Every finding on record at Essential Home Health Inc

Based on record review, policy review, and staff interview, the agency failed to ensure that each patient received an accurate, patient specific comprehensive assessment that included an initial bereavement assessment for 3 (Patients 1, 12 and 14) of 19 sample patients. This failed practice by the hospice placed all patients and their families at risk of unmet needs related to their bereavement plan of care. --- Findings Include: Review of agency policy titled, "Bereavement PC 130," dated 09/01/24, showed, "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. The bereavement assessment will be completed by the Hospice's spiritual counselor, social worker (SW), and /or the registered nurse (RN)." Patient 1 Review of Patient 1's clinical record showed a Start of Care date of 11/23/24 and a Primary Diagnosis of Hemiplegia. Review of the Comprehensive Assessment, dated 11/23/24, lacked documentation to support a bereavement assessment was performed by the Registered Nurse. Review of the Initial visit note for the Chaplin, dated11/25/24, lacked documentation to support a bereavement assessment was performed. Patient 12 Review of Patient 12's clinical record showed a Start of Care date of 11/08/24 and a Primary Diagnosis of Senile Degeneration of Brain. Review of the Comprehensive Assessment, dated 11/08/24, lacked documentation to support a bereavement assessment was performed by the Registered Nurse. Review of the clinical record showed the patient and family had refused Chaplain services. There was no documentation to support the initial bereavement assessment was completed by the RN or SW as part of the Comprehensive Assessment, when Chaplain services were refused. Patient 14 Review of Patient 14's clinical record showed a Start of Care date of 11/21/24 and a Primary Diagnosis of Congestive Obstructive Pulmonary Disease. Review of the Comprehensive Assessment, dated 11/21/24, lacked documentation to support a bereavement assessment was performed by the Registered Nurse. Review of the clinical record showed the Chaplain visit was scheduled to be performed on 12/16/24 (twenty-five days after admission to service) and greater than the allowed time frame to complete the Initial Comprehensive Assessment. During an interview on 12/04/24 at 2:05 PM, Staff A, Administrator, confirmed the agency failed to ensure initial bereavement assessments were completed for patients, as part of the Initial Comprehensive Assessment.

Based on record review and staff interview, the hospice agency failed to send a discharge summary to the certifying physician upon discharge from services for 2 (Patient 15 and 16) of 19 sample patients. The deficient practice had the potential to affect patient safety and to place the patients at risk for adverse outcomes related to the lack of care coordination with other health care services. --- Findings Include: Patient 15 Review of Patient 15's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 01/17/24 and a Primary Diagnosis of Other Cerebral Infarct. Review of episode period 08/14/24 to 10/12/24 showed the patient had requested to go to the hospital for wound care treatments and had signed a revocation form on 10/09/24. Review of the clinical record lacked documentation to show a discharge summary was sent to the certifying physician at the time of the discharge from services or any time thereafter. Patient 16 Review of Patient 16's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 01/03/24 and a Primary Diagnosis of Chronic Obstructive Pulmonary Disease. Review of the episode period 08/30/24 to 10/28/24 showed that the patient was a live discharge due to no longer being terminally ill and a Notice of Medicare Non-Coverage (NOMONC) form was given to and signed by the patient on 10/24/24. The patient was discharged from hospice services on 10/28/24 however, there was no documentation to support a discharge summary was sent to the certifying physician at the time of the discharge or any time thereafter. During an interview on 12/04/24 at 3:35 PM, with Staff A, Administrator, and Staff C, Vice President of Operations (VP), the staff stated there was a system process for generating and sending out a discharge summary however, they confirmed that the patients' discharge summaries had not been sent out to the physicians as required.