Hospice of the Chesapeake, Inc.

“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. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed revealed that the agency did not ensure that an 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 04/18/2024. A communication note dated 04/24/2024 (Day 6) from the Social Worker(Personnel Record 4) stated that an evaluation would be scheduled. The evaluation was completed on 04/25/2024 (day 7). CLINICAL RECORD 19: The patient elected the hospice benefit on 12/07/2023. The initial comprehensive nursing assessment was completed on 12/14/2023 (7 days) after the election of hospice care. In an interview, on 01/30/2025, the Quality Assurance and Performance Improvement (QAPI) Nurse, after a review of the record, confirmed that the assessments were not completed within the required timeframe but was unable to provide an explanation.”

“It is required that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the patient’s terminal illness that are addressed to promote the patient’s well-being, comfort, and dignity throughout the dying process. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 19 (5%) records reviewed revealed that the agency did not ensure that the comprehensive assessment was performed initially in order to identify identifies the physical, psychosocial, emotional, and spiritual needs related to the patient’s terminal illness. Policy: The agency’s policy read in part, “ On admission, the hospice registered nurse will conduct an initial spiritual assessment. The Hospice Chaplain will contact the patient/family by a home visit or telephone based on the patient’s and family’s needs and acceptance of these services. If the patient and family/caregiver refuse these services, the refusal will be documented. The interdisciplinary group members will continue to assess for spiritual needs and offer appropriate services to the patient and family/caregiver. (Spiritual Assessment 2-036.1) (1995) CLINICAL RECORD 10: The patient elected the hospice benefit on 09/28/2024. There was no documented evidence that a spiritual assessment was not included on the admission visit or Comprehensive assessment dated 09/30/2024. The spiritual assessment was only included in the HIS questionnaire (F3000. Spiritual/Existential Concerns) questioned if the patient was asked about spiritual/existential concerns and was answered “Yes and discussion occurred”. In an interview with the Quality Assurance Performance Improvement (QAPI) nurse on 01/29/2025, after a review of the assessment, the QAPI nurse stated that the HIS questionnaire was the only place that spirituality was addressed and agreed that this did not meet the requirement for a spiritual assessment.”

“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 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 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, interview, and observation. In 1 of 19 (5%) observations and clinical record reviews revealed that the agency did not ensure that all initial and updated comprehensive assessments included a drug profile that contained the patient’s current medications and documented evidence of medication review. CLINICAL RECORD 1/Home Visit 1 : The patient elected the hospice benefit on 04/18/20234 and resided in a skilled nursing facility (SNF). A home visit (Home Visit 1) with the hospice aide (Personnel Record 1) on 01/28/2025 included a review of the medications the patient received at the SNF. The SNF’s medications included Bisacodyl 10 mg rectally, every 72 hours if Milk of Magnesia (MOM) was ineffective for constipation (effective 09/17/2024). The medication list from the comprehensive assessment had Bisacodyl 10mg rectally daily as needed for constipation (effective 04/18/2024). The SNF orders included Miralax Powder 17gm every 72 days, as needed, for constipation. The medication list from the comprehensive assessment was Miralax 17gm every two days as needed for constipation. The facility orders included Ammonium Lactate External Lotion 12%, applied to bilateral lower extremities daily and evening for dry skin effective 09/17/2024. The medication list from the comprehensive assessment did not include this medication. There was no documented evidence that the comprehensive assessment included a medication review. The Director of Hospice Operations, on 01/28/2025, after review of the medication profiles, agreed that the medications were not reconciled.”

“It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires but no less frequently than every 15 days. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed revealed the agency did not ensure not ensure that the update of the comprehensive assessment was completed no less frequently than every 15 days. CLINICAL RECORD 8: The comprehensive reassessment (recertification visit) was dated 09/25/2024. There was no documented evidence that the comprehensive assessments of the respiratory, cardiovascular, gastrointestinal, genitourinary, integumentary, musculoskeletal systems, fall risk, or psychological/mental/emotional behavior assessments were completed as these sections were blank at the time of this review January 30, 2025. In an interview with the Quality Assurance Performance Improvement (QAPI) nurse on 01/29/2025, after review of the reassessment, agreed that the reassessment did not take into consideration the changes that have taken place since the initial assessment as much of the reassessment as noted above was blank.”

“It is required that each patient’s individualized written plan of care 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 and interview. In 1 of 19 (5%) clinical records reviewed revealed that the agency did not ensure that each patient’s individualized written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 5: The patient elected the hospice benefit on 11/29/2024 with diagnosis of Abnormal Weight Loss, Abnormal weight loss, Dementia. The comprehensive assessment dated 11/29/2024 included diagnoses of abnormal weight loss (BMI 19 with seven-pound loss in two months), recurrent UTIs, and Dementia (6e). The fall risk assessment was 6/10 (greater than 4 is considered fall risk), and a walker was utilized. The initial comprehensive assessment revealed the patient had intermittent incontinence and was on more than five medications. Prevention of skin breakdown was not identified as a need on the comprehensive assessment and the plan of care did not include interventions for prevention of skin breakdown. In an interview with the Quality Assurance and Performance Improvement (QAPI) nurse on 01/29/2025, the QAPI nurse stated that they do not use the Braden scale to evaluate the risk for skin breakdown but that the assessment included the same questions that are asked on the scale. The QAPI nurse, after a review of the assessment, agreed that the plan of care should have included interventions and goals for the prevention of skin breakdown.”

“It is required that consistent with current professional standards of practice, licensed professionals actively participate in the coordination of all aspects of patient care including conducting ongoing interdisciplinary comprehensive assessments, developing, and evaluating the plan of care, and contributing to patient and family counseling and education. Hospice “core” services are substantially provided directly by hospice employees in a manner consistent with acceptable standards of practice. “Core” services include nursing services, medical social work, and counseling. The hospice may contract for physician services per standard HCDT 5.I in this chapter. This standard was not met as evidenced by clinical record review, document review, and interview. In 5 of 19 (26%) clinical records reviewed revealed that the agency did not ensure that licensed professionals actively participated in all aspects of patient care. Policy: The agency’s policy stated in part, “The Case Manager (or admitting registered nurse) will complete the assessment and will initiate the development of the plan of care after the consent forms are signed. The Case Manager (or admitting registered nurse) will then notify the attending physician and a core member of the interdisciplinary group of the initial findings, the identification of the patient’s needs, and the recommended services to meet those needs. The plan of care will be reviewed prior to care being delivered.” (The Plan of Care 2-044.1) (1995) CLINICAL RECORD 10: The patient’s initial assessment was completed on 09/28/2024 and included notification of the physician but did not include notification of another core member of the interdisciplinary group of the initial assessment findings, the identification of the patient’s needs, and the recommended services to meet those needs as evidenced by unchecked boxes on page 2 (two) of the initial assessment. The checkboxes listed the different members of the Interdisciplinary Group and if notification occurred following the initial assessment the boxes were checked. There was no documented evidence that a core member of the interdisciplinary group was notified after notifying the physician in accordance with agency policy. CLINICAL RECORD 11: The patient’s initial assessment was completed on 07/30/2024 and included notification of the physician but did not include notification of another core member of the interdisciplinary group of the initial assessment findings, the identification of the patient’s needs, and the recommended services to meet those needs as evidenced by unchecked boxes on page 2 (two) of the initial assessment. The checkboxes listed the different members of the Interdisciplinary Group and if notification occurred following the initial assessment the boxes were checked. There was no documented evidence that a core member of the interdisciplinary group was notified after notifying the physician in accordance with agency policy. CLINICAL RECORD 12: The patient’s initial assessment was completed on 10/31/2024 and included notification of the physician but did not include notification of another core member of the interdisciplinary group of the initial assessment findings, the identification of the patient’s needs, and the recommended services to meet those needs as evidenced by uncheck boxes on page 2 (two) of the initial assessment. The checkboxes listed the different members of the Interdisciplinary Group and if notification occurred following the initial assessment the boxes were checked. There was no documented evidence that a core member of the interdisciplinary group was notified after notifying the physician in accordance with agency policy. CLINICAL RECORD 13: The patient’s initial assessment was completed on 05/04/2024 and included notification of the physician but did not include notification of another core member of the interdisciplinary group of the initial assessment findings, the identification of the patient’s needs, and the recommended services to meet those needs as evidenced by uncheck boxes on page 2 (two) of the initial assessment. The checkboxes listed the different members of the Interdisciplinary Group and if notification occurred following the initial assessment the boxes were checked. There was no documented evidence that a core member of the interdisciplinary group was notified after notifying the physician in accordance with agency policy. In an interview with the Director of Quality Assurance and Performance Improvement (QAPI) on 01/30/2025, the QAPI Director stated that the organization had different ways of communicating the initial assessment findings and the identification of the patient’s needs, and the recommended services to other core members of the interdisciplinary group that could include emails, etc. However, the Director agreed that it was not documented when asked where to locate the documentation that the notification had taken place. The Director stated that he understood and agreed if the information was not documented he could not prove the notifications occurred.”

“It is required that all hospice aide services must be provided by an individual who has successfully completed competency evaluations. The individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program. The competency evaluation addresses each of the following subject areas and they are evaluated by observation of an aide’s performance with a patient or pseudo-patient, including Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; Reading and recording temperature, pulse, and respiration; Appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: Bed bath; Sponge, tub, and shower bath; hair shampoo (sink, tub, and bed); Oral hygiene; Toileting and elimination; Safe transfer techniques and ambulation; Normal range of motion and positioning. The hospice maintains documentation that demonstrates the requirements of competency evaluation are met. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) personnel records of a hospice aide revealed that the agency did not ensure that a competency evaluation was completed by an RN prior to providing unsupervised direct patient care. Policy: The agency’s policy stated in part, “The competency of all staff (employed and contract, and volunteers) will be assessed during orientation, during the probation period, periodically throughout the course of a year, when job responsibilities or duties change, and during the annual performance evaluation. Educational activities will be based, in part, on the outcomes of the competency evaluation. (HAC policy 1-012) Personnel Record 12: The aide was hired on 01/29/2025. A review of the aide’s personnel file revealed there was no documented evidence that an initial competency evaluation was completed by the registered nurse to assess the aide’s ability to demonstrate competency with assigned tasks. In an interview with Human Resources on 01/29/2025, they were unable to provide evidence that the initial competency was completed. In a follow up on 01/30/2024 with the Quality Assurance Performance Improvement (QAPI) Director, the QAPI Director confirmed that there was no evidence that the initial competency evaluation was completed.”

“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 3 of 13 (23%) records reviewed for patients receiving aide services revealed the agency did not ensure the RN provided the specific guidance required to perform assigned patient care tasks. CLINICAL RECORD 1: The patient was admitted on 04/9/2024 with a diagnosis of Cerebrovascular accident with right hemiplegia, aphasia, and contractures to the right arm, hand, elbow, and knee. On the comprehensive assessment dated 04/19/2024, the patient was identified as a fall risk with a score of 9/10 (greater than 4 is at risk for falls), and aspiration precautions were included in the plan of care due to dysphagia. The comprehensive assessment included an acceptable level of pain for the patient as 4/10. The aide plan of care dated 04/19/2024 did not include fall precautions or aspiration precautions but did include instructions to assist with feeding the patient. The aide was assigned to report pain levels greater than 6/10. A chair bath and bed bath were both assigned to the patient every visit. The nurse noted on the care plan that the patient had a wound on the right great toe, but did not ensure the RN provided the specific guidance required to perform assigned patient care tasks. CLINICAL RECORD 2: The patient was admitted on 10/09/2024 with diagnoses of Cerebrovascular Disease and Vascular Dementia. The patient was on Aspirin 81mg daily. The Plan of Care for the certification period of 10/09/2024 to 01/06/2025 included aspiration and fall precautions. The aide care plan included transferring the patient every visit. The aide care plan did not include aspiration, fall, or bleeding precautions. There was no documented evidence that the RN provided the specific guidance required to perform assigned patient care tasks. Clinical Record 19: The patient was admitted on 12/07/2023 with multiple diagnoses that included Hypertensive Heart with Heart Failure and was taking Eliquis (blood thinner) 5mg twice daily. The aide care plan included transferring and ambulating the patient. Bleeding precautions were not included in the aide care plan. There was no documented evidence that the RN provided the specific guidance required to perform assigned patient care tasks. In an interview with the Director of Operations on 01/28/2025, the Director, after reviewing the care plan, agreed all precautions were not included in the aide care plan.”