Mary’s Help Hospice Services

“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 document review, clinical record review, and interview. In 5 of 14 (36%) clinical records reviewed, the agency did not ensure the comprehensive assessment included 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. Agency policy No 9-023 Bereavement Services, dated November 2024, required in part, “1. A bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice.” CLINICAL RECORD 1: The patient elected the hospice benefit on 06/23/2025 with a diagnosis of senile degeneration of the brain. Review of the comprehensive assessment revealed no documented evidence that an initial bereavement assessment was completed for the patient’s family or other individuals that could be impacted by the patient’s death. CLINICAL RECORD 3: The patient elected the hospice benefit on 09/19/2025 with a diagnosis of Alzheimer’s disease. Review of the comprehensive assessment revealed no documented evidence that an initial bereavement assessment was completed for the patient’s family or other individuals that could be impacted by the patient’s death. CLINICAL RECORD 4: The patient elected the hospice benefit on 05/23/2025 with a diagnosis of senile degeneration of the brain. Review of the comprehensive assessment revealed no documented evidence that an initial bereavement assessment was completed for the patient’s family or other individuals that could be impacted by the patient’s death. CLINICAL RECORD 5: The patient elected the hospice benefit on 10/15/2025 for a diagnosis of senile degeneration of the brain. A clinical record review on 12/23/2025 revealed the comprehensive assessment did not include documentation of an initial bereavement assessment. CLINICAL RECORD 8: The patient elected the hospice benefit on 06/14/2025 with a diagnosis of Alzheimer’s disease. Review of the comprehensive assessment revealed no documented evidence that an initial bereavement assessment was completed for the patient’s family or other individuals that could be impacted by the patient’s death. During a joint clinical record review and interview on 12/24/2025, the Administrator/Director of Patient Care Services agreed the initial bereavement assessments had not been completed and stated, “I could have done them if I had known they were not going.””

“It is required that the hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG (interdisciplinary group) in collaboration with the attending physician (if any), the patient or representative if any of them so desire, and the primary caregiver in accordance with the patient’s needs if any of them so desire. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure hospice care and services followed the individualized plan of care. CLINICAL RECORD 6: The patient elected the hospice benefit on 06/25/2025 for a diagnosis of malignant neoplasm of overlapping sites of esophagus. The plan of care dated 06/25/2025 included an intervention for Registered Nurse (RN) visit frequency of every 14 days. A review of the clinical record revealed a comprehensive RN visit was completed on 06/25/2025, and the next RN visit was documented on 07/15/2025, a total of 20 days and 5 days outstanding. CLINICAL RECORD 8: The patient elected the hospice benefit on 06/14/2025 with a diagnosis of Alzheimer’s disease. The plan of care dated 06/14/2025 included an intervention for RN visit frequency of every 14 days. A review of the clinical record revealed a comprehensive RN visit was completed on 06/14/2025, and the next RN visit was documented on 07/01/2025, a total of 17 days and 2 days outstanding. During a joint clinical record review and interview on 12/24/2025, the Administrator/Director of Patient Care Services confirmed the missed or late Registered Nurse visits and stated they “previously had a LVN (licensed vocational nurse) who worked in the office who had been responsible for scheduling, and she must have missed these visits.” She further went on to state “it’s disappointing as I am available to do them.””

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by document review, clinical record review, and interview. In 5 of 9 (56%) clinical records reviewed with bereavement services applicable, the agency did not ensure a bereavement plan of care was developed that included the types of bereavement services offered. Agency policy No 9-023 Bereavement Services, dated November 2024, required in part, “1. A bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice. …5. After a death has occurred, the bereavement assessment will be updated. … 10. Within three to five weeks after a patient’s death, a bereavement assessment will be completed. … 13. A bereavement file will be maintained on each family/caregiver unit of care. Each file will contain the following information: a. Copy of the referral and initial bereavement risk assessment. b. Bereavement service report. c. All bereavement assessments made. d. A bereavement plan of care. e. All bereavement clinical notes.” CLINICAL RECORD 6: The patient elected the hospice benefit on 06/25/2025 with a diagnosis of malignant neoplasm of overlapping sites of esophagus and died on 07/16/2025. Clinical record review revealed no documented evidence of a post-death bereavement assessment and no documented evidence that a post-death bereavement plan of care was developed. The clinical record did not contain a coordination or clinical note that indicated why these had not been completed. CLINICAL RECORD 7: The patient elected the hospice benefit on 04/30/2025 with a diagnosis of malignant neoplasm of the prostate and died on 05/18/2025. Clinical record review revealed no documented evidence of a post-death bereavement assessment and no documented evidence that a post-death bereavement plan of care was developed. The clinical record did not contain a coordination or clinical note that indicated why these had not been completed. CLINICAL RECORD 8: The patient elected the hospice benefit on 06/14/2025 with a diagnosis of Alzheimer’s disease and died on 08/03/2025. Clinical record review revealed no documented evidence of a post-death bereavement assessment and no documented evidence that a post-death bereavement plan of care was developed. The clinical record did not contain a coordination or clinical note that indicated why these had not been completed. CLINICAL RECORD 12: The patient elected the hospice benefit on 06/18/2025 with a diagnosis of hypertensive heart and chronic kidney disease and died on 10/10/2025. Clinical record review revealed no documented evidence of a post-death bereavement assessment and no documented evidence that a post-death bereavement plan of care was developed. The clinical record did not contain a coordination or clinical note that indicated why these had not been completed. CLINICAL RECORD 14: The patient elected the hospice benefit on 05/10/2025 with a diagnosis of pulmonary embolism and died on 05/27/2025. Clinical record review revealed no documented evidence of a post-death bereavement assessment and no documented evidence that a post-death bereavement plan of care was developed. The clinical record did not contain a coordination or clinical note that indicated why these had not been completed. During a joint clinical record review and interview on 12/24/2025, the Administrator/Director of Patient Care Services stated, “They have other jobs, and I try to get them to make sure these are done.””

“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 clinical record review and interview. In 3 of 10 (30%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse (RN) provided patient specific written instructions for the hospice aide. CLINICAL RECORD 3: The hospice aide care plan dated 09/19/2025 assigned the aide the following tasks: “Assist to dress, complete bed bath, comb hair, peri care, shampoo hair, skin care, back rub/massage, oral hygiene, check pressure areas, shower, make bed, assist in transfer, incontinent care, record last bowel movement.” The hospice aide care plan did not include instructions to the aide that specified which bath type to provide when a complete bed bath and shower were both assigned in the aide care plan. CLINICAL RECORD 4: The hospice aide care plan dated 05/23/2025 assigned the aide the following tasks: “Assist to dress, complete bed bath, comb hair, peri care, shampoo hair, skin care-lotion to skin, back rub/massage, oral hygiene, check pressure areas, partial bath/shower, make bed, assist in transfer if patient agrees, turn or position, range of motion, incontinent care, record last bowel movement.” The hospice aide care plan did not include instructions to the aide that specified which bath type to provide when a complete bed bath and partial bath/shower were both assigned in the aide care plan. CLINICAL RECORD 6: The hospice aide care plan dated 06/25/2025 assigned the aide the following tasks: “Assist to dress, complete bed bath-if patient did not shower, comb hair, peri care, shampoo hair, skin care, back rub/massage, oral hygiene, check pressure areas, shave, shower, change linens-once a week, make bed, assist in ambulation, assist in transfer, turn or position, range of motion, incontinent care, record last bowel movement.” The hospice aide care plan did not include instructions to the aide that specified which bath type to provide when a complete bed bath and shower were both assigned in the aide care plan. During a joint clinical record review and interview on 12/24/2025, the Administrator/Director of Patient Care Services stated “sometimes patients were too tired or didn’t want one type of bath or another, but I understand why the nurse needs to make a decision on the bath type and not leave it up to the aide especially if the patient was confused. It could be a safety issue.””

“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 to assess the quality of care and services provided by the hospice aide, ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 3 of 10 (30%) clinical records reviewed with hospice aide services provided, the agency did not ensure a Registered Nurse (RN) made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide. CLINICAL RECORD 2: The patient elected the hospice benefit on 12/02/2025 with a diagnosis of senile degeneration of the brain. Clinical record review revealed hospice aide visits began on 12/02/2025. Hospice aide visits were ordered at a frequency of twice a week. As of the date of record review on 12/23/2025, there was no documented evidence in the clinical record that an aide supervisory visit had been completed by the RN. A total of 21 days and 7 days outstanding. CLINICAL RECORD 4: The patient elected the hospice benefit on 05/23/2025 with a diagnosis of senile degeneration of the brain. Clinical record review revealed the RN documented an aide supervisory visit on 06/03/2025, and the next aide supervisory visit was documented by the RN on 06/27/2025, a total of 24 days and 10 days outstanding. CLINICAL RECORD 6: The patient elected the hospice benefit on 06/25/2025 with a diagnosis of malignant neoplasm of overlapping sites of esophagus. Clinical record review revealed the hospice aide documented aide visits were provided three times a week, from 06/29/2025 through 07/16/2025. As of the date of record review on 12/23/2025, there was no documented evidence in the clinical record that an aide supervisory visit had been completed by the RN. During a joint clinical record review and interview on 12/24/2025, the Administrator/Director of Patient Care Services confirmed the missed or late Registered Nurse supervisory visits. The Administrator stated they “previously had a LVN (licensed vocational nurse) who worked in the office who had been responsible for scheduling, and she must have missed these visits.” She further went on to state “it’s disappointing as I am available to do them.””