A Change of Seasons Hospice, Inc.

“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. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records reviewed, the agency did not ensure that the hospice Interdisciplinary Group completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. CLINICAL RECORD 2: A review of the clinical record revealed that the patient elected the hospice benefit, was admitted to hospice service, and the comprehensive nursing assessment was documented on 04/24/2025. The nursing assessment did not include a psychosocial or spiritual assessment. Documentation that the patient declined Spiritual Counselor (SC) services was present. The initial Social Work (SW) assessment was documented on 05/01/2025 (day 7). The SW assessment included a psychological and spiritual assessment; however, the comprehensive assessment was not completed within five (5) calendar days after the election of hospice care. CLINICAL RECORD 3: A review of the clinical record revealed that the patient elected the hospice benefit, was admitted to hospice service, and the comprehensive nursing assessment was documented on 10/24/2024. The nursing assessment did not include a psychosocial or spiritual assessment. Documentation that the patient declined Spiritual Counselor (SC) services was present. The initial Social Work (SW) assessment was documented on 10/31/2024 (day 7). The SW assessment included a psychological and spiritual assessment; however, the comprehensive assessment was not completed within five (5) calendar days after the election of hospice care. CLINICAL RECORD 4: A review of the clinical record revealed that the patient elected the hospice benefit, was admitted to hospice service, and the comprehensive nursing assessment was documented on 07/01/2025. The nursing assessment did not include a psychosocial or spiritual assessment. The initial spiritual counselor assessment was documented on 07/09/2025 (day 8). The initial Social Work (SW) assessment was documented on 07/12/2025 (day 11). The comprehensive assessment was not completed within five (5) calendar days after the election of hospice care. CLINICAL RECORD 6: A review of the clinical record revealed that the patient elected the hospice benefit, was admitted to hospice service, and the comprehensive nursing assessment was documented on 06/20/2025. The nursing assessment did not include a psychosocial or spiritual assessment. Documentation that the patient declined Spiritual Counselor (SC) services was present. The initial Social Work (SW) assessment was documented on 07/22/2025 (day 32). The SW assessment included a psychological and spiritual assessment; however, the comprehensive assessment was not completed within five (5) calendar days after the election of hospice care. CLINICAL RECORD 14: A review of the clinical record revealed that the patient elected the hospice benefit, was admitted to hospice service, and the comprehensive nursing assessment was documented on 05/17/2025. The nursing assessment did not include a psychosocial or spiritual assessment. Documentation was present in the record that the patient declined both Social Work and Spiritual Counselor services. The comprehensive assessment was not completed within five (5) calendar days after the election of hospice care. The Alternate Administrator (Personnel Record 3) was interviewed on 07/30/2025 and stated, “There were reasons for the delay in the services, such as the patient requested a later visit by the social worker or the chaplain, but it wasn’t documented in the chart. The nursing assessment in the EMR (electronic medical record) does not have a place for the nurse to document a psychosocial or spiritual assessment.””

“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, document review, and interview. In 5 of 14 (36%) clinical records reviewed, the agency did not ensure that the initial comprehensive included an assessment of the bereavement needs. Agency Policy #2026, Bereavement Services (Dated 04/01/2019), stated in part, “An initial bereavement risk assessment will be performed as part of the comprehensive assessment. Depending on the initial assessment, a plan of care will be developed to include specific counseling to patient and family members to be provided by the social worker, chaplain, or bereavement counselor. The [bereavement] plan of care will reflect family needs, as well as clear delineation of services to be provided and the frequency of service delivery.” CLINICAL RECORD 2: A review of the clinical record revealed that the patient elected the hospice benefit, was admitted to hospice service, and the comprehensive nursing assessment was documented on 04/24/2025. The initial Social Work (SW) assessment, with the bereavement risk assessment, was documented on 05/01/2025 (day 7). The comprehensive assessment, to include the bereavement risk assessment, was not completed within five (5) calendar days after the election of hospice care. CLINICAL RECORD 3: A review of the clinical record revealed that the patient elected the hospice benefit, was admitted to hospice service, and the comprehensive nursing assessment was documented on 10/24/2024. The initial Social Work (SW) assessment, with the bereavement risk assessment, was documented on 10/31/2024 (day 7). The comprehensive assessment, to include the bereavement risk assessment, was not completed within five (5) calendar days after the election of hospice care. CLINICAL RECORD 4: A review of the clinical record revealed that the patient elected the hospice benefit, was admitted to hospice service, and the comprehensive nursing assessment was documented on 07/01/2025. The initial Social Work (SW) assessment, with the bereavement risk assessment, was documented on 07/12/2025 (day 11). The comprehensive assessment, to include the bereavement risk assessment, was not completed within five (5) calendar days after the election of hospice care. CLINICAL RECORD 6: A review of the clinical record revealed that the patient elected the hospice benefit, was admitted to hospice service, and the comprehensive nursing assessment was documented on 06/20/2025. The initial Social Work (SW) assessment, with the bereavement risk assessment, was documented on 07/22/2025 (day 32). The comprehensive assessment, to include the bereavement risk assessment, was not completed within five (5) calendar days after the election of hospice care. CLINICAL RECORD 14: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 05/17/2025. Documentation in the record indicated that the patient declined both Social Work and Spiritual Counselor services. No initial bereavement assessment was documented, as it is embedded only in the Social Work initial visit assessment note. There was no other documentation in the record that an initial bereavement assessment was completed. The Administrator was interviewed on 07/30/2025 and stated, “The nursing assessment does not currently include a bereavement assessment. We will ask the software vendor to add a bereavement assessment to the nursing assessment.””