Care and Grace Home Health and Hospice

“Based on record review and interview the comprehensive assessment failed to consider the emotional and spiritual needs related to the terminal illness for 3 of 14 patients (Patient #1, #2 and #4) for which records were reviewed in that the agency failed to conduct an initial bereavement assessment for these patients. The clinical record for Patient #1 did not include documentation that an initial bereavement assessment was conducted.The clinical record for Patient #2 did not include documentation that an initial bereavement assessment was conducted.The clinical record for Patient #4 did not include documentation that an initial bereavement assessment was conducted.This Failure placed these patients at risk of not having their spiritual needs met in that they would not be made aware that chaplain/spiritual services were available. Findings Included:Review of the clinical record for Patient #1 revealed a start of care date of 06/21/2025. No documentation was included that indicated an initial bereavement assessment was conducted. Review of the clinical record for Patient #2 revealed a start of care date of 07/04/2025. No documentation was included that indicated an initial bereavement assessment was conducted. Review of the clinical record for Patient #4 revealed a start of care date of 05/08/2025. No documentation was included that indicated an initial bereavement assessment was conducted. An interview was conducted on 09/17/2025 at 2:05 PM with A/SN. Clinical records for Pt#1, #2, & #4 were reviewed. A/SN acknowledged initial bereavement assessments were not conducted. A/SN stated LMSW/CH failed to document declination of spiritual care services. Surveyor asked if LMSW/CH reported during IDG meetings which patients declined services. A/SN stated, “No. He didn’t.” Surveyor asked who is responsible to clinical record reviews. A/SN stated, “I have a consultant that completes the record reviews. I don’t know how they would have missed this.” An interview was conducted 09/18/2025 at 4:15 PM with LMSW/CH.. Surveyor reviewed patient records for Patients #1, #2 and #4. LMSW/CH stated he coordinated with the RN. LMSW/CH stated the nurses tell him when a patient wants spiritual care services. LMSW/CH confirmed he did not complete an initial bereavement assessment for Pt #1, #2, and #4, although he documented that the services were declined. LMSW stated, “I accept fully responsibility. It was my mistake.” Review of the agency’s Policy and Procedure Manual revealed a policy titled, “Policy: PCP-AM6, Comprehensive Assessment, no revision date,” which read “Hospice will establish a written comprehensive plan of care within 5 days of election of hospice services to identify and prioritize patient problems/needs.”.”

“Based on record review and interview the agency failed to ensure clinical notes included documentation of Chaplain visits for 3 of 14 records (Patient #1, #2 and #4) for which records were reviewed.The clinical record for Patient #1 did not include documentation of Chaplain visits for the certification period 06/21/2025 – 08/16/2025.The clinical record for Patient #2 did not include documentation of Chaplain visits for the certification period 07/04/2025 – 08/30/2025.The clinical record for Patient #4 did not include documentation of Chaplain visits for the certification period 05/08/2025 – 07/05/2025.This failure caused valuable patient information to not be available to the IDT so that they could make informed decisions regarding care and services for these patients. Findings Included:Review of the clinical record for Patient #1 for the certification period 06/21/2025-08/16/2025 revealed physician orders for Chaplain visits were 1 time per week + 4 prn. Review of visit notes from 06/21/2025-08/16/2025 revealed no documentation of chaplain visits or missed chaplain visits during the certification period.Review of the clinical record for Patient #2 for the certification period 07/04/2025-08/30/2025 revealed physician orders for Chaplain visits were 1 time per month + 4 prn. Review of visit notes from 07/04/2025-08/30/2025 revealed no documentation of chaplain visits or missed chaplain visits during the certification period.Review of the clinical record for Patient #4 for the certification period 05/08/2025-07/05/2025 revealed physician orders for Chaplain visits were 1 time per month + 4 prn. Review of visit notes from 05/08/2025-07/05/2025 revealed no documentation of chaplain visits or missed visits during the certification period.An interview was conducted 09/18/2025 at 4:15 p.m. with LMSW/CH. Surveyor reviewed patient records for Patients #1, #2 and #4. Surveyor asked if Chaplain visits were conducted for Pt #1, 2, and 4. LMSW/CH stated the nurses told him spiritual care services were declined. LMSW/CH confirmed he did not document that services were declined. A telephone interview was conducted on 09/22/2025 at 2:20 p.m. with the Administrative Assistant. The Administrative Assistant confirmed it is her responsibility to review all patient records to ensure documentation is completed and orders are correct. The clinical records for Pts #1, #2 and #4 were reviewed. Surveyor requested documentation of chaplain visits or missed visits for Pts #1, #2 and #3 during the reviewed certification periods. Administrative Assistant stated, “I see there are no notes or missed visit notes for those patients.” An interview was conducted on 09/22/2025 at 2:25 PM with A/SN. Pt records for Pts #1, #2 and #4 were reviewed. A/SN acknowledged documentation of declination of services, visits and missed visits were not included in the patient record. A/SN stated, “We have a consultant who is responsible for our clinical record reviews. They should document all visits and missed visits. I don’t know why they aren’t.”Review of the agency’s Policy and Procedure Manual revealed a policy titled, “Policy: PCP-CP2 Clinical Record Contents and Direction, no revision date”, which read “The agency maintains a confidential clinical records for each patient/client admitted to care. It includes the following information. Documentation: Clinical notes documenting interventions, care and services provided within established agency timeframe.””