Moments Hospice of Alexandria LLC

“It is required that 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. THIS IS A CMS CONDITION LEVEL DEFICIENCY. It is required that 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. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met, as evidenced by personnel record reviews, observations, clinical record reviews, document reviews, and interviews with the Vice President of Clinical Operations, which revealed that the hospice failed to ensure Hospice medical social work services were substantially provided by hospice employees in a manner consistent with acceptable standards of practice. “Core” services included medical social work, and counseling. The organization failed to ensure that the social worker with a baccalaureate degree, had at least one year of experience as a social worker in a healthcare facility prior to hiring [HSRM.7.D/L787]; Failed to ensure that the social worker with a baccalaureate degree was supervised by an MSW [HSRM.23.I/L787]; and Failed to ensure that a qualified social worker provided medical social work services [HCDT.9.I/594]. The cumulative effect of this deficiency has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.64: Core Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency. A review of core services revealed that the agency did not ensure that social work services were being provided with acceptable standards of care by qualified staff.”

“It is required that medical social services are provided by a qualified social worker. This standard was not met as evidenced by personnel record review, clinical record review, observation, and interview. In 1 of 1 (100%) personnel record review of a Social Worker (SW), the agency did not ensure that a qualified social worker provided medical social services. Personnel Record 3/Home Visit 3: The Social Worker (SW) was hired on 12/18/2023. A personnel record review revealed the SW graduated with a Bachelor of Science in Social Work in December 2023. There was no evidence that the SW had one year of social work experience in a healthcare setting prior to hiring at the agency. A competency assessment was completed on 01/16/2024 by an LSW. During the home visit with the SW [Personnel Record 3] on 07/31/2024, the SW reported that they are a Licensed Social Worker (LSW), which is the bachelor’s license type, and not a Master of Social Work (MSW). The personnel record contained no evidence of supervision by a CMS-qualified MSW. During an interview and joint record review on 07/31/2024, the Vice President (VP) of Clinical Operations stated, “No supervision has been done, but it will be done tonight. We are moving an MSW from a sister agency to this agency to provide MSW coverage.””

“It is required that a social worker has: a Master of Social Work (MSW) degree from a school of social work accredited by the Council on Social Work Education; or a baccalaureate degree in social work from an institution accredited by the Council on Social Work Education; or a baccalaureate degree in social work, psychology, sociology, or other field related to social work and is supervised by an MSW meeting the qualification as stated in No. 1 above; and at least one (1) year of social work experience in a health care setting. OR A baccalaureate degree from a school of social work accredited by the Council on Social Work Education and was employed by the hospice before December 2, 2008, is not required to be supervised by an MSW. This standard was not met as evidenced by interview, document review, observation, and personnel record review. In 1 of 1 (100%) personnel record review of a social worker, the agency did not ensure that the social worker with a baccalaureate degree, had at least one year of experience as a social worker in a healthcare facility prior to hire. Personnel Record 3/Home Visit 3: The Social Worker (SW) was hired on 12/18/2023. A personnel record review revealed the SW graduated with a Bachelor of Science in Social Work, in December 2023. There was no evidence that the SW had one year of social work experience in a healthcare setting prior to hiring at the agency. During the home visit with the SW [Personnel Record 3] on 07/31/2024, the SW reported that they are a Licensed Social Worker (LSW), which is the bachelor’s license type, and not a Master of Social Work (MSW). During an interview on 07/31/2024, the Vice President (VP) of Operations confirmed the finding, stating, “I was not aware she was an LSW. We are moving an MSW from the sister office to this office immediately, and she will begin providing supervision and assistance immediately.””

“It is required that a social worker who holds a bachelor’s degree is supervised by a CMS-qualified MSW who has a degree from a school of social work accredited by the Council on Social Work Education and has one (1) year of experience in a health care setting. This standard was not met as evidenced by interview, observation, document review, and personnel record review. In 1 of 1 (100%) personnel record review of a social worker, the agency did not ensure that the social worker with a baccalaureate degree was supervised by an MSW. Personnel Record 3/Home Visit 3: The Social Worker (SW) was hired on 12/18/2023. A personnel record review revealed the SW graduated with a Bachelor of Science in Social Work, in December 2023. There was no evidence that the SW had one year of social work experience in a healthcare setting prior to hiring at the agency. A competency assessment was completed on 01/16/2024 by an LSW. During the home visit with the SW [Personnel Record 3] on 07/31/2024, the SW reported that they are a Licensed Social Worker (LSW), which is the bachelor’s license type, and not a Master of Social Work (MSW). The personnel record contained no evidence of supervision by a CMS-qualified MSW. During an interview and joint record review on 07/31/2024, the Vice President (VP) of Clinical Operations stated, “No supervision has been done, but it will be getting done tonight. We are moving an MSW from a sister agency to this agency to provide MSW coverage.””

“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. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document review and interview. 1 of 7 (14%) contracts reviewed, the agency did not ensure that the contract required that all contracted employees who have direct patient contact or access to patient records obtained criminal background checks. Contract 1: The contract for Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) dated 10/26/2023 stated in part “agrees to provide proof of current professional licensure/certification, TB Test and Hepatitis B acceptance/declination for all therapists providing services.” The contract did not include required documentation that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. The agency provided evidence that the contracted therapist had criminal background checks. During an interview on 07/30/2024, the Vice President (VP) of Clinical Operation stated “ Ok I will get with them and get it changed.” Contract review revealed that the agency did not ensure that the contract for direct patient care staff included language requiring a background check.”