Every finding on record at Horizon Hospice

Based on interview, record reviews, and facility policy review, it was determined that the facility failed to complete an initial bereavement assessment (an assessment of the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death) for 7 (Patients #1, #2, #3, #4, #5, #8, and #11) of 11 patients reviewed. The failure had the potential for the patients caregivers and family members to not receive needed bereavement services. --- Findings included: Review of a facility policy titled, ";Initial Assessment," reviewed 01/2022, showed that agency staff were to complete a bereavement assessment as part of a patients comprehensive assessment when the agency admitted the patient. 1. A review of Patient #1s ";Patient Face Sheet," undated, showed that the agency admitted Patient #1 on 09/19/2022 with diagnoses that included Parkinsons disease (a disorder of the central nervous system that affects movement, often including tremors) and dementia. A review of Patient #1s ";Skilled Nursing Visit Note," dated 09/19/2022, showed that the agency did not complete an initial bereavement assessment for Patient #1s family members. A review of Patient #1s ";Medical Social Worker Visit Note," dated 09/19/2022, showed that the agency did not complete an initial bereavement assessment for Patient #1s family members. 2. A review of Patient #2s ";Patient Face Sheet," undated, showed that the agency admitted Patient #2 on 10/13/2022 with diagnoses that included anemia (a condition in which the blood does not have enough healthy red blood cells). A review of Patient #2s ";Skilled Nursing Visit Note," dated 10/13/2022, showed that the agency did not complete an initial bereavement assessment for Patient #2s family members. A review of Patient #2s ";Medical Social Worker Visit Note," dated 10/17/2022, showed that the agency did not complete an initial bereavement assessment for Patient #2s family members. 3. A review of Patient #3s ";Patient Face Sheet," undated, showed that the agency admitted Patient #3 on 11/22/2022 with diagnoses that included malignant neoplasm of rectosigmoid junction (cancer of the intestines where the colon meets the rectum). A review of Patient #3s ";Skilled Nursing Visit Note," dated 11/22/2022, showed that the agency did not complete an initial bereavement assessment for Patient #3s family members. A review of Patient #3s ";Medical Social Worker Visit Note," dated 11/22/2022, showed that the agency did not complete an initial bereavement assessment for Patient #3s family members. 4. A review of Patient #4s ";Patient Face Sheet," undated, showed that the agency admitted Patient #4 on 11/12/2022 with diagnoses that included malignant neoplasm of cardia (cancer of the esophagus or stomach). A review of Patient #4s ";Skilled Nursing Visit Note," dated 11/12/2022, showed that the agency did not complete an initial bereavement assessment for Patient #4s family members. A review of Patient #4s ";Medical Social Worker Visit Note," dated 11/15/2022, showed that the agency did not complete an initial bereavement assessment for Patient #4s family members. 5. A review of Patient #5s ";Patient Face Sheet," undated, showed that the agency admitted Patient #5 on 07/28/2021 with diagnoses that included degenerative disease of the nervous system (a nerve disorder that causes loss of memory and the ability to think). A review of Patient #5s ";Skilled Nursing Visit Note," dated 07/228/2021, showed that the agency did not complete an initial bereavement assessment for Patient #5s family members. A review of Patient #5s ";Medical Social Worker Visit Note," dated 07/28/2021, showed that the agency did not complete an initial bereavement assessment for Patient #5s family members. 6. A review of Patient #8s ";Patient Face Sheet," undated, showed that the agency admitted Patient #8 on 04/27/2022 with diagnoses that included malignant neoplasm of bronchus or lung (lung cancer). A review of Patient #8s ";Skilled Nursing Visit Note," dated 04/27/2022, showed that the agency did not complete an initial bereavement assessment for Patient #8s family members. A review of Patient #8s ";Medical Social Worker Visit Note," dated 04/27/2022, showed that the agency did not complete an initial bereavement assessment for Patient #8s family members. 7. A review of Patient #11s ";Patient Face Sheet," undated, showed that the agency admitted Patient #11 on 04/21/2022 with diagnoses that included malignant neoplasm of pancreas (pancreatic cancer). A review of Patient #11s ";Skilled Nursing Visit Note," dated 04/21/2022, showed that the agency did not complete an initial bereavement assessment for Patient #11s family members. A review of Patient #11s ";Medical Social Worker Visit Note," dated 04/21/2022, showed that the agency did not complete an initial bereavement assessment for Patient #11s family members. The agency did not provide any additional documentation that showed that the agency had completed initial bereavement assessments for Patients #1, #2, #3, #4, #5, #8, and #11. During an interview on 12/14/2022 at 11:35 AM, the Hospice Director (HD) confirmed that the agency did not complete initial bereavement assessments for Patients #1, #2, #3, #4, #5, #8, and #11 and acknowledged that the facility was not following its policy.