Every finding on record at Spiritrust Lutheran Home Care & Hospice

Based on a review of agency policy, a review of clinical records, and an interview with the agency Administrator, the agency failed to complete the comprehensive assessment no later than 5 calendar days after the patient election of hospice care for eight (8) of twelve (12) clinical records (CR) reviewed (CR#1- CR#6, CR#8, CR#11). Findings: Agency policy was reviewed May 19, 2022 at approximately 1:00 p.m. Agency policy 'Admission and Certification of Hospice Patients' (D) 'Initial and Comprehensive Assessments' (2) states "Within five (5) days of the election of Hospice, the Hospice IDG (interdisciplinary group), in conjunction with the clients attending physician, will complete a comprehensive assessment of the client and family's needs." A review of CRs was conducted on May 19, 2022 at approximately 12:30 p.m. revealed the following: CR#1 Start of Care 05/22/21: Patients certification period 05/22/21-08/19/21 reviewed. Chaplain did not complete the initial assessment until 06/15/21, twenty-five (25) days after the patients election of hospice benefits. CR#2 Start of Care 11/23/21: Patients certification period 11/23/21-02/20/22 reviewed. Chaplain did not complete the initial assessment until 12/06/21, fourteen (14) days after the patients election of hospice benefits. CR#3 Start of Care 03/24/22: Patients certification period 03/24/22-06/21/22 reviewed. Chaplain did not complete the initial assessment until 04/20/22, twenty-eight (28) days after the patients election of hospice benefits. CR#4 Start of Care 04/30/22: Patients certification period 04/30/22-07/28/22 reviewed. Chaplain did not complete the initial assessment until 05/17/22, eighteen (18) days after the patients election of hospice benefits. CR#5 Start of Care 01/21/22: Patients certification period 01/21/22-04/20/22 reviewed. Patient discharged from the agency on 03/15/22. Chaplain did not complete an initial assessment within five (5) days of the patients election of hospice benefits. CR#6 Start of Care 02/28/22: Patients certification period 02/28/22-05/13/22 reviewed. Patient discharged from the agency on 03/10/22. Chaplain did not complete an initial assessment within five (5) days of the patients election of hospice benefits. CR#8 Start of Care 09/23/21: Patients certification period 09/23/21-12/21/21 reviewed. Social Worker did not complete the initial assessment until 09/30/21, eight (8) days after the patients election of hospice benefits. Chaplain did not complete the initial assessment until 10/15/21, twenty-three (23) days after the patients election of hospice benefits. CR#11 Start of Care 07/01/21: Patients certification period 07/01/21-09/28/21 reviewed. Chaplain did not complete the initial assessment until 07/13/21, thirteen (13) days after the patients election of hospice benefits. Social Worker did not complete the initial assessment until 07/14/21, fourteen (14) days after the patients election of hospice benefits. An interview conducted on May 19, 2022 at approximately 3:00 p.m. with the agency Administrator confirmed the above findings.