Unicare Palliative & Hospice Care, LLC

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals for up to one (1) year following the death of the patient. Bereavement counseling extends to residents of an SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed for patients who expired while on services revealed that the hospice did not ensure that the bereavement services reflected the needs of the bereaved per a bereavement plan of care that included the types of services to be offered and the frequency of the service delivery. Document 1: Agency policy (PC.26) [Last Reviewed:100121] stated in part: that the bereavement risk assessment will be performed on admission and after death. Following death, the agency will develop and implement the bereavement plan of care based on the post-death risk assessment. Clinical Record 13: The patient expired on 04/06/2023 and there was no documented evidence of a completed post-death bereavement risk assessment or developed bereavement plan of care. Clinical Record 14: The patient expired on 03/04/2023 and there was no documented evidence of a completed post-death bereavement risk assessment or developed bereavement plan of care. During a phone interview with the Bereavement Coordinator (BC), when asked where the bereavement plan of care could be located in the electronic medical record, the BC stated she was not sure because she had not used the electronic medical record for a few months and stated she did have some notes on paper but would have to look for them. During a joint clinical record review on 02/09/2024, the Assistant Director of Nursing (ADON) agreed the hospice did not ensure that the bereavement services reflected the needs of the bereaved per a bereavement plan of care.”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid-certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed for patients who were live discharges while on services revealed that the hospice did not ensure that a copy of the hospice discharge summary was forwarded to the receiving Medicare/Medicaid-certified facility where the patient was transferred. Clinical Record 11: The patient was admitted to the hospital on 05/30/2023. There was no documented evidence that the discharge summary was forwarded to the hospital receiving the hospice patient for care. A live discharge note was documented by the registered nurse on 05/30/2023 stating the patient was discharged due to admission to a hospital and non-contracted facility. During an interview and joint clinical record review with the Assistant Director of Nursing (ADON) on 2/09/2024, the ADON agreed that a discharge summary was not completed or sent to the Medicare/Medicaid-certified facility that received the hospice patient for care.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed for patients who were live discharges while on services revealed that the hospice did not ensure that a copy of the hospice discharge summary was forwarded to the attending physician. Clinical Record 12: The patient was discharged on 09/22/2023 due to being no longer terminally ill. There was no documented evidence that the discharge summary was completed and forwarded to the attending physician. A live discharge visit note documented by the registered nurse on 09/22/2023 stated the patient had no decline during the current benefit period. The Assistant Director of Nursing (ADON) on 2/09/2024 agreed that a discharge summary was not completed or sent to the patient’s attending upon discharge.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed for patients who were live discharges while on services revealed that the hospice did not ensure that a copy of the hospice discharge summary was forwarded to the attending physician. Clinical Record 12: The patient was discharged on 09/22/2023 due to being no longer terminally ill. There was no documented evidence that the discharge summary was completed and forwarded to the attending physician. A live discharge visit note documented by the registered nurse on 09/22/2023 stated the patient had no decline during the current benefit period. The Assistant Director of Nursing (ADON) on 2/09/2024 agreed that a discharge summary was not completed or sent to the patient’s attending upon discharge.”