Every finding on record at Mays Hospice Care, Inc

Based on record review and interview, the IDG failed to ensure the comprehensive assessment was completed within 5 days of the election of hospice care for four (#1, #8, #11 and #18) of nineteen (#1 -#19) records reviewed. --- Patient #1 Review of clinical record #1 for certification periods 04/04/24 - 07/02/24 revealed a primary diagnosis of Atherosclerotic Heart Disease and a SOC date of 04/04/24. Further review of Clinical Visit Notes indicated a Social Work Evaluation and the Bereavement Risk Assessment were conducted on 04/10/24 (1 day late). Patient #8 Review of clinical record #8 for certification periods 03/08/24 - 06/05/24 revealed a primary diagnosis of Malignant Neoplasm of the Lung and a SOC date of 03/08/24. Further review of the Client Medication Report indicated a review of the Patient's current medications by the RN was conducted on 03/15/24 (2 days late). Patient # 11 Review of clinical record #11 for certification periods 03/15/24 - 05/13/24 revealed a primary diagnosis of Chronic Obstructive Pulmonary Disease and a SOC date of 03/15/24. Further review of Clinical Visit Notes indicated the Bereavement Risk Assessment was completed on 03/21/24 (1 day late). Patient # 18 Review of clinical record #18 for certification periods 02/01/24 - 04/05/24 revealed a primary diagnosis of Chronic Obstructive Pulmonary Disease and a SOC date of 02/01/24. Further review of Clinical Visit Notes indicated the Bereavement Risk Assessment was completed on 02/29/24 (23 days late). During an interview on 04/24/24 at 10:30 AM, the Director of Nursing stated the IDG members failed to ensure the comprehensive assessment was completed within 5 days as required for Patients #1, #8, #11 and #18.

Based on record review and interview, the IDG failed to conduct a Bereavement Risk Assessment to identify needs of the patient and family and to incorporate that information into the hospice bereavement plan of care for five (#2, #13, #16, #17 and #19) of nineteen (#1 -#19) records reviewed. --- Review of clinical records for Patients #2, #13, #16, #17 and #19, failed to provide evidence of a Bereavement Risk assessment. On 04/24/24 at 10:30 AM, review of a Bereavement Program Client report conducted in coordination with the Director of Nursing and the Vice President failed to provide evidence of Bereavement Risk Assessments for Patients #2, #13, #16, #17 and #19. The Director of Nursing stated the Bereavement Risk Assessments were not completed for the five Patients. (#2, #13, #16, #17 and #19)