Every finding on record at Optimal Hospice, Inc

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. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the hospice did not ensure that the interdisciplinary group completed the comprehensive assessment no later than five (5) calendar days after the election of hospice care. Clinical Record 10: The patient elected hospice care on 11/10/2023. The initial comprehensive assessment documented the need for a spiritual care evaluation. A review of the clinical record revealed the Chaplain made a phone call to the patient on 11/16/2023, six (6) days after the patient's election of hospice care. The spiritual care assessment was documented on 11/24/2023 (visit date at the request of the family). During an interview on 1/8/2024, the Regional Director of Clinical Operations and the Executive Director/Director of Patient Care Services confirmed this finding. In 1 of 14 (7%) clinical records reviewed in which a comprehensive assessment was performed, revealed the hospice did not ensure that the interdisciplinary group completed the comprehensive assessment within 5 calendar days after the election of hospice care.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are noted in the plan of care and documented in the patient record. This standard was not met as evidenced by clinical record review and interview. In 9 of 14 (64%) clinical records reviewed, the hospice did not ensure that volunteer services were offered. Clinical Record 1: The patient elected hospice care on 6/14/2023. A clinical record review revealed no documented evidence that volunteer services were offered or declined. Clinical Record 2: The patient elected hospice care on 4/21/2023. A clinical record review revealed no documented evidence that volunteer services were offered or declined. Clinical Record 3: The patient elected hospice care on 5/5/2023. A clinical record review revealed no documented evidence that volunteer services were offered or declined. Clinical Record 6: The patient elected hospice care on 9/13/2023. A clinical record review revealed no documented evidence that volunteer services were offered or declined. Clinical Record 7: The patient elected hospice care on 7/6/2023. A clinical record review revealed no documented evidence that volunteer services were offered or declined. Clinical Record 8: The patient elected hospice care on 7/3/2023. A clinical record review revealed no documented evidence that volunteer services were offered or declined. Clinical Record 12: The patient elected hospice care on 10/25/2023. A clinical record review revealed no documented evidence that volunteer services were offered or declined. Clinical Record 13: The patient elected hospice care on 5/10/2023. A clinical record review revealed no documented evidence that volunteer services were offered or declined. Clinical Record 14: The patient elected hospice care on 5/18/2023. A clinical record review revealed no documented evidence that volunteer services were offered or declined. During interviews on 1/8/2024 and 1/9/2024, the Regional Director of Clinical Operations and the Executive Director/Director of Patient Care Services confirmed the findings. In 9 of 14 (64%) clinical records revealed there was no evidence that a volunteer was offered and/or the patient declined volunteer services.