Interim Healthcare Hospice - Sacramento Area

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the hospice did not ensure that the interdisciplinary group completed the comprehensive assessment no later than five (5) calendar days after the election of hospice care. Clinical Record 9: The patient elected hospice care on 11/22/2023. The need for a Spiritual Care (SC) and a Medical Social Worker (MSW) evaluation was documented in the comprehensive assessment. The Chaplain documented their initial visit on 11/28/2023, six (6) days after the election of hospice care. The MSW documented their initial visit on 11/28/2023, six (6) days after the patient’s election of hospice care. There was no documentation as to why the assessments were not completed within five (5) calendar days of the patient’s election of hospice care. Clinical Record 18: The patient elected hospice care on 02/21/2022. The need for a SC evaluation was documented in the comprehensive assessment. The Chaplain documented their initial assessment on 07/21/2022, 150 days after the patient’s election of hospice care. There was no documentation as to why the assessment was not completed within five (5) calendar days of the patient’s election of hospice care. During interviews on 02/06/2024 and 02/07/2024, the Administrator and the Registered Nurse (RN)/Quality Assurance (QA) confirmed the findings. In 2 of 19 (11%) clinical records reviewed in which a comprehensive assessment was performed, revealed the hospice did not ensure that the interdisciplinary group completed the comprehensive assessment within 5 calendar days after the election of hospice care.”

“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 clinical record review and interview. In 8 of 19 (42%) clinical records reviewed, the hospice did not ensure that the interdisciplinary group completed the initial bereavement risk assessment. Clinical Record 1: The patient elected hospice care on 10/14/2023. There was no evidence that an initial bereavement risk assessment was completed. Clinical Record 3: The patient elected hospice care on 10/01/2023. There was no evidence that an initial bereavement risk assessment was completed. Clinical Record 6: The patient elected hospice care on 10/16/2023. There was no evidence that an initial bereavement risk assessment was completed. Clinical Record 9: The patient elected hospice care on 11/22/2023. The initial bereavement assessment was documented on 12/27/2023, with 35 days outstanding. Clinical Record 10: The patient elected hospice care on 12/13/2023. There was no evidence that an initial bereavement risk assessment was completed. Clinical Record 15: The patient elected hospice care on 06/14/2023. There was no evidence that an initial bereavement risk assessment was completed. Clinical Record 16: The patient elected hospice care on 04/16/2023. There was no evidence that an initial bereavement risk assessment was completed. Clinical Record 17: The patient elected hospice care on 04/26/2023. There was no evidence that an initial bereavement risk assessment was completed. During interviews on 02/06/2024 and 02/07/2024, the Administrator and the Registered Nurse (RN)/Quality Assurance (QA) confirmed the findings. In 8 of 19 (42%) clinical records reviewed it was revealed that the hospice did not ensure that the interdisciplinary group completed the initial bereavement risk assessment.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed in which a hospice aide (HA) provided services, the hospice did not ensure a Registered Nurse (RN) supervised the HA no less frequently than every 14 days. Clinical Record 5: The patient elected hospice care on 10/09/2023. The HA care plan dated 10/09/2023 ordered HA services three (3) times a week. A clinical record review revealed no documentation of HA supervisory visits between 12/18/2023 and 01/02/2024. The RN documented a HA supervision on 01/03/2024, with 15 days outstanding. During interviews on 02/06/2024 and 02/07/2024, the Administrator and the Registered Nurse (RN)/Quality Assurance (QA) confirmed the findings. In 1 of 14 (7%) clinical records reviewed in which a hospice aide (HA) provided services, revealed that a registered nurse (RN) did not perform HA supervisory visits.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are noted in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 14 of 19 (79%) clinical records reviewed, the hospice did not ensure that volunteer services were offered. Clinical Record 1: The patient’s benefit election was dated 10/14/2023. There was no documentation that a volunteer was offered or declined. Clinical Record 2: The patient’s benefit election was dated 10/04/2023. There was no documentation that a volunteer was offered or declined. Clinical Record 3: The patient’s benefit election was dated 10/01/2023. There was no documentation that a volunteer was offered or declined. Clinical Record 6: The patient’s benefit election was dated 10/16/2023. There was no documentation that a volunteer was offered or declined. Clinical Record 8: The patient’s benefit election was dated 11/10/2023. There was no documentation that a volunteer was offered or declined. Clinical Record 11: The patient’s benefit election was dated 10/12/2023. There was no documentation that a volunteer was offered or declined. Clinical Record 12: The patient’s benefit election was dated 11/22/2023. There was no documentation that a volunteer was offered or declined. Clinical Record 13: The patient’s benefit election was dated 10/12/2023. There was no documentation that a volunteer was offered or declined. Clinical Record 14: The patient’s benefit election was dated 12/18/2023. There was no documentation that a volunteer was offered or declined. Clinical Record 15: The patient’s benefit election was dated 06/14/2023. There was no documentation that a volunteer was offered or declined. Clinical Record 16: The patient’s benefit election was dated 04/16/2023. There was no documentation that a volunteer was offered or declined. Clinical Record 17: The patient’s benefit election was dated 04/26/2023. There was no documentation that a volunteer was offered or declined. Clinical Record 18: The patient’s benefit election was dated 02/21/2022. There was no documentation that a volunteer was offered or declined. Clinical Record 19: The patient’s benefit election was dated 03/14/2023. There was no documentation that a volunteer was offered or declined. During interviews on 02/06/2024 and 02/07/2024, the Administrator and the Registered Nurse (RN)/Quality Assurance (QA) confirmed the findings. In 14 of 19 (79%) clinical records revealed there was no evidence that a volunteer was offered and/or the patient declined volunteer services.”