Professional Healthcare Resources of Washington DC

“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.””