Beth Israel Lahey Health at Home

“Based on record review, policy review and staff interview, the agency failed to ensure initial bereavement risk assessments were completed upon admission for 6 patients (#1, #2, #8, #11, #9, and #4), out of a total sample of 27 patients. Findings include:Review of the agency policy titled “Comprehensive Assessment”, with revised date of 11/7/2024, indicated the following:During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient’s clinical record, including at least the following information, as relevant.*A bereavement assessment of the needs of the patient’s family and other individuals focusing on:-the nature of the relationship to the patient.-circumstances surrounding the illness/prognosis.-behaviors prior and after the illness/prognosis.-survivors need (social, spiritual and cultural) that may impact coping skills.-potential for pathological grief reactions.1.Patient #1 was admitted to the agency in December 2025 with a diagnosis of Alzheimer’s Disease, Demetia with Behavioral Disturbances.Review of the clinical record did not contain documentation that an initial bereavement risk assessment was completed upon admission. 2.Patient #2 was admitted to the agency in November 2025 with a diagnosis of interstitial lung disease.Review of the clinical record did not contain documentation that an initial bereavement risk assessment was completed upon admission. 3.Patient #8 was admitted to the agency in December 2025 with a diagnosis of mild vascular dementia with anxiety.Review of the clinical record did not contain documentation that an initial bereavement risk assessment was completed upon admission. 4.Patient #11 was admitted to the agency in January 2026 with a diagnosis of vascular dementia without behavioral disturbances.Review of the clinical record did not contain documentation that an initial bereavement risk assessment was completed upon admission. During an interview on 2/7/26 at 11:40 A.M., the Executive Director of Quality Compliance and Education reviewed the clinical records for Patient’s #1, #2, #8, and #11 and said the initial bereavement risk assessments were not completed upon admission, as required. Findings include:Review of the agency policy titled “Comprehensive Assessment”, with revised date of 11/7/2024, indicated the following:During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient’s clinical record, including at least the following information, as relevant.*A bereavement assessment of the needs of the patient’s family and other individuals focusing on:-the nature of the relationship to the patient.-circumstances surrounding the illness/prognosis.-behaviors prior and after the illness/prognosis.-survivors need (social, spiritual and cultural) that may impact coping skills.-potential for pathological grief reactions.1.Patient #1 was admitted to the agency in December 2025 with a diagnosis of Alzheimer’s Disease, Demetia with Behavioral Disturbances.Review of the clinical record did not contain documentation that an initial bereavement risk assessment was completed upon admission. 2.Patient #2 was admitted to the agency in November 2025 with a diagnosis of interstitial lung disease.Review of the clinical record did not contain documentation that an initial bereavement risk assessment was completed upon admission. 3.Patient #8 was admitted to the agency in December 2025 with a diagnosis of mild vascular dementia with anxiety.Review of the clinical record did not contain documentation that an initial bereavement risk assessment was completed upon admission. 4.Patient #11 was admitted to the agency in January 2026 with a diagnosis of vascular dementia without behavioral disturbances.Review of the clinical record did not contain documentation that an initial bereavement risk assessment was completed upon admission. During an interview on 2/6/26 at 11:40 A.M., the Executive Director of Quality Compliance and Education reviewed the clinical records for Patient’s #1, #2, #8, and #11 and said the initial bereavement risk assessments were not completed upon admission, as required.5.Patient #4 was admitted to the agency in November 2025 with a diagnosis of Cholangiocarcinoma (cancer forming in the bile ducts) and metastatic to the lung.Review of the clinical record did not contain documentation that an initial bereavement risk assessment was completed upon admission. During an interview on 2/6/26 at 8:30 A.M., the Executive Director of Quality Compliance and Education said she was aware that the initial bereavement risk assessments was not completed upon admission, as required.6.Patient #9 was admitted to the agency in November 2025 with a diagnosis of cancer of the right breast metastatic to the bone.Review of the clinical record did not contain documentation that an initial bereavement risk assessment was completed upon admission.During an interview on 2/6/26 at 9:30 A.M., the Hospice Manager said that the bereavement risk assessment was not completed upon admission, as required.”

“Based on interview and document review, the agency failed to ensure that services were provided in accordance with the plan of care for 2 patients (#9 and #10), out of a total sample of 27 patients.Findings include: Review of the agency policy, titled, Missed Visits, revised 11/7/24, included the following:*Missed visits will be communicated to the Interdisciplinary Group and/or the attending physician. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record.1.Patient #9 was admitted to the agency in November 2025 with a diagnosis of Cholangiocarcinoma (cancer forming in the bile ducts) and metastatic to the lung.Review of the physician ordered plan of care for 11/5/25 to 2/2/26 and 2/3/26 to 5/3/26 included the following:*Skilled Nursing 1-3 visits a week for 14 weeks.Review of the clinical record failed to include documentation that Skilled Nursing visits were provided for the week of 12/7/25 or 12/21/25.During an interview on 2/6/26 at 9:30 A.M., the Hospice Manager said that she was not able to find documentation in the clinical record to indicate why the Skilled Nursing visits were not provided.2.Patient #10 was admitted to the agency in November 2025 with a diagnosis of Severe Late Onset Alzheimer’s Disease.Review of the physician ordered plan of care for 11/23/25 to 2/20/26 included the following:*Medical Social Worker 1-3 visits per month for 4 months.Review of the clinical record failed to include documentation that Medical Social Worker visits were provided for the month of December or January.During an interview on 2/6/26 at 10:30 A.M., the Hospice Manager said that she was not able to find documentation in the clinical record to indicate why the Medical Social Worker visits were not provided.”