Every finding on record at Guiding Light Hospice Inc.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 2 of 3 (67%) clinical records reviewed for patients receiving bereavement services revealed that the agency did not ensure that the bereavement services were provided as ordered on the plan of care. CLINICAL RECORD 16: The patient elected the hospice benefit on 06/09/2025 and died on 07/03/2025. The clinical record review lacked documented evidence that the bereavement plan of care dated 07/16/2025 was followed as evidence by a 2-month bereavement call due September 2025 that was not documented in the clinical record. CLINICAL RECORD 17: The patient elected the hospice benefit on 03/24/2025 and died on 04/24/2025. The clinical record review lacked evidence that the bereavement plan of care dated 04/25/2025 was followed as evidence by a 3-month mailing that was due July 2025 was not documented in the clinical record. During an interview with the bereavement coordinator on 10/16/2025, he stated that they were having an issue keeping up with the mailing but that the electronic medical record has been updated and is now easier to utilize to provide and track bereavement services.

It is required if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of: The hospice discharge summary described in HCDT 40.I. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) of clinical records reviewed for hospice patients transferred to another a Medicare/Medicaid certified facility, the hospice did not ensure a copy of the discharge summary was sent to the receiving facility. CLINICAL RECORD 18: The patient elected the hospice benefit on 03/15/2024 and transferred to another hospice on 07/24/2025. The clinical record review lacked evidence of the discharge summary being sent to the receiving facility. During an interview on 10/16/2025 with the Administrator (Personnel Record 5) stated that they will be reviewing the discharge process and educating the staff.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed for patients that have been discharged revealed that the agency did not ensure that the attending physician was sent a copy of the hospice discharge summary. CLINICAL RECORD 19: The patient elected the hospice benefit on 03/26/2025 and chose to revocate the hospice benefit on 07/18/2025. The clinical record review lacked evidence of the discharge summary being sent to the attending physician after discharge. During an interview on 10/16/2025 with the Administrator (Personnel Record 5) stated that they will be reviewing the discharge process and educating the staff.