Accentcare Hospice & Palliative Care of Washington, DC

“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; [and] 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; [and] 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 measures 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, interview, and observation. Agency policy #HOS-054, “Medication Profile” (revision date 11/13/2024) read in part, “2. The medication profile shall be updated for each change to reflect current medications and new, modified, and /or discontinued medications. 5. The review is conducted to identify drug/food interactions, actual or potential adverse effects, drug reactions, drug therapy effectiveness, duplicative drug therapy, and noncompliance with drug therapy.” In 3 of 19 (16%) clinical records reviewed and home visit observations, it was revealed that the agency did not ensure that the drug profile included all of the patient’s current medications. Clinical Record 1/Home Visit 1: The patient elected hospice care on 10/29/2024 with a diagnosis of Alzheimer’s Dementia. The assisted living facility (ALF) medication profile was reviewed with the Hospice Executive Director (Personnel Record 5) during the home visit on 12/17/2024. The medications at the facility did not match the hospice medication profile, hospice plan of care (10/29/2024), or plan of care updates (10/31/2024 and 12/17/2024). The hospice medication profile did not include: Senna 8.6 mg, give one (1) tablet by mouth two times a day for constipation, order date 10/31/2024; Stress Formula/Zinc Oral Tablet (multiple vitamins w/minerals), give one (1) tablet by mouth one time a day for wound care order date 10/31/2024; and Tylenol Extra Strength oral tablet 500 mg (acetaminophen), give two (2) tablet by mouth three times a day for pain order date 10/31/2024; which were all listed on the ALF medication profile. Clinical Record 2/Home Visit 2: The patient elected hospice care on 10/31/2024 with a diagnosis of cerebral infarction. The skilled nursing facility (SNF) medication profile was reviewed with the Hospice Executive Director (Personnel Record 5) during the home visit on 12/17/2024. The medications at the facility did not match the hospice medication profile, hospice plan of care (10/31/2024), or plan of care updates (11/11/2024 and 11/21/2024). The hospice medication profile did not include: Bisacodyl Rectal Suppository 10mg (Bisacodyl) insert one (1) suppository rectally every 24 hours as needed for bowel regimen, order date 10/31/2024; calcium carbonate tablet chewable 500mg, give one (1)tablet by mouth three times a day for indigestion before meals, order date 07/17/2024; Effexor XR oral capsule extended release 24 Hour 75mg (Venlafaxine HCl), give one (1) capsule by mouth one time a day for anxiety, order date 01/26/2024; ferrous sulfate oral tablet 325 (65Fe) mg (ferrous sulfate), give one (1) tablet by mouth one time a day for anemia, order date 09/06/2024; levothyroxine sodium tablet 112mcg, give one (1) tablet by mouth one time a day for low thyroid hormone, order date 01/26/2024; Miralax oral powder 17gm/scoop (polyethylene glycol 2250), give one (1) scoop by mouth one time per day every Mon, Wed, Fri for bowel regularity, order date 03/13/2024; Multivitamin Women 50+ oral tablet (multiple vitamin w/minerals), give one (1) tablet one time a day for supplement, order date 01/26/2024; oyster shell calcium oral tablet 500-10 mg-mcg (calcium carbonate-cholecalciferol), give one (1) tablet by mouth one time a day for supplement, order date 01/26/2024; potassium chloride ER tablet extended release 20 meq, give one (1) tablet by mouth one time a day for hypokalemia, order date 01/26/2024; rosuvastatin calcium oral tablet 20 mg (rosuvastatin calcium), give one (1) tablet by mouth in the evening for hyperlipidemia; and Stress Formula/Zinc Oxide tablet (multiple vitamins w/Minerals), give one (1) tablet by mouth one time a day for sacral wound healing; which were all listed on the SNF medication profile. The Hospice RN Start of Care was completed on 10/31/2024 and documented, “Currently on oxygen 3 liters.” During the home visit with the Hospice Aide (Personnel Record 2) on 12/17/2024, the patient was observed wearing oxygen. The hospice medication profile did not include oxygen. Clinical Record 11: The patient elected hospice on 09/09/2024 with a hospice diagnosis of hypertensive chronic kidney disease. A skilled nursing visit completed on 12/10/2024 documented, “Is Oxygen Equipment in the Home?-Yes”. The hospice medication profile did not include the oxygen noted in the clinical note. During the joint record review and interview on 12/18/2024, the Executive Director confirmed that the medication profile did not accurately represent the medications the patient received.”

“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, document review, and interview. Agency policy “Plan of Care 2127 Protocol” (revision date: 04/11/2024) read in part, “The POC (Plan of Care) includes the scope and frequency of all services necessary for the palliation and management of the terminal illness and related conditions, reflects the patient and family assessed needs and goals and the interventions needed to address those needs and goals.” In 1 of 19 (5%) clinical records reviewed, it was revealed that the agency did not ensure that the patient’s individualized written plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and comprehensive assessments. Clinical Record 11: The patient elected hospice on 09/09/2024 with a hospice diagnosis of Hypertensive Chronic Kidney Disease. A physician order dated 12/10/2024 read in part, “Cleanse the left leg with normal saline pat dry apply calcium alginate to the wound bed cover with ABD pad. Wrap with gauze and secure with tape using clean and aseptic techniques.” A review of the Hospice POC (Plan of Care) Update Report, dated 12/18/2024, revealed that the individualized plan of care did not reflect patient and family goals and planned interventions for the treatment of the left leg wound. During the joint record review and interview on 12/18/2024, the Executive Director confirmed that the plan of care did not include goals or interventions related to the left leg wound.”

“It is required that each patient’s individualized written plan of care includes all services necessary for palliation and management of the terminal illness, including the following: Drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 19 (11%) clinical records reviewed and home visit observations, the agency did not ensure the patient’s individualized plan of care included the drugs and treatments necessary to meet the patient’s needs. Clinical Record 1/Home Visit 1: The patient elected hospice care on 10/29/2024 with a diagnosis of Alzheimer’s Dementia. The assisted living facility (ALF) medication profile was reviewed with the Hospice Executive Director (Personnel Record 5) during the home visit on 12/17/2024. The medications at the facility did not match the hospice medication profile, hospice plan of care (10/29/2024), or plan of care updates (10/31/2024 and 12/17/2024). The hospice plan of care, and updates to the plans of care, did not include: Senna 8.6 mg, give one (1) tablet by mouth two times a day for constipation, order date 10/31/2024; Stress Formula/Zinc Oral Tablet (Multiple Vitamins w/Minerals), give one (1) tablet by mouth one time a day for wound care order date 10/31/2024; and Tylenol Extra Strength Oral Tablet 500 mg (Acetaminophen), give two (2) tablet by mouth three times a day for pain order date 10/31/2024; which were all listed on the ALF medication profile. Clinical Record 2/Home Visit 2: The patient elected hospice care on 10/31/2024 with a diagnosis of Cerebral Infarction. The skilled nursing facility (SNF) medication profile was reviewed with the Hospice Executive Director (Personnel Record 5) during the home visit on 12/17/2024. The medications at the facility did not match the hospice medication profile, hospice plan of care (10/31/2024), or plan of care updates (11/11/2024 and 11/21/2024). The hospice plan of care, and updates to the plans of care, did not include: Bisacodyl Rectal Suppository 10mg (Bisacodyl) insert one (1) suppository rectally every 24 hours as needed for bowel regimen, order date 10/31/2024; Calcium Carbonate Tablet Chewable 500mg, give one (1)tablet by mouth three times a day for indigestion before meals, order date 07/17/2024; Effexor XR Oral Capsule Extended Release 24 Hour 75mg (Venlafaxine HCl), give one (1) capsule by mouth one time a day for anxiety, order date 01/26/2024; Ferrous Sulfate Oral Tablet 325 (65Fe) MG (Ferrous Sulfate), give one (1) tablet by mouth one time a day for anemia, order date 09/06/2024; Levothyroxine Sodium Tablet 112mcg, give one (1) tablet by mouth one time a day for low thyroid hormone, order date 01/26/2024; MiraLAX Oral Powder 17gm/scoop (Polyethylene Glycol 2250), give one (1) scoop by mouth one time per day every Mon, Wed, Fri for bowel regularity, order date 03/13/2024; Multivitamin Women 50+ Oral Tablet (Multiple Vitamin w/Minerals), give one (1) tablet one time a day for supplement, order date 01/26/2024; Oyster Shell Calcium Oral Tablet 500-10 mg-mcg (Calcium Carbonate-Cholecalciferol), give one (1) tablet by mouth one time a day for supplement, order date 01/26/2024; Potassium Chloride ER Tablet Extended Release 20 MEQ, give one (1) tablet by mouth one time a day for hypokalemia, order date 01/26/2024; Rosuvastatin Calcium Oral Tablet 20 mg (Rosuvastatin Calcium), give one (1) tablet by mouth in the evening for hyperlipidemia; and Stress Formula/Zinc Oxide Tablet (Multiple Vitamins w/Minerals), give one (1) tablet by mouth one time a day for sacral wound healing; which were all listed on the SNF medication profile. The Hospice RN Start of Care was completed on 10/31/2024. The documentation read in part “Currently on oxygen 3 liters”. During the home visit with the hospice aide (Personnel Record 2) on 12/17/2024, the patient was observed wearing oxygen. The hospice medication profile on the plan of care did not include oxygen. During the joint record review and interview on 12/18/2024, the Executive Director confirmed the findings that the medication profile on the plans of care did not accurately represent the medications the patient was receiving.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene; use of gloves, mask, eye protection, or face shield depending on anticipated exposure; safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids; safe handling of soiled items in the patient’s care environment; and other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, interview, and observation. Agency policy “Hand Hygiene 4003 Protocol” (revision date 06/09/2021) read in part, “Decontaminate the hands using an alcohol-based hand rub, or wash hands with antimicrobial soap and water when the hands are not visibly soiled in the following circumstances: b. after removing gloves.” In 1 of 4 (25%) home visit observations, the agency did not ensure that the hospice followed accepted standards of practice and agency policy to prevent the transmission of infection and communicable diseases, including the use of standard precautions such as hand washing, use of gloves and safe handling of soiled items. Home Visit 2: The patient elected hospice care on 10/31/2024 with a diagnosis of cerebral infarction. During the home visit on 12/17/2024 with the hospice aide (Personnel Record 2), the aide was observed washing her hands and setting up the work area to perform a bed bath. The hospice aide donned gloves and began the bed bath by washing the patient’s face and upper body, she then proceeded to look around the room for the waste bin to dispose of the washcloth. The hospice aide, with her gloves donned, removed the bag from the waste bin and lined the waste bin with a new bag to dispose of the washcloth. The hospice aide removed her gloves and donned new gloves. The observation lacked evidence that the hospice aide followed accepted standards of practice to prevent the transmission of infections and communicable diseases, as evidenced by not cleansing hands after removing gloves. During an interview on 12/18/2024, the Executive Director confirmed the finding and the agency policy that hands should be cleansed between and after glove changes.”

“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: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #C.2.5.6 “Documenting in the Electronic Medical Record” (revision date 08/09/2024) read in part, “8. Clinical notes are entered, dictated, or written at the time of service by personnel rendering the services.” In 9 of 19 (47%) clinical records reviewed, the agency did not ensure that documentation for services provided was completed on the same day as services were rendered consistent with agency policy. Clinical Record 1: The patient elected hospice care on 10/29/2024 with a diagnosis of Alzheimer’s Dementia. The hospice aide visited the patient on 12/12/2024. The visit note was signed and submitted on 12/16/2024, four (4) days after the services were provided. The registered nurse visited the patient on 11/27/2024. The visit note was signed and submitted on 12/02/2024, five (5) days after the services were provided. The clinical record lacked evidence that the documentation submitted for the visits complied with agency policy. Clinical Record 2: The patient elected hospice care on 10/31/2024 with a hospice diagnosis of cerebral infarction. The hospice aide visited the patient on 12/12/2024. The visit note was signed and submitted on 12/16/2024, four (4) days after the services were provided. The registered nurse visited the patient on 11/20/2024. The visit note was signed and submitted on 11/25/2024, five (5) days after the services were provided. The clinical record lacked evidence that the documentation submitted for the visits complied with agency policy. Clinical Record 4: The patient elected hospice care on 11/08/2024 with a hospice diagnosis of unspecified severe protein-calorie malnutrition. The hospice aide visited the patient on 12/12/2024. The visit note was signed and submitted on 12/16/2024, four (4) days after the services were provided. The clinical record lacked evidence that the documentation submitted for the visits complied with agency policy. Clinical Record 5: The patient elected hospice care on 08/13/2024 with a hospice diagnosis of chronic obstructive pulmonary disease. The hospice aide visited the patient on 12/12/2024. The visit note was signed and submitted on 12/16/2024, four (4) days after the services were provided. The clinical record lacked evidence that the documentation submitted for the visits complied with agency policy. Clinical Record 7: The patient elected hospice care on 10/12/2024 with a hospice diagnosis of unspecified severe protein-calorie malnutrition. The hospice aide visited the patient on 12/08/2024. The visit note was signed and submitted on 12/11/2024, three (3) days after the services were provided. The clinical record lacked evidence that the documentation submitted for the visits complied with agency policy. Clinical Record 9: The patient elected hospice care on 12/09/2024 with a hospice diagnosis of Alzheimer’s Disease. The registered nurse visited the patient on 12/14/2024. The visit note was signed and submitted on 12/16/2024, two (2) days after the services were provided. The clinical record lacked evidence that the documentation submitted for the visits complied with agency policy. Clinical Record 10: The patient elected hospice care on 04/08/2024 with a hospice diagnosis of Alzheimer’s Disease. The hospice aide visited the patient on 12/12/2024. The visit note was signed and submitted on 12/16/2024, four (4) days after the services were provided. The clinical record lacked evidence that the documentation submitted for the visits complied with agency policy. Clinical Record 12: The patient elected hospice care on 08/28/2024 with a hospice diagnosis of Alzheimer’s Disease. The hospice aide visited the patient on 12/12/2024. The visit note was signed and submitted on 12/16/2024, four (4) days after the services were provided. The clinical record lacked evidence that the documentation submitted for the visits complied with agency policy. Clinical Record 13: The patient elected hospice care on 04/18/2024 with a hospice diagnosis of Alzheimer’s Disease. The hospice aide visited the patient on 12/12/2024. The visit note was signed and submitted on 12/16/2024, four (4) days after the services were provided. The clinical record lacked evidence that the documentation submitted for the visits complied with agency policy. During a joint record review and interview on 12/18/2024, the Executive Director confirmed the findings and stated in part, “They are supposed to complete same day.””

“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: physician orders. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #HOS 2-031 “Verification of Physician Orders” (revision date 10/29/2024) read in part, “Orders shall be obtained from a licensed physician or another qualified non-physician provider for care and services to be provided to hospice patients. A copy of the physician’s or licensed non-physician practitioner’s order shall be kept in the clinical record.” In 2 of 19 (11%) clinical records reviewed, it was revealed that the agency did not ensure the patient’s clinical record contained physician orders for the care and services provided. Clinical Record 2: The patient elected hospice care on 10/31/2024 with a diagnosis of cerebral infarction. The Hospice RN Start of Care was completed on 10/31/2024 and documented “Currently on oxygen 3 liters.” The clinical record lacked evidence that a physician order was obtained for oxygen. Clinical Record 11: The patient elected hospice on 09/09/2024 with a hospice diagnosis of hypertensive chronic kidney disease. A skilled nursing visit completed on 12/10/2024 read in part, “Is Oxygen Equipment in the Home?-Yes.” A skilled nursing visit on 12/16/2024 read in part, “Oxygen liter flow is 3L/Min continuously/at night/prn via nasal cannula/mask.” The clinical record lacked evidence that a physician order was obtained for oxygen. During a joint record review and interview on 12/18/2024, the Executive Director confirmed the findings and stated in part, “There should be orders for the oxygen either on a physician order or IDG update.””