Every finding on record at Dba Catholic Community Service Inc

Based on medical record review, policy review, and interview, the hospice agency failed to ensure all members of the interdisciplinary team (IDT) completed an assessment within five calendar days after election of hospice care for three of nine patients (Patient #3, Patient #4, and Patient #6). Failure of the IDT to complete the components of the comprehensive assessment can result in the patient and family's psychosocial, emotional, and spiritual needs not being identified and included in the plan of care (POC) and can impact all patients admitted for hospice services. Findings include: Review of Patient #3's electronic medical record (EMR) under the "Misc." tab indicated the "Hospice Notice of Election Statement" was signed on 10/8/21 during the start of care (SOC) assessment completed by Registered Nurse (RN)#1. Review of documentation under the "MSW [Medical Social Worker]" tab indicated the MSW first attempted to make contact with Patient #3 via a phone call on 10/15/21 for the initial MSW assessment which was greater than five days after the election of the hospice benefit. Review of Patient #4's EMR under the "Misc." tab indicated the "Hospice Notice of Election Statement" was signed on 10/7/21. Review of documentation under the "MSW" tab revealed the MSW first attempted to make contact with Patient #4 via a phone call on 10/20/21 for the initial MSW assessment which was greater than five days after the election of the hospice benefit. Review of documentation under the "Chaplain/Counselor" tab indicated Chaplain #3 first attempted to make contact with Patient #4 on 10/18/21 for the initial counselor assessment which was greater than five days after the election of the hospice benefit. Review of Patient #6's EMR under the "Misc." tab indicated the "Hospice Notice of Election Statement" was signed on 11/4/21. Review of the "MSW" and "Chaplain/Counselor" tabs revealed no documentation that the MSW and Counselor made any attempt to contact the patient/family to complete an assessment within five days after election of the hospice benefit. Review of the undated hospice agency's policy titled, "Assessment of the Patient," indicated, "The comprehensive assessment of the patient is completed by designated members of the IDT ... no later than five (5) calendar days after the patient elects the hospice benefit." During an interview on 11/12/21 at 11:30 AM, the Clinical Manager confirmed the MSW, and Chaplain/Counselor are supposed to complete a discipline specific initial assessment within five calendar days after the patient elects the hospice benefit unless the patient or family/caregiver refuse a visit. The Clinical Manager stated the patient or family might refuse a visit from the MSW or Chaplain but the attempt to arrange the initial visit should be documented in the EMR within the five days. .