Every finding on record at Hospice Advantage, LLC

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 clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the Interdisciplinary Group completed the initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. Clinical Record 1: The patient elected the hospice benefit on 12/21/2022. The Registered Nurse (RN) completed the initial assessment on 12/21/2022 and did not include documentation of a psychosocial assessment. The initial psychosocial assessment was completed on 01/04/2023, 14 days after the patient's election of the hospice benefit. Clinical Record 12: The patient elected the hospice benefit on 09/12/2023. The RN completed the initial assessment on 09/12/2023 and did not include documentation of a psychosocial and a spiritual assessment. The initial psychosocial and spiritual assessments were completed on 10/23/2023, 41 days after the patient's election of the hospice benefit. During an interview on 01/17/2024, the Director of Clinical Services (DCS) confirmed that the initial psychosocial and spiritual assessments were not completed within five (5) calendar days after the patients' election of hospice care. No further information was provided.

It is required that the comprehensive assessment includes an initial bereavement 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. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the hospice did not ensure an initial bereavement assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. Clinical Record 6: The patient elected the hospice benefit on 11/07/2023. The Registered Nurse (RN) completed the initial assessment on 11/07/2023 and did not include an initial bereavement assessment. The initial bereavement assessment was completed on 01/17/2024, with 71 days outstanding. During an interview on 01/17/2024, the Director of Clinical Services (DCS) confirmed that the initial bereavement risk assessment was not completed within five (5) calendar days. No further information was provided.