Elite Hospice and Palliative Care, LLC

“It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by document review, clinical record review, and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure the comprehensive assessment included an initial bereavement assessment. Agency policy PE.5 Patient Assessments, dated 09/01/2024, required in part, “The Hospice will conduct and document in writing a patient-specific comprehensive assessment... no later than five calendar days after the election of the hospice benefit... An initial bereavement assessment...will be part of the initial assessment/comprehensive assessment.” CLINICAL RECORD 2: The patient elected the hospice benefit on 02/05/2025. The start of care comprehensive assessment completed by the Registered Nurse on 02/05/2025, the psychosocial assessment completed by the Social Worker on 02/08/2025, and the spiritual assessment completed by the Chaplain on 02/08/2025 did not include documentation of an initial bereavement assessment. There was no documented evidence in the clinical record that an initial bereavement assessment was completed as part of assessments completed at the start of care. CLINICAL RECORD 4: The patient elected the hospice benefit on 05/05/2025. The start of care comprehensive assessment completed by the Registered Nurse on 05/05/2025, the psychosocial assessment completed by the Social Worker on 05/08/2025, and the spiritual assessment completed by the Chaplain on 05/09/2025 did not include documentation of an initial bereavement assessment. There was no documented evidence in the clinical record that an initial bereavement assessment was completed as part of assessments completed at the start of care. During a joint clinical record review and interview on 05/16/2025, the Administrator/Supervising Nurse confirmed that the initial bereavement assessments were not documented for Clinical Record 2 or 4.”

“It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by document review, clinical record review, observation, and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the Registered Nurse (RN), as a member of the IDG, provided coordination of care, ensured continuous assessment of patient needs, and implementation of the interdisciplinary plan of care. Agency policy PC.40 Interdisciplinary Group Roles and Responsibilities, dated 09/01/2024, required in part, “The Hospice will designate a Registered Nurse (RN) that is a member of the Interdisciplinary Group/Team (IDG/IDT) to provide coordination of care and to ensure continuous assessment of each patient’s and family’s needs...The Interdisciplinary Group/Team (IDG/IDT) will maintain responsibility for directing, coordinating, and supervising care and services provided...Informal verbal and written communication demonstrating coordination of care of others providing care is documented in the medical record.” Agency policy PC.110 Coordination of Care, dated 09/01/2024, required in part, “The Hospice will develop and maintain a system of communication and integration...to ensure that the Interdisciplinary Group/Team (IDG/IDT) maintains responsibility for directing, coordinating, and supervising the care and services provided...Provide for an ongoing sharing of information with other non-hospice providers furnishing services unrelated to the terminal illness...All communication and coordination of care is documented in the clinical record.” CLINICAL RECORD 1/HOME VISIT 1: The patient elected the hospice benefit on 01/08/2025 with the diagnosis of end-stage heart failure. During the home visit observation on 05/14/2025 with the Medical Social Worker (MSW) (Personnel Record5), the patient’s paid caregiver mentioned the patient was receiving physical therapy. Clinical record review revealed the patient had required hospitalization with surgical intervention after a fall that resulted in a right hip fracture. The patient’s attending physician gave an order for home physical therapy services before the patient’s admission to hospice, when the patient was discharged from the rehabilitation facility to home. When the patient was admitted to hospice, the Interdisciplinary Group (IDG) and the patient’s attending physician determined the physical therapy services were not related to the patient’s hospice admitting diagnosis of end-stage heart failure. The “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” form was furnished to and signed by the patient’s daughter on 01/09/2025. There was no documented evidence in the clinical record that the hospice IDG/IDT and RN were coordinating care and services or that the RN was reporting or discussing the patient’s progress with physical therapy involvement in the IDG Meetings dated 02/07/2025, 02/21/2025, 03/21/2025, 04/04/2025, 04/11/2025, or 05/02/2025. The IDG Meeting dated 03/07/2025 did include documentation that “PT [physical therapy] is working with patient on strengthening and stability twice weekly.” The clinical record did not include care coordination notes, scanned documentation from physical therapy, or documented communication between the hospice and the Physical Therapist regarding interventions, goals, or the patient’s progress related to physical therapy services provided. During joint clinical record review, review of findings, and interview on 05/15/2025, the Administrator/Supervising Nurse and the Alternate Administrator/Alternate Supervising Nurse confirmed that the record did not include documentation of coordinating care and service related to the patient’s physical therapy services.”