Every finding on record at Kaiser Permanente Home Health/Hospice

Based on interview and medical record review, it was determined the hospice failed to complete the comprehensive assessment, that included a bereavement assessment, no later than 5 calendar days after the election of hospice care, for 3 of 23 patient records reviewed (Patients #6, #7, and #14). --- Findings: Review of the electronic medical record of Patient #6 with a hospice election date of 4/29/2023 revealed the comprehensive assessment was started on 4/29/2023. The bereavement assessment portion of the comprehensive assessment was completed on 5/23/2023, twenty-four calendar days after the election date. Review of the electronic medical record of Patient #7 with a hospice election date of 6/28/2023 revealed the comprehensive assessment was started on 6/28/2023. The bereavement assessment portion of the comprehensive assessment was completed on 7/18/2023, twenty calendar days after the election date. Review of the electronic medical record of Patient #14 with a hospice election date of 5/4/2023 revealed the comprehensive assessment was started on 5/4/2023. The bereavement assessment portion of the comprehensive assessment was completed on 6/22/2023, forty-nine calendar days after the election date. During an interview and review of documentation on 8/3/2023 beginning at 2:00 PM via MS Teams, Employees #14 and #15 acknowledged these findings.

Based on interview and medical record review, it was determined the agency failed to include an initial bereavement assessment as part of the initial comprehensive assessment for 2 of 23 patient records reviewed (Patients #9 and #23). --- Findings: Review of the electronic medical record of Patient #9 revealed a start of care date to hospice of 6/1/2023 and an initial comprehensive assessment completed on 6/2/2023. The comprehensive assessment lacked information that a bereavement assessment was performed on this patient. Review of the electronic medical record of Patient #23 revealed a start of care date to hospice of 6/30/2023 and an initial comprehensive assessment completed on 7/3/2023. The comprehensive assessment lacked information that a bereavement assessment was performed on this patient. During the exit conference on 8/3/2023 beginning at 2:00 PM, Employees #14 and #15 acknowledged the findings. Employee #14 stated "This is not a surprise since we were unable to find a bereavement assessment for either patient when requested for one on 8/2/2023."