Every finding on record at Summit View Hospice 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. This standard was not met as evidenced by clinical record review, document review and interview. In 5 of 14 (36%) clinical records reviewed revealed the agency did not ensure an initial bereavement assessment was completed CLINICAL RECORD 1: There was no documented evidence of an initial bereavement assessment. CLINICAL RECORD 2: There was no documented evidence of an initial bereavement assessment. CLINICAL RECORD 3: There was no documented evidence of an initial bereavement assessment. CLINICAL RECORD 11: There was no documented evidence of an initial bereavement assessment. CLINICAL RECORD 14: There was no documented evidence of an initial bereavement assessment. During a joint record review and interview on 06/17/2025, the Clinical Director agreed there was no documented evidence of an initial bereavement assessment. Additionally, the Team Director stated, "We need to figure out how to make it mandatory in the assessment."

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 review clinical record and interview. 7 of 11 (64%) clinical records reviewed revealed the hospice did not ensure the initial bereavement assessments were completed. Record 4: This patient was admitted to hospice on 9/29/2021. The clinical record did not contain an initial bereavement assessment. Record 5: This patient was admitted to hospice on 5/9/2022. The clinical record did not contain an initial bereavement assessment. Record 7: This patient was admitted to hospice on 6/14/2022. The clinical record did not contain an initial bereavement assessment. Record 8: This patient was admitted to hospice on 11/7/2021. The clinical record did not contain an initial bereavement assessment. Record 9: This patient was admitted to hospice on 2/15/2022. The clinical record did not contain an initial bereavement assessment. Record 10: This patient was admitted to hospice on 6/16/2022. The clinical record did not contain an initial bereavement assessment. Record 11: This patient was admitted to hospice on 12/10/2021. The clinical record did not contain an initial bereavement assessment. The Clinical Advisor was interviewed on 7/28/2022 and agreed the initial bereavement assessments were not completed within the records identified. The Administrator was interviewed on 7/28/2022 stated, "we need to update our assessment to require it instead of it being optional." Record 4: This patient was admitted to hospice on 9/29/2021. The clinical record did not contain an initial bereavement assessment. Record 5: This patient was admitted to hospice on 5/9/2022. The clinical record did not contain an initial bereavement assessment. Record 7: This patient was admitted to hospice on 6/14/2022. The clinical record did not contain an initial bereavement assessment. Record 8: This patient was admitted to hospice on 11/7/2021. The clinical record did not contain an initial bereavement assessment. Record 9: This patient was admitted to hospice on 2/15/2022. The clinical record did not contain an initial bereavement assessment. Record 10: This patient was admitted to hospice on 6/16/2022. The clinical record did not contain an initial bereavement assessment. Record 11: This patient was admitted to hospice on 12/10/2021. The clinical record did not contain an initial bereavement assessment. The Clinical Advisor was interviewed on 7/28/2022 stated, the initial bereavement assessments were not completed within the records identified. The Administrator was interviewed on 7/28/2022 stated, "we need to update our assessment to require it instead of it being optional."

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, includes all services necessary for the palliation and management of the terminal illness including intervention to manage pain and symptoms and measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by a review clinical record review and interview. 3 of 11 (27%) clinical records reviewed revealed the hospice did not ensure plans of care included outcomes that were defined and measurable. Clinical Record 1: This patient was admitted to hospice on 2/15/2022. The plan of care on 2/15/2022 was reviewed. Diagnosis Unspecified systolic (congestive) heart failure. Goal: acceptable level of dyspnea. The Clinical Advisor was interviewed on 7/28/2022 and agreed the patient’s acceptable dyspnea level was not identified. Clinical Record 0: This patient was admitted to hospice on 10/14/2021. The plan of care on 6/17/2022 was reviewed. Diagnosis Malignant neoplasm of lower lobe, left bronchus or lung. Goal: acceptable level of dyspnea. The Clinical Advisor was interviewed on 7/28/2022 and agreed the patient’s acceptable dyspnea level was not identified. Clinical Record 10: This patient was admitted to hospice on 6/14/2022. The plan of care on 6/14/2022 was reviewed. Diagnosis Malignant neoplasm of rectum. Goal: pain is reduced to the level personally desired, from complete relief to minimal discomfort. Nursing assessment on 6/14/2022 revealed the patient had pain 7/10. The Clinical Advisor was interviewed on 7/28/2022 and agreed the patient’s acceptable pain level was not identified.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by a review clinical record review and interview. 2 of 7 (29%) records reviewed with a hospice aide ordered revealed, the hospice did not ensure the Registered Nurse provided clear and specific instructions for hospice aide assignments. Record 4: This patient was admitted on 9/29/2021. The hospice aide plan of care completed by the RN on 9/29/2021 assigned “Shower, frequency-other-as requested by patient or family.” Nursing assessment on 9/29/2021 revealed the patient was “oriented to person, disoriented to place time, confused, forgetful” with a comorbidity of dementia. Record 6: This patient was admitted on 4/8/2022. The hospice aide plan of care completed by the RN on 4/8/2022 assigned “Shower, frequency-other-as requested by patient or family.” Nursing assessment on 4/8/2022 revealed the diagnosis senile degeneration of brain. The Clinical Advisor was interviewed on 7/28/2022 and agreed the RN did not assign specific instructions for the aide to follow in the records identified. Record 4: This patient was admitted on 9/29/2021. The hospice aide plan of care completed by the RN on 9/29/2021 assigned “Shower, frequency-other-as requested by patient or family.” Nursing assessment on 9/29/2021 revealed the patient was “oriented to person, disoriented to place time, confused, forgetful” with a co morbidity of dementia. Record 6: This patient was admitted on 4/8/2022. The hospice aide plan of care completed by the RN on 4/8/2022 assigned “Shower, frequency-other-as requested by patient or family.” Nursing assessment on 4/8/2022 revealed the diagnosis senile degeneration of brain. The Clinical Advisor was interviewed on 7/28/2022 stated, the RN did not assign specific instructions for the aide to follow in the records identified.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by a clinical record review and interview. 11 of 11 (100%) clinical records reviewed revealed the hospice did not ensure the hospice election statement included the patient's request or declination of the Patient Notification of Hospice Non-Covered Items, Services, and Drugs. Record 1: This patient was admitted on 10/14/2021. The hospice election statement signed by the patient’s daughter on 10/14/2021 did not include a section for the patient or legal representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 2: This patient was admitted on 5/24/2022. The hospice election statement signed by the patient on 5/24/2022 did not include a section for the patient or legal representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." int 7/26 Record 3: This patient was admitted on 6/22/2021. The hospice election statement signed by the patient on 6/22/2021 did not include a section for the patient or legal representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 4: This patient was admitted on 9/29/2021. The hospice election statement signed by the patient’s daughter on 9/29/2021 did not include a section for the patient or legal representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 5: This patient was admitted on 5/9/2022. The hospice election statement signed by the patient’s daughter on 5/9/2022 did not include a section for the patient or legal representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 6: This patient was admitted on 4/6/2022. The hospice election statement signed by the patient’s mother-in-law on 4/6/2022 did not include a section for the patient or legal representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 7: This patient was admitted on 6/14/2022. The hospice election statement signed by the patient on 6/14/2022 did not include a section for the patient or legal representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 8: This patient was admitted on 11/7/2021. The hospice election statement signed by the patient on 11/7/2021 did not include a section for the patient or legal representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 9: This patient was admitted on 2/15/2022. The hospice election statement signed by the patient on 2/15/2022 did not include a section for the patient or legal representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 10: This patient was admitted on 6/16/2022. The hospice election statement signed by the patient on 6/16/2022 did not include a section for the patient or legal representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 11: This patient was admitted on 12/10/2021. The hospice election statement signed by the patient’s daughter on 12/10/2021 did not include a section for the patient or legal representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." The Registered Nurse Case Manager was interviewed on 7/28/2022 and stated, “I haven’t been offering the addendum.” The Clinical Advisor was interviewed on 7/28/2022 and agreed there was no documentation of the patient’s acceptance or declination of the covered/non covered addendum in the records identified. The Administrator was interviewed on 7/28/2022 stated, the form was updated 10/2021 and is in the patient and family guide but staff continued using the previous copy without the yes and no checkbox. Record 1: This patient was admitted on 10/14/2021. The hospice election statement signed by the patient’s daughter on 10/14/2021 did not include a section for the patient or legal representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 2: This patient was admitted on 5/24/2022. The hospice election statement signed by the patient on 5/24/2022 did not include a section for the patient or legal representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." int 7/26 Record 3: This patient was admitted on 6/22/2021. The hospice election statement signed by the patient on 6/22/2021 did not include a section for the patient or legal representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 4: This patient was admitted on 9/29/2021. The hospice election statement signed by the patient’s daughter on 9/29/2021 did not include a section for the patient or legal representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 5: This patient was admitted on 5/9/2022. The hospice election statement signed by the patient’s daughter on 5/9/2022 did not include a section for the patient or legal representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 6: This patient was admitted on 4/6/2022. The hospice election statement signed by the patient’s mother-in-law on 4/6/2022 did not include a section for the patient or legal representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 7: This patient was admitted on 6/14/2022. The hospice election statement signed by the patient on 6/14/2022 did not include a section for the patient or legal representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 8: This patient was admitted on 11/7/2021. The hospice election statement signed by the patient on 11/7/2021 did not include a section for the patient or legal representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 9: This patient was admitted on 2/15/2022. The hospice election statement signed by the patient on 2/15/2022 did not include a section for the patient or legal representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 10: This patient was admitted on 6/16/2022. The hospice election statement signed by the patient on 6/16/2022 did not include a section for the patient or legal representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 11: This patient was admitted on 12/10/2021. The hospice election statement signed by the patient’s daughter on 12/10/2021 did not include a section for the patient or legal representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." The Registered Nurse Case Manager was interviewed on 7/28/2022 and stated, “I haven’t been offering the addendum.” The Clinical Advisor was interviewed on 7/28/2022 and stated, there is no documentation of the patient’s acceptance or declination of the covered/non covered addendum in the records identified. The Administrator was interviewed on 7/28/2022 stated, the form was updated 10/2021 and is in the patient and family guide but staff were using the previous copy without the yes and no checkbox.