Every finding on record at Victory Hospice

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 a review of clinical records, document review, and interviews. 1 of 11 (9%) clinical records reviewed revealed the hospice did not ensure that an initial bereavement assessment was completed as part of the comprehensive assessment, as per the hospice's policy. The hospice's policy #1-021, "Bereavement Assessment" (11/2020), stated in part, "Procedure.. … On admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that is given to the Bereavement Coordinator." Clinical Record 3: The patient elected hospice care on 3/12/21. The record did not include a completed initial bereavement assessment as part of the comprehensive assessment. The initial bereavement assessment was completed on 4/7/21, 26 days after the patient elected hospice care. During an interview on 12/6/22, the Administrator/Director of Patient Care Services (DPCS) and the Administrator/DPCS designee both reviewed and agreed with the above finding. They both reported that this finding was identified by the agency prior to this site visit, and a performance improvement plan has been developed, and in process of being implemented.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. 4 of 4 (100%) clinical records reviewed for patients receiving routine hospice care in a Skilled Nursing Facility (SNF) revealed the hospice did not ensure the hospice plan of care (POC) identified the care and services that are needed and specified which provider is responsible for performing the functions. The hospice's policy #1-030, "Provision of Care to Residents of SNF/NF or ICF/IID" (11/2020), stated in part, "Procedure... Identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions." Clinical Record 8: The patient elected hospice care on 8/18/21. The plan of care did not specify which provider was responsible for performing the functions that were agreed upon and included in the plan of care. Clinical Record 7: The patient elected hospice care on 10/21/21. The plan of care did not specify which provider was responsible for performing the functions that were agreed upon and included in the plan of care. Clinical Record 11: The patient elected hospice care on 2/22/21. The plan of care did not specify which provider was responsible for performing the functions that were agreed upon and included in the plan of care. Clinical Record 9: The patient elected hospice care on 6/14/22. The plan of care did not specify which provider was responsible for performing the functions that were agreed upon and included in the plan of care. During an interview on 12/7/22, the Administrator/Director of Patient Care Services (DPCS) and the Administrator/DPCS Designee both reviewed and agreed with the above findings.