New Hope Hospice

“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 5 of 5 (100%) clinical records reviewed revealed the agency did not ensure that an initial bereavement assessment was completed as part of the comprehensive assessment. CLINICAL RECORD 1: The patient elected the hospice benefit on 04/26/2025. 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 03/04/2025. 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 03/17/2025. 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 12/05/2024. 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 12/03/2024. The clinical record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. The Administrator/Registered Nurse (RN), Director of Patient Care Services (DPCS), Alternate DPCS, and Bereavement Coordinator stated in an interview on 05/22/2025 that the agency did not ensure that an initial bereavement assessment was completed as part of the comprehensive assessment. The Administrator/RN stated, “The electronic medical record (EMR) has had some challenging areas of learnings.” The agency had identified how-to add the initial bereavement assessment to the clinician assignment prior to this site visitor completing the exit conference.”

“It is required that each patient’s individualized written plan of care reflects patient, and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 4 of 5 (80%) clinical records reviewed revealed the agency did not ensure the plan of care (POC) reflected patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 1: The initial nursing assessment narrative dated 04/26/2025 stated, “She’s skipping meals and takes one (1) Ensure supplement instead of a meal a day”. The interdisciplinary group (IDG) POC dated 04/26/2025 lacked evidence that the POC included Ensure and goals and interventions for the altered nutritional status. CLINICAL RECORD 2: The initial nursing assessment narrative dated 03/04/2025 stated, “Patient has poor food and fluid intake and Ensure is provided by the agency to help nutritional intake”. The IDG POC dated 03/04/2025 lacked evidence that the POC included Ensure and goals and interventions for the altered nutritional status. CLINICAL RECORD 3: The initial social work and spiritual counselor assessments dated 03/21/2025 and 03/19/2025 respectively had a visit frequency of one (1) time per month with one (1) as needed visit for psychosocial or spiritual crisis. The interdisciplinary group (IDG) POC dated 03/25/2025 lacked evidence of goal(s) and intervention(s) for both the social worker and the spiritual counselor. CLINICAL RECORD 4: The initial nursing assessment dated 12/05/2024 stated for the locator “Nutrition/Hydration” - “Dysphagia - Yes”. The IDG POC dated 12/05/2024 lacked evidence of the goal(s) and intervention(s) for dysphasia. The Administrator/Registered Nurse, Director of Patient Care Services (DPCS), and Alternate DPCS stated in an interview on 05/22/2025 that the agency did not ensure the POC reflected patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments.”

“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. 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 clinical record review and interview. In 2 of 2 (100%) clinical records reviewed for patients that expired revealed the agency did not ensure a post-death bereavement plan of care (POC) was completed. CLINICAL RECORD 4: The patient death was on 01/03/2025. There was evidence of a completed post-death bereavement assessment, but the record lacked evidence of a post-death bereavement POC. CLINICAL RECORD 5: The patient death was on 02/09/2025. There was evidence of a completed post-death bereavement assessment, but the record lacked evidence of a post-death bereavement POC. The Administrator/Registered Nurse (RN), Director of Patient Care Services (DPCS), Alternate DPCS, and Bereavement Coordinator stated in an interview on 05/22/2025 that the agency did not ensure a post-death bereavement plan of care (POC) was completed. The Administrator/RN stated, “The electronic medical record (EMR) has had some challenging areas of learnings.” The agency had identified how-to add a post-death bereavement POC for the survivors prior to this site visitor completing the exit conference.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are noted in the plan of care and documented in the patient record. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed for patients that elected volunteer services revealed the agency did not ensure the plan of care (POC) included the volunteer goals and interventions. CLINICAL RECORD 4: The interdisciplinary group (IDG) POC dated 12/05/2024 ordered the volunteer services frequency as one (1) time per week with one (1) visit, as needed per patient/family request. There was evidence of volunteer visits completed on 12/06/2024, 12/11/2024, 12/18/2024, 12/20/2024, 12/23/2024, and 01/03/2025. The IDG POC dated 12/05/2024 lacked goal(s) and intervention(s) for the volunteer. CLINICAL RECORD 5: The IDG POC dated 12/03/2024 ordered the volunteer services frequency as one (1) time per week with one (1) visit, as needed per patient/family request. There was evidence of volunteer visits completed on 12/05/2024, 12/12/2024, 12/19/2024, 12/26/2024, 01/2/2025, 01/9/2025, 01/16/2025, 01/23/2025, 01/30/2025 and 02/06/2025. The IDG POC dated 12/05/2024 lacked goal(s) and intervention(s) for the volunteer. The Administrator/Registered Nurse, Director of Patient Care Services (DPCS), Alternate DPCS, and Volunteer Coordinator stated in an interview on 05/23/2025 that the agency did not ensure the POC included the goal(s) and intervention(s) for the volunteer services being provided.”