Spirit Hospice LLC

“Based on review of the patient information handbook, volunteer training manual, and staff interview, the agency failed to have a volunteer coordinator or use volunteers per the requirements of: 42 CFR 418.78 Review of the patient information handbook revealed “Volunteers provide support and companionship to you and your family. Trained Volunteers can provide such services as running errands, grocery shopping or providing respite services to caregivers and family members.” Interview with Staff B on 01/08/24 at 11:00 AM revealed the hospice agency had not had a volunteer coordinator since they opened three years ago. Staff A provided the Volunteer Training Program Manual but revealed the agency did not have volunteers.”

“Based on medical record review, interview and review of the bereavement procedure, the agency failed to make bereavement services available to the family and other individuals in the bereavement plan of care up for four of four closed medical records reviewed (Patient #1, #3, #4 and #5). The patient census is two. Findings include: 1. Review of the medical record for Patient #1 revealed a start of care of 12/09/23 and the date of death was on 12/13/23. The services provided were for skilled nursing (SN) one time a week times one week. The primary diagnosis was congestive heart failure (CHF). There was no documentation in the patient’s record that bereavement services were made to the family another other individuals. 2. Review of the medical record for Patient #3 revealed a start of care of 08/19/23 and the date of death was on 08/25/23. The services provided were for SN two times a week times nine weeks. The primary diagnosis was malignant neoplasm of the lung. There was no documentation in the patient’s record that bereavement services were made to the family another other individuals. 3. Review of the medical record for Patient #4 revealed a start of care of 06/14/23 and the date of death was on 06/16/23. The services provided were for SN one times a day times one week, three times a day times two weeks, and four times a day times three weeks. Comfort care was initiated on 06/15/23. The primary diagnosis was acute respiratory failure. There was no documentation in the patient’s record that bereavement services were made to the family another other individuals. 4. Review of the medical record for Patient #5 revealed a start of care of 11/28/23 and the date of death was on 11/28/23. The services provided were for SN three times a week times nine weeks and aide services five times a week times nine week. The primary diagnosis was chronic obstructive pulmonary disease (COPD). There was no documentation in the patient’s record that bereavement services were made to the family another other individuals. Review of the procedure for Bereavement revealed hospice will provide bereavement services to the families/caregivers of Hospice patients both before and after the patient’s death. The purpose of these services is to facilitate a normal grieving process and to identify and appropriately refer those persons who may be experiencing pathological grief reactions which may interfere with the eventual resolution and integration of their losses. Bereavement services will be coordinated with the individual’s spiritual counselor or Hospice Chaplain as well as with other community resources judged to be useful and beneficial to the family/caregiver. Bereavement assessment and clinical notes are documented in the patient’s permanent medical record. Interview with Staff A on 01/11/24 at 11:39 AM revealed she documented in her notebook that bereavement services were offered for Patient’s #1, #3, #4 and #5 including the dates of the phone calls and the follow ups but she did not document this information in the patients’ medical records.”