DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
491500 A. BUILDING __________
B. WING ______________ 		10/16/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
CAPITAL HOSPICE 2900 TELESTAR COURT, FALLS CHURCH, VA, 22042
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0513      
36946 Based on medical record review and staff interview, it was determined the agency failed to ensure the patient and/or caregiver was involved in developing his or her hospice plan of care in two (2) of ten (10) of the medical records reviewed in the survey sample. Medical record #'s 1 and 7. Findings: Ten (10) medical records were reviewed in the agency on 10/15-16/2019 with the Compliance Manager assisting with the navigation of the electronic medical record. 1. The patient with medical record #1 contained an order on the initial plan of care dated 5/31/19 for a hospice aide to visit the patient three (3) times a week. The care plan dated 6/4/19 contained an order to change the hospice aide visit frequency to five (5) days per week. The visit frequency was reviewed for the months of July and August 2019 (the timeframe provided by the complainant). The hospice aide visited the patient three (3) times per week in July and August with the exception of two (2) weeks, the weeks of July 28, 2019 and August 11, 2019 in which the aide only visited the patient two (2) times per week. The medical record failed to contain documentation that the aide visited the patient five (5) times per week as ordered in the plan of care on any of the weeks in July or August 2019. The medical record failed to contain evidence of the reason why aide visits were not performed as ordered or that the family was notified that the aide was not coming at the ordered frequency. 2. The medical record for patient #7 was reviewed. The agency's complaint log contained a complaint that partially reads as follows: "Daughter reports that our patient, her mother, facility staff, and a private hire have all reported that our CNA had only been visiting once a week and the visitor log confirms this information. Visits were initially ordered for twice a week, then since early April were increased to 5 days a week. Unable to substantiate. CNA and her visits documented in the electronic medical record do not substantiate the complaint. Employee does admit to forgetting to sign the visitor log occasionally." The patient's medical record contained an order for hospice aide visits 5 times per week. The medical record contained documentation of only four (4) visits being made for the week of September 1, 2019. The medical record failed to contain evidence of the reason why aide visits were not performed as ordered or that the patient and/or caregiver was informed that the aide was not providing visits at the ordered frequency. These findings were confirmed with the Compliance Manager at the time of medical record review. He/she was also unable to produce documentation of the reason for the missed visits or that the patient/caregiver was notified in visits not made according to the ordered frequency.