Crest Palliative Care

“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 3 of 19 (16%) clinical records reviewed revealed that the agency did not ensure that the initial comprehensive assessment, including the bereavement and spiritual assessment, was completed no later than five calendar days after the election of hospice care. CLINICAL RECORD 1: The date of the hospice election was 08/07/2024 with a primary diagnosis of Other specified degenerative diseases of basal ganglia. There was no documented evidence that an initial bereavement assessment occurred in the first five days of the election of hospice or at any point throughout the course of care. CLINICAL RECORD 4: The date of the election was 05/29/2024 with a diagnosis of Cerebral infarction, Alzheimer’s disease, hypertension, type 2 diabetes mellitus without complications, chronic kidney disease. There was no documented evidence that an initial bereavement assessment occurred in the first five days of the election of hospice or at any point throughout the course of care. CLINICAL RECORD 16: The date of the election was 05/29/2024. The clinical record lacked evidence that a spiritual assessment occurred in the first five days or at any point throughout the course of care. The Admission (RN [Registered Nurse]) Clinical Note dated 05/29/2024 documented, “ Spiritual - A spiritual assessment could not be completed. I was unable to assess [patient’s name] because the chaplain will perform this assessment.” The CH [Chaplain]) Clinical Note dated 05/29/2024, documented, “Initial Assessment - I was unable to assess the patient because the patient declined to discuss when asked. Patient declined Chaplain upon initial assessment by RN.” During a joint record review and an interview on 01/24/2025, the Director of Clinical Services/Registered Nurse agreed there was no documented evidence that the initial bereavement and spiritual assessments were completed no later than five calendar days after the election of hospice care.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records with hospice aide services reviewed revealed that the agency did not ensure the hospice aide notified the registered nurse of the changes in the patient’s plan of care. CLINICAL RECORD 1: The Hospice Aide Clinical Note dated 08/28/2024 documented, “Missed Visit Reason: Pt was at appointments at time of visit. Other comment: Pt was at a dentist appointment upon arrival wife refused visit and wanted to resume visit on Friday.” The Hospice Aide Clinical Note dated 09/04/2024 documented, “Missed Visit Reason: Pt is out with friends.” The Hospice Aide Clinical Note dated 10/29/2024 documented, “Missed Visit Reason: Wife cancel visit.” The Hospice Aide Clinical Note dated 11/29/2024 documented, “Missed Visit Reason: Pt wife refused visit.” The Hospice Aide Clinical Note dated 01/21/2025 documented, “Missed Visit Reason: Missed visit due to weather.” There was no documented evidence that the aide notified the registered nurse of changes to the plan of care. CLINICAL RECORD 5: The Hospice Aide Clinical Note dated 11/29/2024 documented, “Missed Visit Reason: Pt refused visit. Other comments: Wife refused visit will resume next visit.” The Hospice Aide Clinical Note dated 01/04/2025 documented, “Missed Visit Reason: Patient refuses visit.” There was no documented evidence that the aide notified the registered nurse of changes to the plan of care. During a joint clinical record review and interview on 01/24/2025, the Director of Clinical Services/Registered Nurse confirmed that the hospice aide documentation lacked notification to the registered nurse of the changes in plan of care.”