Every finding on record at Mclaren Health Management Group

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. This standard was not met as evidenced by clinical record review and interview. In 3 of 27 (11%) clinical records reviewed, the agency did not ensure that the hospice interdisciplinary group (IDG) completed an initial comprehensive assessment no later than five (5) calendar days after the patient's election of hospice care. Clinical Record 9: The patient elected the hospice benefit on 03/19/2025. A clinical record review revealed no evidence that the Social Worker (SW) completed an initial assessment within five (5) calendar days. There was evidence of a missed visit documented by the SW on 03/25/2025, which is six (6) days after the election of the hospice benefit. Clinical Record 12: The patient elected the hospice benefit on 03/27/2025. A clinical record review revealed no evidence that the SW completed an initial assessment within five (5) calendar days. There was evidence of the SW's initial assessment dated 04/03/2025, which was seven (7) days after the election of the hospice benefit. Clinical Record 22: The patient elected the hospice benefit on 07/17/2024. A clinical record review revealed no evidence that the SW or Chaplain (SC) completed an initial assessment within five (5) calendar days. There was evidence of a missed visit documented by the SW dated 07/30/2024, which was thirteen (13) days after the election of the hospice benefit, and documentation of the SC's missed visit dated 08/02/2024, which was sixteen (16) days after the election of the hospice benefit. During an interview on 07/11/2025, the Director of Hospice confirmed that the members of the IDG had not completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, or had no documentation supporting the patient and family/caregiver refused Chaplain and Social Work services during the 5-day period after the election of hospice care.

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. This standard was not met as evidenced by a review of clinical records. In 1 of 20 (5%) records reviewed, the hospice Interdisciplinary group did not complete the initial comprehensive assessment within 5 calendar days after the election of hospice care. Clinical Record 19 - The admission to hospice was completed on 9/3/33 by the RN, and the Social Worker's comprehensive assessment was completed on 9/9/22, which was 6 days after hospice was elected. There was no documented evidence present in the clinical record that described the reason for the delay in the initial evaluation by the social worker.