Every finding on record at Genesis Health Services, Inc.

Observed in Record Review. The surveyor observed on 2/12 records reviewed that the initial bereavement assessment not completed and documented. The issue was discussed and confirmed with organization leaders.

Observed in Record Review. In 5 of 12 patient records reviewed, the surveyor observed RN had not visited the hospice patient every 15 days to conduct an assessment. On 1/12 patients reviewed it had been greater than 15 days since the RN visited the home and in 4/12 the RN had visited every 15 days, but had on most visits only completed the short form that included the supervision of LVN and CHHA, but had not contained the comprehensive assessment as required by organization policy and CMS. The short form had the RN fill in a narrative note and supervision . This issue was discussed and confirmed with organization leader.

Observed in Data Tracer. The surveyor observed that although the hospice identified specific performance improvement projects that were being conducted they did not document the reasons for conducting the projects and had not documented collected data for project. This was confirmed with organization leadership.

Observed in Individual Tracer. The surveyor observed the SN cleaned hands with hand gel while holding dirty used gloves in hand. This was not in accordance to organization policy and was discussed and confirmed with organization leadership.

Observed in Proficiency Testing. In 2 of 3 patient records reviewed, The Surveyor observed that in the 2/3 that had been transferred or discharged to other care providers that the hospice had not sent discharge summary or any information to next provider. This issue had been discussed and confirmed with hospice leadership