background checks (42 CFR 418.114(d)(1))

“Observed in Leadership Session. In 1 out of 5 reviewed contracts, the written agreement with an outside agency providing contracted services for the hospice did not have a stipulation that the outside agency would complete criminal background checks on contracted employees who provided direct patient care or have access to patient records. Example: The written agreement with an outside agency for therapy services did not include the stipulation that the outside agency would complete criminal background checks. This was confirmed with the Business Office Manager.”

Rule L0795. Standard-level.