Capital Hospice

“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 an RN who is responsible for the supervision of the hospice aide. THIS IS A CONTINUED REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. In 2 of 3 (67%) clinical records reviewed for patients receiving hospice aide services, it was revealed that the agency did not ensure the registered nurse (RN) prepared a hospice aide plan of care that documented clear and specific instructions for the patient’s care. Clinical Record 2: The hospice aide was ordered on 11/11/2024 with a frequency of 3 times a week. The aide plan of care (POC) included an assigned task for catheter care per visit. However, the patient had no catheter and wore incontinence briefs only. This task continued to be assigned as of the review dated 11/25/2024. The aide did document the catheter care task as N/A (not applicable) for each visit. Clinical Record 3: The hospice aide plan of care (POC) was documented on 11/09/2024 with an ordered visit frequency of 3 times a week. The POC was not updated as of 11/25/2024. The following assigned tasks had no documented frequency: assist with dressing; peri care; skin care; oral care; and bed bath. A review of all aide notes revealed that all tasks were provided at each visit, which occurred three times a week. During an interview, the Director of Clinical Services and the Executive Director confirmed the findings and stated the hospice aide plans of care were not accurate.”

“The Condition of Participation requires that a hospice that provides inpatient care directly in its own facility is responsible to ensure the level of intensity of services needed to ensure that the patient’s plan of care outcomes are achieved and negative outcomes avoided. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This Condition of Participation was not met as evidenced by observation, document review and interview, which revealed the hospice’s inability to ensure the avoidance of negative outcomes for patients in the inpatient care facility. The hospice failed to maintain a safe physical environment free of hazards for patients, staff and visitors [L824/418.110(c)]. The hospice failed to address real or potential threats to the health and safety of the patients, others and property [L825/418.110(c)(1)]. The cumulative effect of this deficiency has resulted in the hospice’s inability to ensure the provision of quality care for the Condition of Participation CFR 418.110, Hospices that provide inpatient care directly. The collective deficient practice illustrated a systemic process failure that had the potential to affect all patients receiving hospice inpatient care.”

“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 2 of 11 (18%) clinical records reviewed, in which chaplain services were accepted, it was revealed that the agency did not ensure that a spiritual initial assessment was completed no later than five calendar days after the election of hospice care. Clinical Record 2: The patient elected the hospice benefit on 05/27/2024. On the initial plan of care dated 05/27/2024 the chaplain was ordered 1 time a month for 3 months effective 06/01/2024. The chaplain made a phone call on 05/31/2024 with no answer from the patient. The chaplain documented that he would “follow up appropriately.” There was no follow up documented until 06/28/2024 which was an initial assessment via phone call. In an interview and joint review of the clinical record with the compliance director she confirmed the clinical record lacked documented evidence the chaplain followed up with the patient/family between 05/31/2024 and 06/28/2024. Clinical Record 8: The patient elected the hospice benefit on 04/23/2024. On the initial plan of care dated 04/23/2024 there was an order for the chaplain for 1 time for 1 month. The chaplain made a call to the patient with no answer on 04/26/2024 and left a message for patient and family. There was no documented evidence of any contact made by the chaplain again until 06/25/2024 in this note he documented that he family refused chaplain services. There was no spiritual assessment found in the RN initial assessment dated 04/23/2024. In an interview and joint review of the clinical record with the compliance director she confirmed that the initial assessment was not completed by the chaplain in a timely manner.”

“It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 22 (14%) clinical records reviewed it was revealed that the records did not include evidence of an initial bereavement assessment. Clinical Record 6: The patient elected the hospice benefit on 10/03/2024. During review of the clinical record there was no documented evidence that an initial bereavement risk assessment was completed. There was no bereavement risk assessment in the initial RN assessment made on 10/03/2024, it was not found in the social work assessment made on 10/07/2024 or in the chaplain visit made on 10/07/2024. Clinical Record 8: The patient elected the hospice benefit on 04/23/32024. During review of the clinical record there was no documented evidence that an initial bereavement risk assessment was completed by the interdisciplinary team. Clinical Record 9: The patient elected the hospice benefit on 07/16/2024. During review of the clinical record there was no documented evidence that an initial bereavement risk assessment was completed by the interdisciplinary team. During joint review of the clinical record and interview with the compliance director, she confirmed these clinical records did not include evidence that an initial bereavement risk assessment had been completed.”

“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 the following 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 2 of 22 (9%) clinical records reviewed it was revealed that the agency did not ensure that the plan of care included measurable outcomes to problems identified in the comprehensive assessment. Clinical Record 4: The patient elected the hospice benefit on 04/07/2024. The RN documented on the initial assessment that the patient had a feeding tube that was being used for enteral feedings and medication administration. On the face-to-face assessment completed by the nurse partitioner (NP) for certification period 07/30/2024 -09/27/2024 the NP documented that the patient was receiving Nepro 3 cans per day. The plans of care, effective from 04/07/2024 to current, included the problem of “Diet/Hydration: Diet as tolerated effective 04/07/2024 (no changes since last certification period); Nutritional supplement: Regular; Enteral/Parenteral: Enteral feeding of ________amount of_____ formula every ______effective date 04/07/2024.” Durning an interview and joint review of the clinical record with the compliance director she confirmed that the plan of care was lacking measurable outcomes required to meet the patient’s needs. Clinical Record 5: The patient elected the hospice benefit on 08/29/2024 with a diagnosis of malignant neoplasm of the esophagus. The initial RN assessment dated 08/29/2024 documented throat pain and intermittent esophagus pain as a problem, rated by patient as “intermittent pain, characteristic unbearable, worsened by movement, relieved by medication, effects on activities.” Initial plan of care dated 08/29/2024 and updated plan of care dated 09/05/2024 did not include measurable outcomes for pain, the pain goal read “patient/caregiver goals: pain rating of _____/10 will be maintained by: ____Achieve by date: 09/19/2024 start effective date 08/29/2024” During joint clinical record review and interview with the compliance director she confirmed that the documentation for the goal was incomplete as it lacked measurable outcomes.”

“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. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed in which wounds were documented revealed that the agency did not ensure that individualized plan of care was reviewed and revised as frequently as the patient’s condition required. Clinical Record 3: The patient elected the hospice benefit on 01/13/2022 with a diagnosis of Alzheimer’s Disease. Per the clinical record the patient was bedbound and had a long history of wounds. An order was documented on the plan of care effective 03/25/2024, “cleanse sacral wound with wound cleanser. Apply zinc to peri wound area, apply calcium alginate to wound bed, apply 4x4 gauze and cover with Opti foam dressing reinforce with pink zinc tape every 3 to 5 days as needed.” On 09/09/2024 the RN documented a wound assessment and the wound care done was cleansed with wound cleanser zinc paste, adhesive dressing and reinforced with pink zinc tape (this did not follow the order on the plan of care). The same wound care was performed on 09/16/2024, 09/23/2024, and 09/30/2024. There was no wound care discussed or updated during IDT meetings dated 09/05/2024, 09/20/2024, and 10/03/2024. In an interview and joint review with the compliance director she agreed and confirmed that the wound care was not updated as frequently as the patient care needs were changing according to wound documentation by the RN.”

“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 4 of 11 (36%) clinical record reviewed, in which hospice aide services were accepted, it was revealed that the agency did not ensure the RN provided clear and specific written instructions for the aide assignments. Clinical Record 2: The patient elected the hospice benefit on 05/27/2024 with a diagnosis of Senile Degeneration of the Brain. The Aide plan of care initiated on admission instructed the aide to perform hair care as needed every visit. The aide plan of care did not provide instructions to define “as needed” and the patient was unable to direct their own care. Clinical Record 3: The patient elected the hospice benefit on 01/13/2022 with a diagnosis of Alzheimer’s Disease. The plan of care for certification period 08/30/2024 – 10/28/2024 documented that the patient was on Oxygen, had a foley in place (effective since 03/28/2024), and wounds to the sacral area that were being covered with dressings. The aide plan of care (08/30/2024 – 10/28/2024) did not specific instructions for foley care, what the aide should for dislodged or soiled wound dressings, or if the aide could or could not remove oxygen for cares, and the patient was unable to direct their own care. Clinical Record 4: The patient elected the hospice benefit on 04/07/2023 with a diagnosis of Parkinson’s disease. The clinical record documentation revealed the patient had a feeding tube and foley catheter in place. The aide plan of care, dated 09/30/2024, included the following tasks: range of motion exercises for right and left arms and legs “as needed” and shave with electric razor “as needed.” On the visits reviewed the aide had marked that these tasks had been completed. The aide plan of care (effective as of 09/30/2024) did not provide additional instructions for the “as needed” tasks, nor did it include specific instructions on RN notification for malfunctioning of the feeding tube or if the aide was to provide foley catheter care, and it did not state the patient could direct the cares. Clinical Record 9: The patient elected the hospice benefit on 07/16/2024 with a diagnosis of acute respiratory failure with hypoxia. The aide plan of care dated 07/23/2024 ordered “assist with toileting bathroom, raised toilet seat, beside commode as needed when toileting.” The aide care plan did not provide specific instructions for when the patient would use the bedside commode versus the bathroom toilet, and it did not state the patient could direct the cares. In an interview and joint record review with the compliance director she agreed and confirmed that these aide care plans were not specific.”

“It is required that a hospice aide provides services are ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 1 of 11 (9%) clinical records reviewed, in which hospice aide services were accepted, it was revealed that the agency did not ensure that the aide provided services as ordered by the interdisciplinary group. Clinical Record 8: The patient elected the hospice benefit on 04/23/2024. For the certification period 04/23/2024 - 07/21/2024 the plan of care ordered aide visits 1 time per week for 8 weeks starting on 05/01/2024. The week of 05/12/2024 the clinical record lacked evidence that an aide visit was completed nor was there evidence of why the visit was not provided. In an interview and joint review of the clinical record with the compliance officer she stated that there was no evidence of a visit made the week of 05/12/2024.”

“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 clinical record review and interview. In 1 of 3 (33%) clinical records reviewed, in which volunteer services were requested, it was revealed that the agency did not ensure that a volunteer request was followed through. Clinical Record 1: The patient elected the hospice benefit on 09/01/2024. During the social worker’s visit dated 09/19/2024 it was documented that the patient requested volunteer services 2 times a week for companionship. During further review of the clinical record there was no documented evidence that a volunteer had been provided for this patient. As of 10/15/2024 when the clinical record was reviewed there was still no follow up for volunteer services. During joint review of the clinical record and interview with the compliance director she stated that this happened during a time when the volunteer coordinator was in transition, and she confirmed there was no follow up with volunteer services.”

“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. This standard was not met as evidenced by document review, personnel record review and interview. In 2 of 7 (29%) personnel records of staff who provided direct care, it was revealed that the agency did not ensure that competency testing was performed annually. The agency’s Staff Competency Assessment policy, with a date of 04/22/2024, stated, in part, that “Annual skills for direct care staff, and other staff members whose work directly affects patient care, are assessed by observation, simulated demonstration, or other knowledge-based evaluation methods. Staff includes...Certified Nursing Assistants.” Per the Public Health Emergency (PHE) waiver: Condition of participation 418.103(g)(3) hospice’s requirement for hospices to annually assess the skills and competence of all staff furnishing care and provide in-service training and education programs where required. The PHE ended on 05/11/2023 and the guidance stated, “All postpones assessments must be completed by the end of the first full quarter after the expiration of the PHE (09/30/2023).” Personnel Record 8: The personnel record for this certified nursing assistant (CNA), who was hired on 10/05/2015 and who provided care in the home, contained a field review checklist that was completed on 10/15/2024 and stated that it covered the year of 2022. There was no other documented evidence that the annual competency assessment was completed for 2023. Personnel Record 12: The personnel record for this CNA, who was hired on 03/07/2016 and who provided care in the inpatient unit, contained a field review checklist that was completed on 01/09/2023 and stated that it covered the year of 2022. There was no other documented evidence that the annual competency assessment was completed for 2023. During an interview with the Corporate Compliance Manager on 10/16/2024, it was confirmed after following up with the human resources staff that they were unable to locate evidence of skills competency testing for these two personnel records for year of 2023.”

“It is required that the inpatient hospice facility physical environment maintains a safe environment free of hazards and addresses real or potential threats to the health and safety of patients, hospice staff, visitors, others, and property. This standard was not met as evidenced by observation, document review and interview. Observation revealed that the inpatient hospice facility did not maintain a safe environment free of hazards and did not address real or potential threats to the health and safety of patients, hospice staff, visitors and others. 418.110(i) stated in part, “The intent of this regulation is that the temperature of water at fixtures and in showers and tubs used by patients shall be automatically regulated by control valves and delivered for use at the appropriate temperature. There is a risk that patients or staff may be scalded by excessively hot water discharged by plumbing fixtures. Water that is too hot may scald individuals who are exposed to it. This danger is particularly significant for patients who may have circulatory or other neurological deficits that prevent the instantaneous recoil from water that is too hot...The recommended water temperatures at the plumbing fixtures should be maintained at or below 110 degrees.” During the IPU observation, conducted on 10/15/2024, a test of the hot water in the patient room that was furthest from the source of hot water resulted in a temperature reading of 112.4 degrees Fahrenheit. This was 2.4 degrees higher than the 110 degrees required by regulation. During an interview on 10/15/2024, the IPU Clinical Director confirmed the water temperature of 112.4 and stated that he was unaware of the requirement to monitor water temperatures. Agency policy, Patient Restraints, dated 11/04/2022, stated in part, “It is the policy of the above organization(s) to maintain a restraint free patient environment.” This policy defined physical restraint in part as, “Any manual method, physical or mechanical device...that involve[s] the physical holding of a patient from falling out of bed...[and] devices with multiple purposes such as side-rails...when they cannot be easily removed by the patient and restrict the patient’s movement, constitute a restraint.” During a tour of the inpatient unit (IPU) on 10/15/2024, all 5 patients currently admitted to the IPU were observed to be in hospital beds with bed rails in the extended position and blocking egress to and from the bed. Three patients were in beds with all 4 beds rails up (2 upper and 2 lower), and 2 patients were in beds with 3 of the 4 bed rails up (1 lower rail down). There were 2 models of hospital beds in use. Both models were inspected. It was observed that the bed rails could not be moved or retracted by the patient. Both models had 4 bed rails attached to the bed (2 upper and 2 lower). During an interview on 10/15/2024, the Regional Executive Director and IPU Clinical Director confirmed the IPU had a no restraint policy and stated that bed rails were routinely used for patients to prevent them from falling from the bed and for repositioning. The Regional Executive Director and Clinical Director confirmed that staff immediately discontinued the use of the lower bed rails for all patients, and all staff were educated on the agency Patient Restraints policy. The cumulative effect of this deficiency has revealed that the hospice in-patient facility did not maintain a safe environment free of hazards and did not address real or potential threats to the health and safety of patients, hospice staff, visitors and others.”

“It is required that each patient in the hospice inpatient facility always has an adequate supply of hot water and has plumbing fixtures with control valves that automatically regulate the temperature of the hot water used by patients. This standard was not met as evidenced by document review, interview and observation. During observation of the inpatient unit (IPU) on 10/15/2024, it was revealed that the agency did not regulate the temperature of the hot water used by patients. 418.110(i) stated in part, “The intent of this regulation is that the temperature of water at fixtures and in showers and tubs used by patients shall be automatically regulated by control valves and delivered for use at the appropriate temperature. There is a risk that patients or staff may be scalded by excessively hot water discharged by plumbing fixtures. Water that is too hot may scald individuals who are exposed to it. This danger is particularly significant for patients who may have circulatory or other neurological deficits that prevent the instantaneous recoil from water that is too hot...The recommended water temperatures at the plumbing fixtures should be maintained at or below 110 degrees.” During the IPU observation, conducted on 10/15/2024, a test of the hot water in the patient room that was furthest from the source of hot water resulted in a temperature reading of 112.4 degrees Fahrenheit. This was 2.4 degrees higher than the 110 degrees required by regulation. During an interview on 10/15/2024, the IPU Clinical Director confirmed the water temperature of 112.4 and stated that he was unaware of the requirement to monitor water temperatures. A review of the water temperature testing logs for the inpatient unit (IPU) revealed that the agency did not ensure that tests of the hot water temperature in the patients’ rooms were completed and documented on a regular basis.”

“It is required that the use of restraint or seclusion in the hospice inpatient facility is in accordance with safe and appropriate restraint and seclusion techniques, as determined by hospice policy in accordance with state law. This standard was not met as evidenced by document review, interview and observation. Observation revealed that the hospice did not ensure the use of restraint in the hospice inpatient facility in accordance with safe and appropriate restraint and seclusion techniques, as determined by hospice policy. Agency policy, Patient Restraints, dated 11/04/2022, stated in part, “It is the policy of the above organization(s) to maintain a restraint free patient environment.” This policy defined physical restraint in part as, “Any manual method, physical or mechanical device...that involve[s] the physical holding of a patient from falling out of bed...[and] devices with multiple purposes such as side-rails...when they cannot be easily removed by the patient and restrict the patient’s movement, constitute a restraint.” During a tour of the inpatient unit (IPU) on 10/15/2024, all 5 patients currently admitted to the IPU were observed to be in hospital beds with bed rails in the extended position and blocking egress to and from the bed. Three patients were in beds with all 4 beds rails up (2 upper and 2 lower), and 2 patients were in beds with 3 of the 4 bed rails up (1 lower rail down). There were 2 models of hospital beds in use. Both models were inspected. It was observed that the bed rails could not be moved or retracted by the patient. Both models had 4 bed rails attached to the bed (2 upper and 2 lower). During an interview on 10/15/2024, the Regional Executive Director and IPU Clinical Director confirmed the IPU had a no restraint policy and stated that bed rails were routinely used for patients to prevent them from falling from the bed and for repositioning. The Regional Executive Director and Clinical Director confirmed that staff immediately discontinued the use of the lower bed rails for all patients, and all staff were educated on the agency Patient Restraints policy. A tour of the inpatient unit (IPU) and interviews with the IPU leadership on 10/15/2024 revealed that the agency did not ensure that patients remained without restraint in accordance with their policy.”