Guardian Hospice of Oklahoma

“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 5 of 14 (36%) clinical records reviewed revealed that the agency did not ensure that the initial comprehensive assessment, including the spiritual and social work assessment, was completed no later than five calendar days after the election of hospice care. Clinical Record 1: The election of the hospice benefit was dated 1/6/2023. A review of the clinical record revealed that the chaplain services were declined upon admission and there was no documented evidence that a spiritual assessment was completed at admission or at any time point during the course of care. Clinical Record 4: The election of the hospice benefit was dated 2/1/2023. The patient was discharged under insurance and then readmitted under Medicare. The initial medical social work assessment occurred on 2/8/2023 (2 days late). A review of the clinical record revealed that the chaplain services were declined upon admission and there was no documented evidence that a spiritual assessment was completed at admission or at any time point during the course of care. Clinical Record 7: The election of the hospice benefit was dated 5/30/2023. A review of the clinical record revealed that the chaplain services were declined upon admission and there was no documented evidence that a spiritual assessment was completed at admission or at any time point during the course of care. Clinical Record 9: The election of the hospice benefit was dated 2/14/2023. A review of the clinical record revealed that the chaplain services were declined upon admission and there was no documented evidence that a spiritual assessment was completed at admission or at any time point during the course of care. Clinical Record 10: The election of the hospice benefit was dated 10/30/2023. A review of the clinical record revealed that the chaplain services were declined upon admission and there was no documented evidence that a spiritual assessment was completed at admission or at any time point during the course of care. The Director of Nursing confirmed in a joint record review and interview on 12/14/2023 that the initial comprehensive assessment, including the spiritual and social work assessment, was completed no later than five days after the election of hospice care. The DON stated, “If the chaplain did not go, then the spiritual assessment was not done.” The Chaplain/Bereavement Coordinator confirmed during a joint record review and interview on 12/13/2023 that the spiritual assessment was not completed as the patient/family had declined spiritual care at admission.”

“It is required that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the patient’s terminal illness that are addressed to promote the patient’s well-being, comfort, and dignity throughout the dying process. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records reviewed revealed that the agency did not ensure that the spiritual assessment was completed. Clinical Record 1: The date of the election was 1/6/2023. The chaplain services were declined upon admission. The clinical record lacked evidence that a spiritual assessment occurred at admission or at any time point during the course of care. Clinical Record 4: The date of the election was 2/1/2023. The chaplain services were declined upon admission. The clinical record lacked evidence that a spiritual assessment occurred at admission or at any time point during the course of care. Clinical Record 7: The date of the election was 5/30/2023. The chaplain services were declined upon admission. The clinical record lacked evidence that a spiritual assessment occurred at admission or at any time point during the course of care. Clinical Record 9: The date of the election was 2/14/2023. The chaplain services were declined upon admission. The clinical record lacked evidence that a spiritual assessment occurred at admission or at any time point during the course of care. Clinical Record 10: The date of the election was 10/30/2023. The chaplain services were declined upon admission. The clinical record lacked evidence that a spiritual assessment occurred at admission or at any time point during the course of care. The Director of Nursing confirmed in a joint record review and interview on 12/14/2023 that the initial comprehensive assessment was completed no later than five days after the election of hospice care. The DON stated, “If the chaplain did not go, then the spiritual assessment was not done.” The Chaplain/Bereavement Coordinator confirmed during a joint record review and interview on 12/13/2023 that the spiritual assessment was not completed as the patient/family had declined spiritual care at admission.”