Every finding on record at Montana Hospice, Inc.

Upon patient record review, 1 of 14 (Patient #10) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes 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 is considered in the bereavement plan of care. #10-The initial bereavement assessment was not completed within 5 days-patient was admitted on 09/03/24 and the bereavement assessment was completed on 10/01/24.

Upon patient record review, 1 of 14 (Patient #10) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. #10-The patient's religion is unclear in the chart. The demographic information states the patient as Jewish and the spiritual screening by the RN states the patient is Christian. The spiritual care assessment did not address a religious preference.

Upon observation, there was no evidence the hospice provides orientation to personnel of a SNF/NF or ICF/IID regarding the policies and procedures of the provision of care/service including all required content.