Big Sky Hospice

“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, document review and interview. 3 of 6 (50%) clinical records reviewed revealed the agency did not ensure completion of the initial comprehensive assessments within five calendar days after the election of hospice care. DOCUMENT 1: The agency’s policy 4-042, titled Comprehensive Assessment, dated November 2022, stated in part, “A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after election of hospice care.” CLINICAL RECORD 1: The patient elected the hospice benefit on September 5, 2025. The initial comprehensive nursing assessment was completed on September 5, 2025. The initial psychosocial assessment was completed on September 9, 2025. The initial spiritual care assessment was completed on October 8, 2025 (33 calendar days from the initial nursing comprehensive assessment). During the review of the clinical record, no documentation was found to determine the reason for the delayed spiritual care assessment. CLINICAL RECORD 2: The patient elected the hospice benefit on October 15, 2025. The initial comprehensive nursing assessment was completed on October 15, 2025. The initial psychosocial assessment was completed on October 15, 2025. The initial spiritual assessment was completed on October 28, 2025 (13 calendar days from the initial nursing comprehensive assessment). During the clinical record review, no documentation was found to determine the reason for the delayed spiritual care assessment. CLINICAL RECORD 3: The patient elected the hospice benefit on October 17, 2025. The initial comprehensive nursing assessment was completed on October 17, 2025. The initial psychosocial assessment was completed on October 17, 2025. The initial spiritual assessment was completed on October 24, 2025 (7 calendar days from the initial nursing comprehensive assessment). During the clinical record review, no documentation was found to determine the reason for the delayed spiritual care assessment. An interview with the Clinical Director was conducted on December 2, 2025. She acknowledged that the clinical records do not reflect the reason for the delay in the initial spiritual assessments, and the agency had identified the issue before the site visit.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription drugs. This standard was not met as evidenced by clinical record review, document review and observation. 2 of 3 (67%) home visits observed revealed that the agency did not ensure the comprehensive assessments included a drug profile that contained the patient’s current prescription drugs. DOCUMENT 2: The agency’s policy 4-050 titled Medication Profile, dated November 2022, stated in part, “The medication profiles will be updated for each change to reflect current medications.” Additionally stated in part, “a drug regimen review will be performed by a registered nurse at the time of initial and comprehensive assessments are performed.” HOME VISIT 1: On an observed home visit with the registered nurse (PERSONNEL RECORD 1), dated December 3, 2025, the caregiver/spouse provided all prescribed medications for review. It was found that a medication the patient is currently using was not listed on the agency’s medication profile: Oxybutynin chloride ER 10 mg, once daily, dispensed on November 12, 2025. HOME VISIT 2: On an observed home visit with the hospice aide (PERSONNEL RECORD 2), dated December 3, 2025, the caregiver/spouse provided all prescribed medications for review. It was found that two medications the patient is currently using were not listed on the agency’s medication profile: Cymbalta 60 mg, administered once daily, dispensed on October 1, 2025, and Lorazepam 1 mg, administered once daily, dispensed on November 20, 2025.”