Every finding on record at Bdmack Inc

It is required that each patient’s individualized written plan of care reflects patient and family goals and 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, document review and interview. In 1 of 14 (7%) clinical records reviewed, it was revealed that the patient's individualized written plan of care (POC) lacked goals and interventions based on problems identified in the initial and updated comprehensive assessments. Document 2: Policy #9.12, IDG Care Planning Process (Dated: 2/2022), stated in part, "Procedure: 8. The plan of care reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments." Clinical Record 1: The patient elected the hospice benefit on 2/16/23. The MSW initial assessment was dated 2/20/23 and had a frequency of 1m2. The Interdisciplinary Group (IDG) POC dated 2/21/23 lacked a goal(s) and intervention(s) for the MSW. Upon interview on 8/23/23, the Executive Director and the Director of Clinical Services reviewed and agreed the POC lacked goal(s) and intervention(s) based on problems identified in the initial comprehensive assessment.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 11 (36%) clinical records reviewed for patients that died, it was revealed that the agency did not ensure a bereavement plan of care was developed that included the types of bereavement services to be offered and the frequency of service delivery. Document 3: Policy #4.26, Bereavement Services (Dated: 2/2022), stated in part, "Procedure: 5. Unless Bereavement Services have been refused, a Bereavement Counselor, Chaplain or Social Worker will call designated bereaved to continue bereavement supportive or counseling services. A bereavement plan of care will be initiated..." Clinical Record 1: The patient elected the hospice benefit on 2/16/23. The patient died on 3/19/23. The record lacked a bereavement plan of care (POC) that included the types of bereavement services to be offered and the frequency of service delivery. There was evidence of interventions being completed within the one (1) year post-death that included support letters. Clinical Record 5: The patient elected the hospice benefit on 8/9/23. The patient died on 8/11/23. The record lacked a bereavement plan of care (POC) that included the types of bereavement services to be offered and the frequency of service delivery. There was evidence of interventions being completed within the one (1) year post-death that included support letters. Clinical Record 6: The patient elected the hospice benefit on 5/2/23. The patient died on 5/6/23. The record lacked a bereavement plan of care (POC) that included the types of bereavement services to be offered and the frequency of service delivery. There was evidence of interventions being completed within the one (1) year post-death that included support letters. Clinical Record 8: The patient elected the hospice benefit on 3/30/23. The patient died on 4/12/23. The record lacked a bereavement plan of care (POC) that included the types of bereavement services to be offered and the frequency of service delivery. There was evidence of interventions being completed within the one (1) year post-death that included support letters. Upon interview on 8/23/23, the Executive Director and the Director of Clinical Services reviewed the records and agreed that the agency did not ensure that a post-death bereavement POC was created for the survivors that elected to continue with bereavement services (1) year following the death of the patient.