Every finding on record at Holy Cross 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. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. 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 1 of 1 (100%) clinical record review of patients who died while on hospice services, the agency did not ensure the bereavement plan of care included the types of bereavement services to be offered and the frequency of service delivery. CLINICAL RECORD 8: The patient elected the hospice benefit on 06/17/2025 and died on 07/02/2025. There was no documented evidence in the clinical record that the bereavement plan of care was developed. The end of care summary documented "family opted for bereavement program." A bereavement risk assessment (post-death) was completed; however, the bereavement plan of care section was left blank. During an interview on 01/21/2026, the Director of Patient Care Services stated he did not know how that was left blank, but stated they keep a spreadsheet to track mailing and phone calls, and services are being provided. He also stated, they are not on the plan of care and not documented in the electronic medical record.

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. (L523) This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 11 (9%) records reviewed revealed the hospice did not ensure that the initial comprehensive assessment was completed within 5 calendar days after the election of hospice care. Clinical Record 6: The patient elected hospice care on 12/5/2022. The comprehensive psychosocial assessment had not been completed 12/16/22. The record lacked evidence of why the assessment was not completed within the five days of electing the hospice benefit. The Director of Nurses was interviewed during a joint review of the clinical record on 12/16/22 who confirmed that there was no documentation of an initial psychosocial comprehensive assessment completed by the Social Worker or documentation of why the assessment was not completed.

It is required that a hospice aide provides services: (L626) ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 11 (18%) it was revealed that the agency did not ensure that the hospice aide provided services according to the plan of care visit frequency orders. Clinical Record 6: The patient elected hospice care on 12/5/2022. The Plan of Care (POC) dated 12/5/2022 ordered Aide services one to two times weekly. A missed Aide visit was identified the week ending 12/10/2022. The record lacked documentation of why the visit was not provided as ordered and that the RN or Physician were notified. Clinical Record 12: Director of Patient Care Services was interviewed during a joint review of the clinical record on 12/16/2022 who confirmed that the Aide visit was not documented, and that the agency did not have documentation of a missed visit or why the missed visit was not provided.

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: (L683) a copy of the hospice discharge summary and the patient's record, if requested This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 11 (9%) Records reviewed for patient discharged or revoked from service revealed that the agency did not ensure that a discharge summary was forwarded to the patient's attending physician. Clinical Record 11: The patient was discharged from services on 10/22/22. The record lacked evidence that the discharge summary had been forwarded to the patient's physician. The Director of Patient Care Services acknowledged in an Interview on 12/16/22 that the record lacked documentation validating that the discharge summary was provided to the patient's physician.

It is required that the hospice discharge summary be provided to a facility receiving a hospice patient for care or to the patient’s community attending physician upon hospice discharge—includes at least the following: (L684) a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 11 (9%) Records reviewed for patient discharged revealed that the Hospice did not ensure that a discharge summary was completed. Clinical Record 11: The patient revoked hospice services on 10/22/2022. Review of the clinical record revealed a discharge summary had not been documented or provided to Physician. On 12/16/22 the Director of Patient Care Services acknowledged that a discharge summary had not been completed or documented.