Signature Healthcare at Home

“Based on patient record review and interview, it was determined that the agency failed to complete a bereavement assessment, which is part of the initial comprehensive assessment, in the timeframe as stipulated in the requirements of this standard. Findings:Review of 14 patient medical records revealed that 3 patient records (#5, #7 and #14) lacked documentation of a bereavement assessment completed with the initial comprehensive assessment.Review of Patient medical record #5 with an election of hospice care date of 01/17/2025, revealed the bereavement assessment was not completed until 03/28/2025, which exceeds the 5 calendar days after the election of hospice care.Review of Patient medical record #7 with an election of hospice care date of 08/18/2025, revealed the bereavement assessment was not completed until 09/03/2025, which exceeds the 5 calendar days after the election of hospice care.Review of Patient medical record #14 with an election of hospice care date of 05/02/2025, revealed the bereavement assessment was not completed until 06/02/2025, which exceeds the 5 calendar days after the election of hospice care.During interview with the Bereavement Coordinator on 09/22/2025 beginning at 09:30 AM, it was acknowledged the three assessments were not completed in the timeframe as required. “This has been a struggle and because of this we have created a PIP.””

“Based on patient medical record review, it was determined the agency failed to include on the individualized care plan for each patient, the problems identified during the initial, comprehensive and updated comprehensive assessments. Findings:Review of 7 patient medical records (Patients #7-14) revealed that patient problems identified during the initial comprehensive assessment were not included in the patient care plan.Review of Patient #7 medical record revealed a document titled, “SOC Initial Comprehensive Assessment” dated 06/20/2025. Problems identified during the initial comprehensive assessment included risk for falls, pain, bowel elimination and dysphagia. Review of the document titled, “Comprehensive Care Plan Report” failed to include the problems identified and individualized goals to meet the patient’s needs.Review of Patient #8 medical record revealed a document titled, “SOC Initial Comprehensive Assessment” dated 04/08/2025. A problem identified during the initial comprehensive assessment included a need for bowel care. Review of the document titled, “Comprehensive Care Plan Report” failed to include the problem identified and an individualized goal to meet the patient’s need.Review of Patient #10 medical record revealed a document titled, “SOC Initial Comprehensive Assessment” dated 06/27/2025. A problem identified during the initial comprehensive assessment included nutritional impairment, weight loss. Review of the document titled, “Comprehensive Care Plan Report” failed to include the problem identified and an individualized goal to meet the patient’s need.Similar findings were revealed for Patient’s #9 and #11-14.During an interview with the Executive Director, Director of Clinical Services and Clinical Manager on 09/23/2025 beginning at 1:30 PM, the above findings were presented. The Director of Clinical Services acknowledged the findings.”

“Based on patient medical records reviewed, it was determined the agency failed to include individualized measurable outcomes anticipated from implementing and coordinating the care plan for 12 of 14 patient care plans reviewed (Patients #1, 2, 3, 5, 6, 7, 8, 9, 10, 11, and 12). Findings:Review of the medical record of Patient #1 reflected an admission date on 01/23/2025. The “Hospice IDG Comprehensive Assessment and Plan of Care Update Report” revealed the problem, “Pain Managment” with the goal “Pain is managed at a level acceptable to the patient.” The care plan lacked individualized and measurable patient goals/outcomes anticipated from implementing the plan of care to address pain management.Similar findings were identified for patients #2, 3, 5, 6, 9, 10, 11, and 12. Review of the medical record of Patient #6 reflected an admission date on 04/21/2025. The “Hospice IDG Comprehensive Assessment and Plan of Care Update Report” revealed the problem, “Nutrition/Hydration management” with the goal “Patient is in control of what, how much, and when to eat.” The care plan lacked individualized and measurable patient goals/outcomes anticipated from implementing the plan of care to address nutrition/hydration management.Similar findings were identified for patients #7, 9, 11, and 12.Review of the medical record of Patient #8 reflected an admission date on 08/04/2025. The “Hospice IDG Comprehensive Assessment and Plan of Care Update Report” revealed the problem, “Gastrointestinal Managment “ with the goal “Patient ‘s constipation will be controlled/relieved.” The care plan lacked individualized and measurable patient goals/outcomes anticipated from implementing the plan of care to address gastrointestinal management.Similar findings were identified for patients #7 and 11.During an interview with the Executive Director, Director of Clinical Services, and Clinical Manager on 09/23/2025 beginning at 1:30 PM, the above findings were presented and acknowledged.”