Concordia Hospice of Washington

“Based on clinical record (CR) and policy reviews, and interviews with the administrator, the hospice failed to provide services as ordered for four (4) of five (5) CRs reviewed. (CRs 1, 2, 3, and 5) Findings include:A review of Policy 9.4 Plan of Care on 3/24/26 revealed: “All hospice care and services provided to patients/families must follow an individualized written plan of care…”A review of clinical records was conducted on 3/24/26, from approximately 11:30 AM to 3:00 PM which revealed:CR1: Start of Care (SOC): 1/23/26. CR1’s Hospice Certification Plan of Care dated 1/23/26 – 4/22/26 contained an order for a Chaplain (CH) visit “to evaluate patient/family/caregiver and develop a plan of care.” A review of CR1’s visit schedule from the start of care, 1/23/26, to the date of death, 2/2/26, failed to reveal a completed chaplain visit or visit note. CR2: SOC: 3/3/26. CR2’s Hospice Certification Plan of Care dated 3/3/26 – 5/31/26 contained an order for a Spiritual Care (SC) visit “Chaplain to evaluate patient/family/caregiver and develop a plan of care.” A review of CR2’s visit schedule from the start of care, 3/3/26, to the date of death, 3/8/26, failed to reveal a completed chaplain visit or visit note.CR3: SOC: 1/7/26. CR3’s Hospice Certification Plan of Care dated 1/7/26 – 4/6/26 contained an order for a Chaplain (CH) visit “to evaluate patient/family/caregiver and develop a plan of care.” A review of CR3’s visit schedule from the start of care, 1/7/26, to 1/12/26, five days after the benefit election, failed to reveal a completed chaplain visit or visit note.CR5: SOC: 1/21/25. CR5’s Hospice Certification Plan of Care dated 1/21/25 - 4/20/25 contained an order for a Chaplain (CH) visit “to evaluate patient/family/caregiver and develop a plan of care.” A review of CR5’s visit schedule from the start of care, 1/21/25, to the date of death, 2/2/26, failed to reveal a completed chaplain visit or visit note.During an interview with the administrator (EMP1) on 3/24/26 at approximately 3:15 pm it was determined that CRs 1, 2, 3, and 5 did not contain documentation of a completed chaplain or spiritual care visit to evaluate the spiritual care/counseling assessment component of hospice care. EMP1 was unable to produce documentation of CR 1, 2, 3, or 5’s declination of chaplain or spiritual counseling services. The administrator stated, “nursing can complete the spiritual care assessment.”The agency failed to follow policy and provide CR 1, 2, 3, and 5’s spiritual counseling and chaplain visits as ordered.The finding was reviewed during an exit interview with EMP1 administrator, EMP2 Clinical Manager, and EMP3 Director of Compliance on 3/24/26 at approximately 4:00 pm.”

“Based on reviews of hospice policy and clinical records (CR) and staff interviews, the hospice failed to ensure that patient and family spiritual counseling needs were addressed and met for four (4) of five (5) CRs reviewed. (CRs 1, 2, 3, and 5) Findings include:A review of Policy 8.2 Core Services on 3/25/26 revealed: “Core Services…must be provided in a manner consistent with acceptable standards of practice. The following are hospice core services: physician services, nursing services, medical social services, counseling (including but not limited to, bereavement, dietary, and spiritual counseling)…”A review of Policy 8.6 Spiritual Counseling Services on 3/25/26 revealed: “[agency] will provide spiritual counseling to hospice patients consistent with the belief system of the patients and families…If a spiritual need is identified or requested the clinician will obtain an order from the physician for spiritual care…Spiritual Care Counselor will complete a spiritual care assessment in a timely manner…A spiritual counselor could be termed as a chaplain, rabbi, minister, or priest. The spiritual counselor interfaces with patients and their family members during the patients episode of care…”A review of clinical records was conducted 3/24/26, from approximately 11:30 AM to 3:00 PM:CR1: Start of Care (SOC): 1/23/26. CR1’s Hospice Certification Plan of Care dated 1/23/26 – 4/22/26 contained an order for a Chaplain (CH) visit “to evaluate patient/family/caregiver and develop a plan of care.” A review of CR1’s visit schedule from the start of care, 1/23/26, to the date of death, 2/2/26, failed to reveal a completed chaplain visit or visit note. CR2: SOC: 3/3/26. CR2’s Hospice Certification Plan of Care dated 3/3/26 – 5/31/26 contained an order for a Spiritual Care (SC) visit “Chaplain to evaluate patient/family/caregiver and develop a plan of care.” A review of CR2’s visit schedule from the start of care, 3/3/26, to the date of death, 3/8/26, failed to reveal a completed chaplain visit or visit note.CR3: SOC: 1/7/26. CR3’s Hospice Certification Plan of Care dated 1/7/26 – 4/6/26 contained an order for a Chaplain (CH) visit “to evaluate patient/family/caregiver and develop a plan of care.” A review of CR3’s visit schedule from the start of care, 1/7/26, to 1/12/26, five days after the benefit election, failed to reveal a completed chaplain visit or visit note.CR5: SOC: 1/21/25. CR5’s Hospice Certification Plan of Care dated 1/21/25 - 4/20/25 contained an order for a Chaplain (CH) visit “to evaluate patient/family/caregiver and develop a plan of care.” A review of CR5’s visit schedule from the start of care, 1/21/25, to the date of death, 2/2/26, failed to reveal a completed chaplain visit or visit note.During an interview with the administrator (EMP1) on 3/24/26 at approximately 3:15 pm it was determined that CRs 1, 2, 3, and 5 did not contain documentation of a completed chaplain or spiritual care visit to evaluate the spiritual care/counseling assessment component of hospice care. EMP1 was unable to produce documentation of CR 1, 2, 3, or 5’s declination of chaplain or spiritual counseling services. The administrator stated, “nursing can complete the spiritual care assessment.”The agency failed to provide the core hospice service of spiritual counseling and assessment to CRs 1, 2, 3, and 5 as per the patient’s written Plan of Care.The finding was reviewed during an exit interview with EMP1 administrator, EMP2 Clinical Manager, and EMP3 Director of Compliance on 3/24/26 at approximately 4:00 pm.”

“Based on clinical record (CR), patient information booklet, and policy reviews and interviews with staff, the agency failed to provide counseling, education, and discharge planning at least two days prior to the date of discharge for one (1) of five (5) CRs reviewed. (CR4) Findings include:A review of Policy 5.6 Discharge on 3/24/26 revealed: “…Discharge Planning As soon as the interdisciplinary group (IDG) is aware of the possibility of a discharge, discharge planning is started. Discharge planning includes: …informing the patient, family, caregivers/facility staff and attending physician of the potential for discharge…b. If the IDG determines a participant no longer meets the hospice’s eligibility requirements, discharge planning should occur as follows: …The Case Manager, Clinical Leadership or Social Worker arranges for those services/equipment/medications after acquiring physician approval. The patient and/or caregiver/facility staff are included in the discharge planning process and members of the IDG provide appropriate education and support as needed…”A review of [agency] Patient & Family Guide on 3/24/26 revealed: “When can a patient stop receiving hospice care…Patients can also stop receiving hospice care as a result of discharge when: …The beneficiary ceases to be eligible for the Medicare hospice benefit…The beneficiary meets the hospice’s internal policy regarding discharge for cause…When discharged, the hospice is required to provide a minimum of 2 days notice prior to date of discharge and provide planning for the patient/family including education, counseling and coordination of other services. …”A review of CR4 on 3/24/25 at approximately 11:30 am revealed: Start of Care (SOC): 2/18/26. CR4 contained a Discharge-Transfer Summary dated 3/3/26 which listed a patient disposition of “Discharge to Home or Self Care” and noted the “Patient No Longer [met] Criteria” due to “Independent in the Home.”A review of CR4’s Visit Notes revealed that a staff nurse provided notification of the intent to discharge on 3/2/26, one day prior to the discharge date, 3/3/26. The 3/2/26 Visit Note failed to reveal evidence of patient/family education related to discharge or counseling and coordination of other services. A review of CR4’s IDG Summary Report dated 3/3/26, the date of discharge, failed to reveal evidence of a discharge plan. The agency failed to provide CR4 with counseling, education, and discharge planning at least two days prior to the date of discharge.”

“Based on a review of clinical records (CR), observations during home visits, policy reviews and interviews with staff (EMP) and patients, the agency failed to complete medication reviews consistent with agency policy for one (1) of thirteen (13) CRs reviewed. (CR 7) Findings included: A review of agency policy titled Managing Drugs and Biologicals on 5/16/24 revealed: “;Procedures...Medication Administration...4. A medication profile will be completed for each patient at the time of admission and will be updated as needed to include any changes or additions of new medications...” A review of agency procedure Medication Reconciliation revealed: “;20. Compare the information gathered from the patient, family, or caregivers with the most recent medication lists found in the patients record, pharmacy medication list, and pharmacy labels. Identify the differences and document them...24. Communicate all changes to the patient, family, and caregivers...” CR7: Start of Care (SOC) 6/30/23. Certification period reviewed 4/25/24 - 6/23/24. During a home visit conducted on 5/15/24 at approximately 10:00 am with the patient of CR7, two medications were identified as currently being taken by the patient but not listed on the CR7’s current Medicine List [printed 5/14/2024]: 1. metoclopramide 10 milligram tablets to be administered every six hours as needed for nausea and 2. Miralax 17 grams to be taken with 8 ounces of water twice a day for three days. The finding was reviewed with EMP4 (Clinical Manager) and EMP7 (RN) on site. The finding was reviewed during an exit conference on 5/20/24 at approximately 11:30 am with EMP1, Administrator, EMP2, Clinical Supervisor, EMP3, Compliance and Education, EMP4, Clinical Manager, EMP5, Human Resources, and EMP6, Director of Compliance.”

“Based on an observation during a home visit, employee interviews (EMP), and clinical record reviews (CR), the agency failed to develop a plan of care which included the medical supplies and appliances necessary to meet the needs of the patient for one (1) of thirteen (13) CRs reviewed. (CR7) Findings included: During a home visit conducted on 5/15/24 at approximately 10:00 am with the patient involved in CR7, a hospital bed was noted at the patients residence. CR7 Start of Care (SOC) 6/30/23. CR7s plan of care for certification period 4/25/24 – 6/23/24 did not contain the bed within the durable medical equipment (DME) list. During an interview with EMP4 (Clinical Manager) conducted after the home visit, it was determined that the bed was supplied by the hospice but was not listed within the plan of care. EMP4 was unable to obtain an existing order for the equipment. The finding was reviewed during an exit conference on 5/20/24 at approximately 11:30 am with EMP1, Administrator, EMP2, Clinical Supervisor, EMP3, Compliance and Education, EMP4, Clinical Manager, EMP5, Human Resources, and EMP6, Director of Compliance.”

“Based on a review of Clinical Records (CR), agency policy, and interviews with staff, the agency failed to document wound care services in a manner that was consistent with agency procedures or accepted standards of practice for two (2) of (13) CRs reviewed. (CRs 4 and 9) Findings included: A review of agency procedure for Pressure Injury and Wound Assessment on 5/16/24 revealed: “;Documentation...Wound Assessment...Appearance of the wound...wound size (length, depth, and width) ... presence of tunneling...status of surrounding skin...amount of drainage...phase of healing...undermining, if present...” A review of pressure ulcer assessment and staging guidance published by Agency for Healthcare Research and Quality states, “;Assessment and Staging...The nurse should assess and stage the pressure ulcer at each dressing change. Experts believe that weekly assessments and staging of pressure ulcers will lead to earlier detection of wound infections as well as being a good parameter for gauging of wound healing....” Lyder CH, Ayello EA. Pressure Ulcers: A Patient Safety Issue. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 12. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2650/ A review of CR4 on 5/17/24 at approximately 11:35 am revealed: CR4: Start of Care (SOC): 10/2/23. CR 4 contained a hospice plan of care certification period 3/30/24 - 5/28/24 which contained an order for a single skilled nursing visit per week for 8 weeks and 6 as needed nursing visits to “;...observe and assess the patient to identify changes...” Skilled Nurse Visit Notes for CR4 dated 5/1/24 -5/15/24 revealed: 5/1/24 narrative note identified a stage 2 pressure ulcer to coccyx. A wound assessment was not documented as per agency procedure or per standard of care. 5/8/24 narrative note identified skin “;impaired” to coccyx, but a wound assessment was not documented as per agency procedure or per standard of care. 5/15/24 note identified “;discoloration to coccyx.” A wound assessment was not documented as per agency procedure or per standard of care. A review of CR9 on 5/16/24 at approximately 9:45 am revealed: CR9: SOC: 12/15/23. CR 9 contained a hospice plan of care with a certification period of 3/14/24 – 6/11/24 which contained orders for skilled nursing to “;observe and assess the patient to identify changes...” Skilled Nurse Visit Notes for CR9 dated 3/18/24 - 3/28/24 revealed: 3/18/24 note contained an integumentary assessment note identifying an area of skin abnormality on the coccyx stating, “;Abnormal Integumentary Assessment Findings...erythema [redness], pale, turgor...Indicate Location of Erythema...small spot on back/coccyx...” The area was not identified as “;blanchable” to exclude pressure ulcer staging criteria. Therefore, a wound assessment was not documented as per agency procedure or per standard of care. 3/23/24 note identified a “;Stage 2” [partial thickness skin loss] coccyx wound. Wound assessment was not documented as per agency procedure or per standard of care. 3/24/24 note identified a “;Stage 2” coccyx wound. Wound assessment was not documented as per agency procedure or per standard of care. 3/25/24 note identified a “;Stage 2 pressure ulcer.” Wound assessment was not documented as per agency procedure or per standard of care. 3/26/24 note identified a “;ST[age] 2 coccyx” wound. Wound assessment was not documented as per agency procedure or per standard of care. 3/27/24 note identified a”ST[age] 2 coccyx” wound. Wound assessment was not documented as per agency procedure or per standard of care. The finding of incomplete wound assessment documentation was reviewed during an exit conference on 5/20/24 at approximately 11:30 am with EMP1, Administrator, EMP2, Clinical Supervisor, EMP3, Compliance and Education, EMP4, Clinical Manager, EMP5, Human Resources, and EMP6, Director of Compliance.”

“Based on a review of facility agreements (AG), policies, and staff interviews (EMP) the agency failed to maintain documentation verifying the training of staff within facilities contracted for inpatient care for two (2) of two (2) agreements reviewed. (AG 1 and 2) Findings included: A review of agency policy titled, Hospice in SNF/PCH on 5/15/24 revealed, “;Procedures...6. Orientation and Training of Facility Staff...a. The hospice must assure orientation of facility staff furnishing care to hospice patients...b. The hospice is responsible for: Assessing the need for staff training...Coordinating staff training with facility representatives...Determine how frequently training needs to be offered...” A review of facility agreements was conducted on 5/15/24: AG1: Agreement date: 11/11/2018. Titled Facility Provider Agreement revealed: “;2.3 Orientation and Education: Both parties agree to provide sufficient orientation and in-service education...Such in-servicing to personnel shall occur at least annually...Education will be documented including names of those giving and receiving education...C. Personnel and Training...Upon hospices request, facility shall cause facility personnel who provide Facility services to Hospice patients under this agreement to 1) attend annual training...” No documentation of annual facility staff hospice training for 2023 or 2024 was available as per agency policy or signed agreement. AG2: Agreement date: 10/16/2018. Titled Facility Provider Agreement revealed: “;2.3 Orientation and Education: Both parties agree to provide sufficient orientation and in-service education to personnel...Such in-servicing to personnel shall occur at least annually...Education will be documented including names of those giving and receiving education. C. Personnel and Training...Upon hospices request, facility shall cause Facility personnel who provide Facility services to Hospice patients under this agreement to 1) attend annual training...” No documentation of annual facility staff hospice training for 2023 or 2024 was available as per agency policy or signed agreement. The findings were reviewed during an exit conference on 5/20/24 at approximately 11:30 am with EMP1, Administrator, EMP2, Clinical Supervisor, EMP3, Compliance and Education, EMP4, Clinical Manager, EMP5, Human Resources, and EMP6, Director of Compliance.”