Every finding on record at Belmont Hospice & Palliative Care, Inc

Upon patient record review, 6 of 14 (Patients #4, 5, 6, 10, 11, 12) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes 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 is considered in the bereavement plan of care. Patients #4, 5, 6, 10, 11, 12: The initial bereavement assessment was completed. However, it was incomplete as there was no primary bereaved identified.

Upon patient record review, 2 of 14 (Patients #6, 10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #6: The record reflected that this patient had a cane and walker. These were not included on the Plan of Care. Corrected on site. Patient #10: The record reflected that this patient had a cane. This was not included on the Plan of Care. Corrected on site.

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis Patient #5: The physician written certification included hospice primary diagnosis only. This certification did not include any related or unrelated diagnosis on the document.

Upon patient record review, 2 of 14 (Patients #8, 10) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #8, 10: The Election of Benefit form did not have effective date filled in on the space provided on the form.

Upon SNF/NF contract review, 1 of 4 (Oak Park Healthcare Center contract) did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation. Agency has signed an addendum with the above. Agency working with SNF/NF for their signature/acknowledgement.