Every finding on record at Charlin Hospice 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 and interview. In 3 of 14 (21%) clinical records reviewed revealed that the agency did not ensure that the initial comprehensive assessment, including the bereavement assessment, was completed no later than five calendar days after the election of hospice care. Clinical Record 3: The patient's date of the election was 03/29/2023. The initial bereavement assessment occurred on 04/04/2023 (1 day late). Clinical Record 4: The patient's date of the election was 10/26/2023. The initial bereavement assessment occurred on 07/08/2024 (256 days late). Clinical Record 6: The date of the election was 05/22/2024. The initial bereavement assessment occurred on 06/11/2024 (20 days late). During a joint clinical record review and interview on 07/18/2024, the Director of Nursing confirmed that the initial comprehensive assessment, including the bereavement assessment, was completed later than five days after the election of hospice care.

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 4 of 14 (29%) clinical records reviewed revealed that the agency did not ensure the comprehensive assessment included 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. Clinical Record 1: The patient's date of election was 06/07/2023. The record lacked evidence of an initial bereavement assessment. Clinical Record 5: The patient's date of election was 04/22/2024. The record lacked evidence of an initial bereavement assessment. Clinical Record 7: The patient's date of election was 05/03/2024. The record lacked evidence of an initial bereavement assessment. Clinical Record 8: The patient's date of election was 01/19/2023. The record lacked evidence of an initial bereavement assessment. During a joint clinical record review and interview on 07/18/2024, the Director of Nursing confirmed that the record lacked 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.

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires and no less frequently than every 15 days. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed that the agency did not ensure that an update of the comprehensive assessment was completed as frequently as the condition of the patient requires and no less frequently than every 15 days. Clinical Record 6: The patient's date of election was 05/22/20243. The Initial Nursing Assessment was dated 05/22/2024. The Licensed Vocational Nurse saw the patient on 05/24/2024, 05/28/2024, 05/31/2024, 06/04/2024, 06/07/2024, 06/11/2024, 06/14/2024, and 06/17/2024. The RN comprehensive was dated 06/25/2024, 34 days. The record lacked evidence of a comprehensive assessment no less than every 15 days. During a joint clinical record review and interview on 07/18/2024, the Director of Nursing confirmed that an update of the comprehensive assessment was not completed as frequently as the patient's condition requires but no less frequently than every 15 days.