Every finding on record at Cascade Springs Home Health & Hospice, LLC

Based on interview and record review, it was determined the hospice agency did not ensure an initial bereavement assessment was completed. Specifically, for 5 of 19 sample patients who had a full medical record review completed by the survey team there was no documented evidence of 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. (Patient identifiers: 2, 4, 17, 18 and 19.) --- Findings include: 1. Patient 2 was admitted to the agency on 1/24/2023 with a terminal diagnosis of Parkinsons Disease. A review of patient 2's medical record was completed on 11/15/2023. No documented evidence of a bereavement assessment could be found in patient 2's medical record. An e-mail was sent to the Administrator (ADM) on 11/15/2023 at 8:48 AM related to the missing bereavement assessment. On 11/15/2023 at 9:26 AM, the ADM confirming the bereavement assessment for patient 2 was not completed. 2. Patient 4 was admitted to the agency on 10/12/2023 with a terminal diagnosis of respiratory failure. A review of patient 4s medical record was completed on 11/15/2023. No documented evidence of a bereavement assessment could be found in patient 4s medical record. An e-mail was sent to the ADM on 11/15/2023 at 8:51 AM related to the missing bereavement assessment. The ADM responded on 11/15/2023 at 2:14 PM confirming the bereavement assessment was not completed. 3. Patient 17 was admitted to the agency on 11/2/2022 with a terminal diagnosis of sepsis. A review of patient 17s medical record was completed on 11/15/2023. No documented evidence of a bereavement assessment could be found in patient 17s medical record. An e-mail was sent to the ADM on 11/15/2023 at 10:45 AM related to the missing bereavement assessment. The ADM responded on 11/15/2023 at 10:15 AM confirming the bereavement assessment was not completed. 4. Patient 18 was admitted on 6/15/2023 to the agency with a terminal diagnosis of senile degeneration of the brain. A medical record review was completed on 11/16/2023. No documentation could be located in the medical record to indicate that an initial bereavement assessment, that included social, spiritual and cultural factors, that may impact family or individual's ability to cope, had been completed. On 11/15/2023 at 11:15 am, an email was sent to the administrator requesting information on patient 18s bereavement assessment. On 11/15/2023 at 12:06 PM, an email was received from the administrator that stated, no pre or post bereavement assessment could be located. 5. Patient 19 was admitted to the agency on 12/6/2022 with a terminal diagnosis of systolic heart failure. A review of patient 19s medical record was completed on 11/15/2023. No documented evidence of a bereavement assessment could be found in patient 19s medical record. An e-mail was sent to the ADM on 11/15/2023 at 11:42 AM related to the missing bereavement assessment. The ADM responded on 11/16/2023 at 9:23 AM confirming the bereavement assessment was not completed.