Every finding on record at Southern Grace Hospice West LLC.

Observed in Record Review. In 1 of 14 records, the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. During review of patient record 1 it was noted that the patient goals in the care plan lacked dates or time frames for attainment. This was confirmed by the Administrator.

Observed in Record Review. In 1 of 19 records the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: Interventions to manage pain and symptoms. During review of patient record 12 it was noted that the patient was assessed to be at moderate risk for falls, but there were no interventions for fall prevention in the plan of care. This was confirmed by the COO.

Based on review of Patient Records, the Bereavement Plan of Care review, and interviews, the hospice agency failed to ensure bereavement services were provided to the family following the death of a patient. The agency failed to provide bereavement services for 2(#1 and #2) of 2(#1and #2) patients sampled for bereavement plans of care. --- Patient #1Review of Patient #1's Clinical Record revealed a Start of Care date of 01/11/2022. Further review revealed the Patient #1 expired on 01/14/2022. Review of Patient #1's Bereavement Plan of Care revealed the following: No documentation Patient #1s family/caregiver was contacted at 3 months or 6 months after Patient #1 expired. Patient #2Review of Patient #2's Clinical Record revealed a Start of Care date of 01/06/2023. Further review revealed the Patient #2 expired on 01/09/2023. Review of Patient #2's Bereavement Plan of Care revealed the following: No documentation Patient #2s family/caregiver was contacted at 3 months or 6 months after Patient #2 expired. An interview was conducted on 08/21/2023 at 10:20 a.m. with S2P. He verified he was responsible for conducting follow up contacts with patients family/caregiver after a patients death. He confirmed he did not contact Patient #1 or Patient #2s family at three months and six months after the patients death and should have. An interview was conducted on 08/21/2023 at 10:30 a.m. with S1ADM. He reviewed Patient #1 and Patient #2s clinical record and confirmed S2P did not conduct follow up contacts with the family/caregiver at 3 months or 6 months after the patients death.