Bridgewater Hospice

Timeframe for completion of assessment (42 CFR 418.54(b))

“Upon patient record review 1 of 14 (Patient #1) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #1 - Patient was admitted on 12/05/25. The spiritual comprehensive assessment was not completed until 12/17/25.”

Rule L0523. Standard-level.

Content of comprehensive assessment (42 CFR 418.54(c))

“Upon patient record review 1 of 14 (Patient #12) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. Patient #12 - Patient was admitted on 02/18/25. There is no evidence of an psychosocial comprehensive assessment in the medical record. The elements of that comprehensive were not captured in the nursing comprehensive dated 02/18/25.”

Rule L0524. Standard-level.

Approach to service delivery (42 CFR 418.56(a)(1))

Rule L0540. Standard-level.

Content of plan of care (42 CFR 418.56(c))

Rule L0545. Standard-level.

Content of plan of care (42 CFR 418.56(c)(2))

Rule L0547. Standard-level.

Content of plan of care (42 CFR 418.56(c)(4))

“Upon patient record review, 1 of 14 (Patient #7) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #7 - The nursing comprehensive dated 12/18/24 documented patient’s diet as a pureed diet with thickened liquids. There was no evidence of an order on the patient’s plan of care for this diet.”

Rule L0549. Standard-level.

Content of plan of care (42 CFR 418.56(c)(5))

“Upon patient record review, 1 of 14 (Patient #6) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #6 - The medication profile indicated patient was on nebulized albuterol and ipratropium. There was no evidence of a nebulizer on the plan of care.”

Rule L0550. Standard-level.

Coordination of services (42 CFR 418.56(e)(2))

“Upon client record review, 1 of 14 (Patient #12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #12 - The initial plan of care dated 02/18/25, contained an order for spiritual care assessments to be completed monthly. Spiritual care assessments were completed on 02/21/25, 04/16/25, and 06/16/25. There was no evidence of assessments completed in March or May.”

Rule L0555. Standard-level.

Hospice aide assignments and duties (42 CFR 418.76(g)(2))

Rule L0626. Standard-level.

Discharge or transfer of care (42 CFR 418.104(e))

“Upon client record review, 1 of 14 (Patient #11) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #11 - Patient signed a transfer form transferring to another hospice on 05/12/25. There was no evidence indicating that transfer form or summary was forwarded to the receiving hospice.”

Rule L0682. Standard-level.

Discharge or transfer of care (42 CFR 418.104(e)(2))

“Upon client record review, 1 of 14 (Patient #11) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient’s attending physician: • A copy of the hospice discharge summary • The patient’s clinical record, if requested Patient #11 - The discharge summary dated 05/12/25, stated “tx to another hospice”. There was no evidence this summary was sent to patient’s attending MD.”

Rule L0683. Standard-level.

Discharge or transfer of care (42 CFR 418.104(e)(3))

“Upon client record review, 2 of 14 (Patient #11,12) did not have evidence that the discharge summary includes all required information. Patient #11 - The discharge summary dated 05/12/25, stated “tx to another hospice”. The summary did not include the necessary elements of the discharge summary. Patient #12 - The medical record indicated the patient was discharged due to extended prognosis on 06/17/25. There was no evidence that the discharge summary was completed.”

Rule L0684. Standard-level.