Every finding on record at South Central Clinics Inc

Based on staff interview, medical record review, and review of the facility policy and procedure related to admission and bereavement programs, the facility failed to include a bereavement risk assessment in the initial plan of care for 12 of 15 patient medical records on two (2) of four (4) days of survey; Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 and #13. --- Interview with Social Services (MSW) #1 at 2:45 p.m. on 11/15/2023 confirmed an initial bereavement risk assessment, to determine any grief/loss issues that should be included in the plan of care, was not performed during the comprehensive assessment at the time of admission to hospice services. An interview with Registered Nurse (RN) #1 at 3:40 p.m. on 11/16/2023 confirmed during the Hospice Initial Nursing Assessment, the RNs did not perform an initial bereavement risk assessment to determine grief/loss issues of the patient and family that should be included in the plan of care, at the time of admission to hospice services. Documentation review of medical records titled, ";Hospice Initial Assessment (ver. 23.2)," for patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 and #13 does not contain an initial bereavement risk assessment documented at the time of admission to service. Review of facility policy and procedure titled, Procedure for Admission to Hospice, (12/27/2022) reveals, ";...An RN is responsible for the admission to hospice...initial nurse visit involves...intensive assessment and information process...that relate to...care provided...services to patient and family...Baseline Guidelines, and General Decline in Clinical Status is completed at admission and each recertification...". Review of facility policy and procedure titled, Bereavement Program, dated 12/27/2022, reveals the facility has no documented evidence in its policy and procedure related to the initial bereavement risk assessment. During the exit conference on 11/16/2023 at 12:30 p.m. with Administrator, Assistant Director of Nursing, Hospice Coordinator, and Quality RN survey findings were discussed, and no further documentation was submitted for further review.