Every finding on record at Ras Mgmt LLC

It is required that the comprehensive assessment includes an initial bereavement assessment of 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 considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 5 of 5 (100%) clinical records reviewed, the agency did not ensure the comprehensive assessment included an initial bereavement assessment, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. CLINICAL RECORD 1: The patient elected the hospice benefit on 05/08/2025 with a terminal diagnosis of senile degeneration of the brain. There was no documented evidence in the clinical record that the initial bereavement risk assessment was completed, as of the date of record review on 06/05/2025. CLINICAL RECORD 2: The patient elected the hospice benefit on 03/25/2025 with a terminal diagnosis of Alzheimer's Disease late onset. There was no documented evidence in the clinical record that the initial bereavement risk assessment was completed, as of the date of record review on 06/05/2025. CLINICAL RECORD 3: The patient elected the hospice benefit on 04/15/2025 with a terminal diagnosis of traumatic brain injury secondary to progressive subnuclear palsy. There was no documented evidence in the clinical record that the initial bereavement risk assessment was completed, as of the date of record review on 06/05/2025. CLINICAL RECORD 4: The patient elected the hospice benefit 05/13/2025 with a terminal diagnosis of cirrhosis of the liver. There was no documented evidence in the clinical record that the initial bereavement risk assessment was completed, as of the date of record review on 06/05/2025. CLINICAL RECORD 5: The patient elected the hospice benefit on 03/19/2025 with a terminal diagnosis of Alzheimer's Disease late onset. There was no documented evidence in the clinical record that the initial bereavement risk assessment was completed, as of the date of record review on 06/05/2025. During an interview and joint review of the clinical records on 06/05/2025, the Alternate Director of Nursing (Personnel Record 1) stated that the initial bereavement risk assessment was attached to both the initial psychosocial assessment and the initial spiritual assessment, but the form was not activated to complete the initial bereavement risk assessment. The Alternate Administrator (Personnel Record 4) stated the agency's expectation was that the initial bereavement risk assessment was to be completed by the Chaplain, but the agency had not ensured that the task was assigned to the Chaplain, so he did not complete it.

It is required that the Interdisciplinary Group ensures instruction of the patient, as appropriate, and the family and/or other caregivers on the proper handling, storage, and safe utilization of durable medical equipment and/or supplies. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed, the agency did not ensure the patient, family, and/or other caregivers received instructions on the proper handling, storage, and safe utilization of durable medical equipment (DME) and/or supplies. CLINICAL RECORD 1: The patient elected the hospice benefit on 05/08/2025 with a hospice diagnosis of senile degeneration of the brain. Clinical record review revealed the patient was ordered a rollator walker, raised toilet seat, nebulizer kit, bedside commode, and a shower chair with an adjustable back on 05/08/2025. The clinical record contained no documented evidence that the patient and/or caregiver was instructed on the proper handling, storage, and safe utilization of the DME equipment ordered for the patient. CLINICAL RECORD 2: The patient elected the hospice benefit on 03/25/2025 with a terminal diagnosis of Alzheimer's Disease late onset. Clinical record review revealed the patient was ordered an over-the-bed table, wheelchair, rollator walker, wheelchair footrests and leg rests on 03/25/2025. The clinical record contained no documented evidence that the patient and/or caregiver was instructed on the proper handling, storage, and safe utilization of the DME equipment ordered for the patient. During an interview and joint review of records on 06/05/2025, the Alternate Director of Nursing (Personnel Record 1) stated there was no documentation in the clinical records of DME education provided to the patient, the family, or caregivers. She explained that the new EMR [electronic medical record] did not have a designated section in the comprehensive assessment or plan of care to document this education, so there was no prompt to document the DME instructions in the clinical record. This resulted in the DME instructions not being documented in the clinical records.