Every finding on record at A Bridge Home LLC

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, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review. In 1 of 11 (9%) clinical records reviewed, the hospice did not ensure the interdisciplinary team completed the initial comprehensive assessment within 5 calendar days of election of hospice care. Clinical Record 8: The patient elected the hospice benefit on 6/28/23, with a terminal diagnosis of chronic combined systolic and diastolic heart failure. The initial plan of care included an order for the Medical Social Worker (MSW) to complete a psychosocial evaluation as part of the initial comprehensive assessment effective 7/2/23. Clinical record review revealed the psychosocial evaluation completed by the MSW was dated 7/8/23, 7 days after the start of care. The psychosocial assessment was not completed within 5 calendar days of the patient’s election of benefit.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 11 (9%) clinical records reviewed, the hospice did not ensure the initial bereavement risk assessment was completed as part of the comprehensive assessment. Clinical Record 2: The patient elected the hospice benefit on 5/26/23, with a terminal diagnosis of unspecified dementia. The clinical record contained no documented evidence that an initial bereavement assessment was completed for the patient's family or other individuals. During a joint review of the clinical record and interview with the Director of Clinical Services and the Registered Nurse, they confirmed that an initial bereavement risk assessment was not completed by the interdisciplinary team.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed with hospice aide services, the hospice did not ensure the hospice aide provided care as ordered by the interdisciplinary team in the plan of care. Clinical Record 5: The patient elected the hospice benefit on 5/10/23, with a terminal diagnosis of personal history of malignant neoplasm of breast. The aide visit note dated 5/12/23 contained no documented evidence that the aide provided the tasks ordered on the aide plan of care assignment. There were no tasks documented as completed by the aide on the aide visit note. The record contained no documentation that the patient refused services or that the aide notified the Registered Nurse Case Manager of unperformed tasks. During a joint review of the clinical record, the Director of Clinical Services agreed the documentation was not found in the clinical record.

It is required that 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. In 1 of 11 (9%) clinical records reviewed, the hospice did not ensure that each patient’s clinical record contained completed documentation per agency policy. Agency policy titled Timely Submissions of Patient Documentation stated in part, "Itineraries, with all visit reports attached, must be submitted the next scheduled workday, not exceeding three (3) business days." Clinical Record 4: The patient elected the hospice benefit on 4/5/23, with a terminal diagnosed of malignant neoplasm of the sigmoid colon. Clinical record reviewed revealed the last updated patient assessment was dated 7/1/23. The Registered Nurse (RN) had not documented a patient assessment in approximately 22 days. During a joint review of the clinical record, the Director of Clinical Services confirmed the RN Case Manager had not completed documentation of updated assessments since 7/1/2023. The agency policy titled Timely Submissions of Patient Documentation states in part, "Itineraries, with all visit reports attached, must be submitted the next scheduled workday, not exceeding three (3) business days.