Every finding on record at Concord Hospice LLC

Based on record review and interview, the agency failed to take in required factors that must be incorporated into the plan of care and considered in the bereavement plan of care in that: the agency did not incorporate an initial bereavement assessment that considered the needs of the client's family and other persons that focuses on the social, spiritual, and cultural factors that may impact their ability to cope with the client's death in 4 of 4 deceased client's records reviewed. Citing Client #11, Client #12, Client #13 and Client #14.This failure could mean that the bereaved were not given adequate tools to cope with the death of their loved one. --- Findings:Review of the medical record of Patient #11 revealed a start of care date of 8/1/2025 and a diagnosis of end stage heart failure. End stage heart failure is the most advanced stage of heart failure, where the heart can no longer pump enough blood to meet the body's needs.  Further review of the medical record revealed a date of death as 8/5/2025. Nowhere in the medical record was there an inital bereavement assessment.Review of the medical record of Patient #12 revealed a start of care date of 7/16/2025 and a diagnosis of senile degeneration of the brain. Senile degeneration of the brain encompasses a range of neurological disorders characterized by a progressive decline in cognitive function, impacting memory, reasoning, and the ability to perform everyday activities. Further review of the medical record revealed a date of death as 8/5/2025. Nowhere in the medical record was there an initial bereavement assessment.Review of the medical record of Patient #13 revealed a start of care date of 5/23/2025 and a diagnosis of cerebral atherosclerosis. Cerebral atherosclerosis occurs when the arteries in the brain become narrowed or blocked due to plaque buildup. Further review of the medical record revealed a date of death as 7/29/2025.  Nowhere in the medical record was there an initial bereavement assessment.Review of the medical record of Patient # 14 revealed a start of care date of 8/1/2025 and a diagnosis of cerebral infarction. A cerebral infarction is a when a blood vessel to the brain is blocked leading to a blockage of blood supply and oxygen to the brain tissue. Further review of the medical record revealed a date of death as 8/1/2025.  Nowhere in the medical record was there an inital bereavement assessment.Review of the agency’s undated bereavement binder did not contain any bereavement assessments for the above-mentioned patients.An interview was conducted with the agency’s Bereavement Coordinator/Chaplain E on 8/28/2025 at approximately 1:06 p.m.  The surveyor inquired as to the bereavement process.  Bereavement Coordinator/Chaplain E stated, “…we do the assessment within 5 days of starting care of admission and so I visit with the family and in some cases by phone…we've been missing doing the bereavement assessments…”  The surveyor inquired as to what was the agency’s policy on bereavement assessments.  Bereavement Coordinator/Chaplain E stated, “…a bereavement assessment has to be completed within five days…”  The surveyor inquired as to whose responsibility it was to make sure the bereavement assessments are completed.  The Bereavement Coordinator/Chaplain E stated, “… that's mine…I'm the lead chaplain and the bereavement coordinator…”  The surveyor inquired as to how this failure could affect the bereaved.  The Bereavement Coordinator/Chaplain E stated, “…We would have to make sure they have resources and that they know there is follow up…”Review of the agency’s policy titled, “Bereavement  PC.130 page 1 of 3 and page 2 of 3 Last Reviewed 090124” read, in part, “…Procedure I. The Hospice will perform an initial bereavement assessment of the needs of the patient’s family and other care individuals focusing on the social, spiritual and cultural factors that may impact their ability to cope with the patient’s death as part of the Initial Comprehensive Assessment…IV. The bereavement coordinator will review the assessment for potential family and/or caregiver needs…”