Every finding on record at Glory Health Network

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 with the Administrator. 3 of 9 (33%) records revealed the agency failed to ensure that the Spiritual Assessment component of the Initial Comprehensive Assessment was completed within 5 days of the patients' admission to hospice. Record #25071: The patient was admitted to hospice on 12/21/2021. The Initial Spiritual Assessment was documented as completed on 12/28/2021, which was 7 calendar days after admission. There was no documentation that the Chaplain contacted the family/patient within 5 days of admission to hospice. Record #80810: The patient was admitted to hospice on 12/22/2021. The Initial Spiritual Assessment was documented as completed on 12/28/2021, which was 6 calendar days after admission. There was no documentation that the Chaplain contacted the family/patient within 5 days of admission to hospice. Record #34384: The patient was admitted to hospice on 1/6/2022. The Initial Spiritual Assessment was documented as completed on 1/25/2022, which was 19 calendar days after admission. There was no documentation that the Chaplain contacted the family/patient within 5 days of admission to hospice, or described the reason for the delay. An interview was conducted on 3/10/2022 and 3/11/2022 with the Director of Nursing (DON) (Staff #58809) and the CEO/Administrator/ (Staff #72670) who stated after review, that there was no documentation explaining the reason, that the chaplain assessment had been delayed.

It is required that the Interdisciplinary Group ensures instruction of the patient, as appropriate, and the family and/or other caregivers on the proper handling, storage, and safe utilization of durable medical equipment and/or supplies. The patient, family and/or other caregivers must be able to demonstrate the appropriate use of the DME to the satisfaction of the IDG. The IDG documents that the patient, family, and/or caregivers can demonstrate appropriate use of the delivered DME. This standard was not met as evidenced by observation during home visits on 3/09/2022, clinical record review, and interviews. 1 the 1 (100%) applicable observation during home visits of patients utilizing oxygen, revealed there was no evidence that the agency ensured there was an oxygen safety sign posted in the home. Record #30222: During the observed home visit on 3/9/2022, with Staff #59841, the patient was observed to be wearing continuous oxygen. This patient had a primary diagnosis of senile degeneration of brain, not otherwise classified. There was no oxygen safety sign posted in the home. During interview with the clinician (Staff #59841) on 3/9/2022, they stated they needed to call the DME company for a sign. During interviews on 03/09/2022 and 3/11/2022, with the Administrator/Director of Clinical Services (Staff #59841) and Alternative Administrator (Staff #31844), they stated that the agency will follow up with the DME provider to provide oxygen safety signs for posting in patients' homes.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by a review of contracts and an interview, which revealed the Pharmacy contract failed to include the clause, in writing, between the contractor/contracted for the provision that requires criminal background checks. During an interview with the CEO/Administrator (Staff #31844) on 03/09/2022 and 3/11/2022, it was stated that an addendum would be completed to ensure compliance going forward.