Every finding on record at Lifted Healthcare Group, Inc

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. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed revealed that the agency did not ensure the comprehensive assessment included an initial bereavement assessment. Clinical Record 1: The patient elected the hospice benefit on 05/18/2024. There was an admission visit done by the registered nurse (RN) on 05/18/2024, an initial visit made by the chaplain on 05/19/2024, and an initial visit made by the social worker on 05/23/2024 no documented evidence of an initial bereavement risk assessment. In an interview and joint review of the clinical record with the clinical manager she confirmed there was no initial bereavement assessment completed. Clinical Record 3: The patient elected the hospice benefit on 05/31/2024. The admission visit was made by the RN on 05/31/2024. There was an initial visit made by the Chaplain and the Social worker the week of 06/02/2024. In a joint review of the clinical record with the clinical manager there was no documented evidence that an initial bereavement risk assessment had been done by any interdisciplinary team member. Clinical Record 13: The patient elected the hospice benefit on 12/19/2023. An initial comprehensive assessment was done by the RN on 12/20/2023. The chaplain and social worker also made initial visits during this week. During a joint review of the clinical record with the clinical manager there was no documented evidence that the initial bereavement risk assessment had been done by any interdisciplinary team member.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. During an interview and joint review of the volunteer program with the Volunteer Coordinator on 08/01/2024 it was determined that the hospice is not meeting the minimum 5% of provided volunteer hours. The agency had a change of ownership in October 2023 and started over with all new staff and volunteers. They have 4 active volunteers currently and have been trending up in their numbers since March. They continue to be around 3% but have a solid plan in place to grow this program. Documentation of volunteer tracking and a plan for the volunteer program was provided to the surveyor. During an interview and joint review of the volunteer program with the Volunteer Coordinator on 08/01/2024 it was determined that the hospice is not meeting the minimum 5% of provided volunteer hours. The agency had a change of ownership in October 2023 and started over with all new staff and volunteers. They have 4 active volunteers currently and have been trending up in their numbers since March. They continue to be around 3% but have a solid plan in place to grow this program. Documentation of volunteer tracking and a plan for the volunteer program was provided to the surveyor.