Every finding on record at One-Courageous Healthcare Services, Inc.

Based on record review and interview, the hospice Interdisciplinary Group (IDG) which included a Chaplain and MSW failed to complete the initial comprehensive assessment no later than five days after the election of hospice care for 2 of 11 active patients (#5, #9) whose records was reviewed, in that: Patient #1's bereavement assessment and chaplain assessment were not completed within 5 days; and Patient #9's MSW assessment and bereavement assessment were not completed within 5 days This deficient practice placed the agency's active hospice patients at risk of harm for the IDT not completing the comprehensive assessment timely which could cause a delay in service. Findings include: Patient #1 Record review of Patient #1's CR revealed Patient #1 was admitted with terminal diagnoses of Vascular Dementia without behavioral Disturbances, and Seizures. The CR also revealed the election of benefit was dated 12/22/2020. Record review of the initial assessment was dated 01/04/2021 and the initial plan of care was dated 01/06/2021. Further review revealed the initial RN assessment was completed 11 days after the election of benefit. Record review of the CR also revealed that the bereavement assessment and the Chaplain assessment were both conducted on 01/04/2021 - 8 days after the due date of 12/27/2020. Patient #9 Record review of Patient #9's CR revealed Patient #9 was admitted with terminal diagnosis of Malignant neoplasm of unspecified bronchus or lung. The CR also revealed the election of benefit was dated 04/12/2022; the start of care was dated 04/12/2022 and the initial plan of care was dated 04/12/2022 Record review of the initial plan of care revealed order for MSW: 2 PRN (As needed) Record review of Patient #9's CR did not reveal that the MSW assessment was completed within 5 days Record review of Patient #9 revealed the bereavement assessment was conducted on 04/25/2022; further record review revealed there was no of evidence that the initial bereavement assessment was completed within 5 days An attempted phone call was made to interview Patient #9 and the patient's person of contact on 04/28/2022 but the surveyor was unable to reach Patient #9 or the patient's person of contact In an interview with Administrator and telephone interview with RN-C on 04/28/2022 at approximately 12:00 PM; the above findings were presented and reviewed with the representatives of the agency; RN-C stated that it was a mistake that the assessment was not done on time; the administrator stated the QA reviewer would have caught the error and ensured compliance, and the QA reviewer was yet to get to the patients' record for review. In an interview with the Administrator and the DON who was also the QA reviewer on 04/28/2022 at approximately 12:30 PM, the Administrator stated that SW-D was not available for interview in person or by phone for interview. The DON acknowledge the above findings, and stated that she has not got to review the charts for the affected patients, and that she would have caught the error. No other supporting documentation or explanation were provided to the surveyor at the time of the survey.