Sierra Hospice & Palliative Care of Nevada, LLC

“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 3 of 14 (21%) clinical records reviewed that received hospice services at least five (5) days revealed the agency did not ensure that the hospice interdisciplinary group (IDG) completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. CLINICAL RECORD 5: The patient elected the hospice benefit on 01/10/2026. The record lacked evidence of the spiritual counselor (SC) completing an initial assessment within the five (5) day window. The record also lacked evidence of the patient/family refusing or postponing the SC initial patient assessment during the 5-day window. There was evidence of a Spiritual initial assessment completed by the SC on 01/17/2026 (Day 7). CLINICAL RECORD 7: The patient elected the hospice benefit on 03/03/2025. The record lacked evidence of the spiritual counselor (SC) completing an initial assessment within the five (5) day window. The record also lacked evidence of the patient/family refusing or postponing the SC initial patient assessment during the 5-day window. There was evidence of a Spiritual initial assessment completed on 01/17/2026 (Day 11). CLINICAL RECORD 11: The patient elected the hospice benefit on 10/02/2025. The record lacked evidence of the spiritual counselor (SC) completing an initial assessment within the five (5) day window. The record also lacked evidence of the patient/family refusing or postponing the SC initial patient assessment during the 5-day window. There was evidence of a Spiritual initial assessment completed on 10/09/2025 (Day 7). The Administrator/Director of Patient Care Services (DPCS)/Nurse Practitioner (NP), Alternative DPCS/Registered Nurse Case Manager (RNCM), and Alternate Administrator/Master of Social Work/Bereavement Coordinator/Volunteer Coordinator stated in an interview on 06/3/2026 that the SC did not complete the initial Spiritual assessment within the required initial 5-day comprehensive 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. This standard was not met as evidenced by clinical record review and interview. In 14 of 14 (100%) clinical records reviewed that received hospice services at least five (5) days revealed the agency did not ensure that an initial bereavement assessment was completed as part of the initial comprehensive assessment. CLINICAL RECORD 1: The patient elected the hospice benefit on 05/28/2026. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. CLINICAL RECORD 2: The patient elected the hospice benefit on 05/04/2026. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. CLINICAL RECORD 3: The patient elected the hospice benefit on 03/19/2026. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. CLINICAL RECORD 4: The patient elected the hospice benefit on 02/25/2026. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. CLINICAL RECORD 5: The patient elected the hospice benefit on 01/10/2026. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. CLINICAL RECORD 6: The patient elected the hospice benefit on 12/29/2025. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. CLINICAL RECORD 7: The patient elected the hospice benefit on 03/03/2025. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. CLINICAL RECORD 8: The patient elected the hospice benefit on 04/24/2026. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. CLINICAL RECORD 9: The patient elected the hospice benefit on 11/17/2025. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. CLINICAL RECORD 10: The patient elected the hospice benefit on 10/31/2025. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. CLINICAL RECORD 11: The patient elected the hospice benefit on 10/02/2025. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. CLINICAL RECORD 12: The patient elected the hospice benefit on 04/04/2025. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. CLINICAL RECORD 13: The patient elected the hospice benefit on 05/18/2026. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. CLINICAL RECORD 14: The patient elected the hospice benefit on 04/28/2026. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. The Administrator/Director of Patient Care Services (DPCS)/Nurse Practitioner (NP), Alternative DPCS/Registered Nurse Case Manager (RNCM), and Alternate Administrator/Master of Social Work/Bereavement Coordinator/Volunteer Coordinator stated in an interview on 06/3/2026 that the clinical records were missing an initial bereavement assessment as required by regulation during the 5-day comprehensive assessment window. The Administrator/DPCS/NP stated, “The initial bereavement assessment has been added to all existing active patients and is now set-up to be assigned to the admission RN and will be completed as required.” It was also stated that the Bereavement Coordinator / MSW had been doing an initial bereavement assessment of sorts on an excel spreadsheet just not officially in the record - the EMR had changed and so that’s why it got missed. The bereavement assessment was immediately added to the clinical records before the visit ended.”