Every finding on record at Good Shepherd Hospice, Inc.

Based on record review and interview, the hospice failed to ensure completion of an initial evaluation within 48 hours from receipt of referral for hospice services for three (Patients #3, 16 and #17) of 24 patients. --- Findings: Patient #3A review of the clinical record showed a referral for hospice services on 05/30/24 and showed an evaluation in conjunction with an initial comprehensive assessment dated 06/04/24 (five days from receipt of the referral). The clinical record showed no patient or caregiver refusal or request to delay hospice services, no communication with the physician and no change in hospice orders. Patient #16A review of the clinical record showed a referral for hospice services on 02/19/26 and showed an evaluation in conjunction with an initial comprehensive assessment dated 03/09/26 (18 days from receipt of the referral). The clinical record showed no patient or caregiver refusal or request to delay hospice services, no communication with the physician and no change in hospice orders. Patient #17A review of the clinical record showed a referral for hospice services on 05/06/26 and showed an evaluation in conjunction with an initial comprehensive assessment dated 05/14/26 (eight days from receipt of the referral). The clinical record showed no patient or caregiver refusal or request to delay hospice services, no communication with the physician and no change in hospice orders. On 05/22/26 from 11:40 a.m. to 12:30 p.m., Staff C stated the initial hospice evaluations for patients #3, 16 and #17 were not completed within 48 hours from receipt of referral.

Based on record review and interview, the hospice failed to ensure bereavement care plans were initiated or were included as a part of the overall POC after the initial bereavement assessments for six (Patients #6, 13, 14, 16, 17 and #18) of 24 patients. --- Findings: Patient #6A review of the clinical record showed an election of the hospice benefit on 04/14/26 with the completion of the initial spiritual and bereavement assessment on 04/16/26. A review of a POC dated 04/14/26 to 07/12/26 and IDG updates to the POC on 04/16/26, 04/23/26 and on 05/06/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC.  On 05/22/26 at 11:55 a.m., Staff C stated the patient did not have a bereavement care plan in place. Patient #13A review of the clinical record showed an election of the hospice benefit on 02/09/26 with the completion of the initial spiritual and bereavement assessment on 02/10/26. A review of a POC dated 02/09/26 to 05/09/26 and IDG updates to the POC on 02/19/26, 03/05/26, 03/19/26, 04/02/26, 04/16/26, 04/30/26 and on 05/14/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC.  On 05/22/26 at 12:15 p.m., Staff C stated the patient did not have a bereavement care plan in place. Patient #14A review of the clinical record showed an election of the hospice benefit on 04/20/26 with the completion of the initial spiritual and bereavement assessment on 04/23/26. A review of a POC dated 04/21/26 to 07/19/26 and IDG updates to the POC on 04/30/26 and on 05/14/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC.  On 05/22/26 at 12:20 a.m., Staff C stated the patient did not have a bereavement care plan in place. Patient #16A review of the clinical record showed an election of the hospice benefit on 03/09/26 with the completion of the initial spiritual and bereavement assessment on 03/10/26. A review of a POC dated 03/09/26 to 05/07/26 and IDG updates to the POC on 03/19/26, 04/02/26, 04/16/26 and on 04/30/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC.  On 05/22/26 at 12:27 p.m., Staff C stated the patient did not have a bereavement care plan in place. Patient #17A review of the clinical record showed an election of the hospice benefit on 05/14/26 with the completion of the initial spiritual and bereavement assessment on 05/15/26. A review of a POC dated 05/14/26 to 08/11/26 and IDG updates to the POC on 05/14/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC.  On 05/22/26 at 12:30 a.m., Staff C stated the patient did not have a bereavement care plan in place. Patient #18A review of the clinical record showed an election of the hospice benefit on 02/25/26 with the completion of the initial spiritual and bereavement assessment on 02/26/26. A review of a POC dated 02/25/26 to 05/25/26 and IDG updates to the POC on 03/05/26, 03/19/26, 04/02/26, 04/16/26, 04/30/26 and on 05/14/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC.  On 05/22/26 at 12:35 p.m., Staff C stated the patient did not have a bereavement care plan in place.

Based on record review and interview, the hospice failed to ensure care was provided in accordance with the POCs for seven (Patients #1, 3, 4, 10, 19, 20 and #21) of 24 patients. --- Findings: Patient #1A review of the plan of care dated 03/10/26 to 06/07/26 ordered the SN to monitor the patient’s weight and fluid intake every visit. SN visit notes dated 03/26/26, 04/09/26, 04/24/26, 04/29/26 and 05/07/26 showed no monitoring of the patient’s weight or fluid intake. The clinical record showed no patient or family refusal of monitoring the patient’s weight or fluid intake and showed no changes in the physician’s orders.  On 05/22/26 at 11:20 a.m., Staff C stated the SN did not monitor the patient’s weight or fluid intake during the visits. Patient #3A review of the plan of care dated 03/26/26 to 05/24/26 ordered a SN visit frequency of two times a week and the SN to monitor the patient’s nutrition and oral intake every visit. SN visit notes dated 03/26/26, 04/02/26, 04/08/26, 04/09/26, 04/14/26, 04/16/26, 04/19/26, 04/20/26, 04/22/26, 04/28/26, 05/06/26, 05/08/26, 05/12/26 and 05/14/26 showed no monitoring of the patient’s nutrition or oral intake and a SN missed visit note dated 04/30/26 documented the SN visit was missed due to car trouble. The clinical record showed no attempt to make up the SN visit and showed no patient or family refusal of monitoring the patient’s nutrition or oral intake and showed no changes in the physician’s orders.  On 05/22/26 at 11:40 a.m., Staff C stated the SN did not monitor the patient’s nutrition or intake during the visits and the missed visit on 04/30/26 should have been made up by the nurse. Patient #4A review of the plan of care dated 04/15/26 to 06/13/26 ordered the SN to monitor the patient’s weight, nutrition and oral intake every visit and showed a chaplain visit frequency of one time a month for one month and a medical social work visit frequency of four times a month for one month with an update to the POC on 04/27/26 for two medical social work visits a month. SN visit notes dated 04/16/26, 04/22/26, 04/23/26, 04/27/26, 04/29/26, 05/04/26, 05/07/26 and 05/11/26 showed no monitoring of the patient’s weight, nutrition or oral intake and showed no chaplain visit from 04/15/26 to 05/02/26 (one visit ordered, no visit conducted) and from 04/15/26 to 05/02/26 showed a medical social work visit on 04/30/26 (two visit ordered, one visit conducted). The clinical record showed no patient or family refusal of monitoring the patient’s weight, nutrition or oral intake, chaplain visits or medical social work visits and showed no changes in the physician’s orders.  On 05/22/26 at 11:47 a.m., Staff C stated the SN did not monitor the patient’s weight, nutrition or intake during the visits and the chaplain and social work visits were not provided as ordered in the plan of care. Patient #10A review of the plan of care dated 03/17/26 to 05/15/26 ordered the SN to monitor the patient’s weight, oral intake and nutrition every visit. SN visit notes dated 03/25/26, 03/30/26, 04/14/26, 04/16/26, 04/20/26, 04/22/26, 04/30/26, 05/04/26, 05/06/26 and 05/13/26 showed no monitoring of the patient’s weight, nutrition or oral intake. The clinical record showed no patient or family refusal of monitoring the patient’s weight, nutrition or oral intake and showed no changes in the physician’s orders.  On 05/22/26 at 12:06 p.m., Staff C stated the SN did not monitor the patient’s weight, nutrition or oral intake during the visits. Patient #19A review of the plan of care dated 03/17/26 to 05/15/26 ordered a SN visit frequency of two times a week and chaplain visits at one time a month for one month.  During the weeks of:11/19/25 to 12/06/25 showed no chaplain visit was conducted (one visit ordered, no visit conducted).11/23/25 to 11/29/25 showed a SN visit was conducted on 11/26/25 (two visits ordered, one visit conducted).12/21/25 to 12/27/25 showed a SN visit was conducted on 12/23/25 (two visits ordered, one visit conducted). The clinical record showed no patient or family refusal of visits and no changes in the ordered frequencies. On 05/22/26 at 12:40 p.m., Staff C stated the nurse and chaplain visits were not provided as ordered in the POC.   Patient #20A review of the plan of care dated 02/03/26 to 04/03/26 ordered SN to monitor the patient’s nutrition every visit. SN visit notes dated 02/16/26, 02/09/26, 02/11/26, 02/18/26, 02/23/26, 03/05/26 and 03/12/26 showed no monitoring of the patient’s nutrition. The clinical record showed no patient or family refusal of monitoring the patient’s nutrition and showed no changes in the physician’s orders.  On 05/22/26 at 12:45 p.m., Staff C stated the SN did not monitor the patient’s nutrition during the visits. Patient #21A review of the plan of care dated 12/02/25 to 03/01/26 ordered a hospice aide visit frequency of two times a week for one week, then three times a week.  During the weeks of:12/02/25 to 12/06/25 showed a hospice aide visit was conducted on 12/04/26 (two visits ordered, one visit conducted).12/07/25 to 12/13/25 showed hospice aide visits were conducted on 12/08/26 and 12/11/26 (three visits ordered, two visits conducted).12/14/25 to 12/20/25 showed hospice aide visits were conducted on 12/15/26 and 12/18/26 (three visits ordered, two visits conducted). The clinical record showed no patient or family refusal of visits and no changes in the ordered frequencies. On 05/22/26 at 12:50 p.m., Staff C stated the aide visits were not provided as ordered in the POC.

Based on record review and interview, the hospice failed to ensure POCs were fully developed to include interventions and goals related to: 1.The hospice diagnosis for 18 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 11, 12, 13, 14, 15, 18, 20, 21, 22 and #24) of 24 patients. 2. Hospice aide services for 16 (Patients #2, 3, 4, 6, 7, 8, 10, 11, 12, 13, 14, 15, 18, 22, 23 and #24) of 24 patients. --- Findings: Patient #1A review of a POC dated 03/10/26 to 06/07/26 with IDG updates on 03/27/26, 04/10/26, 04/24/26 and on 05/08/26 showed no SN interventions and goals that addressed the hospice diagnosis of cerebral infarction with hemiplegia and showed no communication between the IDG to update the POC. On 05/22/26 at 11:20 a.m., Staff C stated the POC did not have interventions or goals for cerebral infarction with hemiplegia. Patient #2A review of a POC dated 04/13/26 to 06/11/26 with IDG updates on 04/10/26, 04/24/26 and on 05/08/26 showed no SN interventions and goals that addressed the hospice diagnosis of heart failure, no hospice aide interventions and goals and showed no communication between the IDG to update the POC. On 05/22/26 at 11:25 a.m., Staff C stated the POC did not have interventions or goals for heart failure or aide services. Patient #3A review of a POC dated 03/26/26 to 05/24/26 with IDG updates on 03/27/26, 04/10/26, 04/24/26 and on 05/08/26 showed no SN interventions and goals that addressed the hospice diagnoses of heart failure, no hospice aide interventions and goals and showed no communication between the IDG to update the POC. On 05/22/26 at 11:40 a.m., Staff C stated the POC did not have interventions or goals for heart failure or aide services. Patient #4A review of a POC dated 04/15/26 to 06/13/26 with IDG updates on 04/10/26, 04/24/26 and on 05/08/26 showed no SN interventions and goals that addressed the hospice diagnoses of senile degeneration of the brain and dementia, no hospice aide interventions and goals and showed no communication between the IDG to update the POC. On 05/22/26 at 11:47 a.m., Staff C stated the POC did not have interventions or goals for senile degeneration of the brain, dementia or aide services. Patient #5A review of a POC dated 03/11/26 to 05/09/26 with IDG updates on 03/12/26, 03/26/26, 04/09/26, 04/23/26 and on 04/30/26 showed no SN interventions and goals that addressed the hospice diagnosis of hypertensive heart failure and showed no communication between the IDG to update the POC. On 05/22/26 at 11:50 a.m., Staff C stated the POC did not have interventions or goals for hypertensive heart failure.  Patient #6A review of a POC dated 04/14/26 to 07/12/26 with IDG updates on 04/09/26, 04/16/26, 04/23/26 and on 05/06/26 showed no SN interventions and goals that addressed the hospice diagnosis of congestive heart failure and management of a foley catheter, no hospice aide interventions and goals and showed no communication between the IDG to update the POC. On 05/22/26 at 11:55 a.m., Staff C stated the POC did not have interventions or goals for heart failure, the foley catheter or aide services.Patient #7A review of a POC dated 04/13/26 to 06/11/26 with IDG updates on 04/16/26, 04/23/26 and on 05/06/26 showed no SN interventions and goals that addressed the hospice diagnosis of cerebral infarction, no hospice aide interventions and goals and showed no communication between the IDG to update the POC. On 05/22/26 at 12:02 p.m., Staff C stated the POC did not have interventions or goals for cerebral infarction or aide services. Patient #8A review of a POC dated 03/06/26 to 05/04/26 with IDG updates on 03/19/26, 04/02/26, 04/16/26, 04/23/26 and on 05/06/26 showed no SN interventions and goals that addressed the hospice diagnoses of senile degeneration of the brain, dementia, no hospice aide interventions and goals and showed no communication between the IDG to update the POC. On 05/22/26 at 12:05 p.m., Staff C stated the POC did not have interventions or goals for senile degeneration of the brain, dementia or aide services. Patient #10A review of a POC dated 03/17/26 to 05/15/26 with IDG updates on 03/13/26, 03/27/26, 04/10/26, 04/24/26 and on 05/08/26 showed no hospice aide services interventions and goals and showed no communication between the IDG to update the POC. On 05/22/26 at 12:06 a.m., Staff C stated the POC did not have interventions or goals for aide services. Patient #11A review of a POC dated 03/20/26 to 05/18/26 with IDG updates on 03/27/26, 04/10/26, 04/24/26 and on 05/08/26 showed no SN interventions and goals that addressed the hospice diagnosis of Alzheimer’s, no hospice aide interventions and goals and showed no communication between the IDG to update the POC. On 05/22/26 at 12:10 p.m., Staff C stated the POC did not have interventions or goals for Alzheimer’s or aide services. Patient #12A review of a POC dated 03/11/26 to 05/09/26 with IDG updates on 03/12/26, 03/26/26, 04/09/26, 04/23/26 and on 05/14/26 showed no SN interventions and goals that addressed the hospice diagnoses of senile degeneration of the brain, Alzheimer’s, no hospice aide interventions and goals and showed no communication between the IDG to update the POC. On 05/22/26 at 12:12 p.m., Staff C stated the POC did not have interventions or goals for senile degeneration of the brain, Alzheimer’s or aide services. Patient #13A review of a POC dated 02/09/26 to 05/09/26 with IDG updates on 02/19/26, 03/05/26, 03/19/26, 04/02/26, 04/16/26, 04/30/26 and on 05/14/26 showed no SN interventions and goals that addressed the hospice diagnosis of Alzheimer’s, no hospice aide interventions and goals and showed no communication between the IDG to update the POC. On 05/22/26 at 12:15 p.m., Staff C stated the POC did not have interventions or goals for Alzheimer’s or aide services. Patient #14A review of a POC dated 04/21/26 to 07/19/26 with IDG updates on 04/30/26 and on 05/14/26 showed no SN interventions and goals that addressed the hospice diagnosis of lung cancer with metastasis, no hospice aide interventions and goals and showed no communication between the IDG to update the POC. On 05/22/26 at 12:20 p.m., Staff C stated the POC did not have interventions or goals for lung cancer with metastasis or aide services. Patient #15A review of a POC dated 04/14/26 to 06/12/26 with IDG updates on 04/16/26, 04/30/26 and on 05/14/26 showed no SN interventions and goals that addressed the hospice diagnoses of senile degeneration of the brain, dementia, no hospice aide interventions and goals and showed no communication between the IDG to update the POC. On 05/22/26 at 12:25 p.m., Staff C stated the POC did not have interventions or goals for senile degeneration of the brain, dementia or aide services. Patient #18A review of a POC dated 02/24/26 to 05/25/26 with IDG updates on 03/05/26, 03/19/26, 04/02/26, 04/16/26, 04/30/26 and on 05/14/26 showed no SN interventions and goals that addressed the hospice diagnosis of senile degeneration of the brain, no hospice aide interventions and goals and showed no communication between the IDG to update the POC. On 05/22/26 at 12:35 p.m., Staff C stated the POC did not have interventions or goals for senile degeneration of the brain or aide services. Patient #20A review of a POC dated 02/06/26 to 04/03/26 with IDG updates on 02/04/26, 02/19/26 and on 03/05/26 showed no SN interventions and goals that addressed the hospice diagnoses of senile degeneration of the brain and dementia and showed no communication between the IDG to update the POC. On 05/22/26 at 12:45 p.m., Staff C stated the POC did not have interventions or goals for senile degeneration of the brain or dementia. Patient #21A review of a POC dated 12/02/25 to 03/01/26 with IDG updates on 12/04/26 and on 12/18/25 showed no SN interventions and goals that addressed the hospice diagnoses of cancer of the hard palate and showed no communication between the IDG to update the POC. On 05/22/26 at 12:50 p.m., Staff C stated the POC did not have interventions or goals for cancer of the hard palate. Patient #22A review of a POC dated 12/11/25 to 02/08/26 with IDG updates on 12/04/25 and on 12/18/25 showed no SN interventions and goals that addressed the hospice diagnosis of leukemia and management of a foley catheter, no hospice aide interventions and goals and showed no communication between the IDG to update the POC. On 05/22/26 at 12:52 p.m., Staff C stated the POC did not have interventions or goals for leukemia, the foley catheter or aide services. Patient #23A review of a POC dated 04/08/26 to 07/06/26 with IDG updates on 04/16/26 and on 04/23/26 showed no SN interventions and goals of a PEG feeding tube, no hospice aide interventions and goals and showed no communication between the IDG to update the POC. On 05/22/26 at 12:54 p.m., Staff C stated the POC did not have interventions or goals for the PEG feeding tube or aide services. Patient #24A review of a POC dated 02/23/26 to 04/23/26 with IDG updates on 02/25/26 and on 03/11/26 showed no SN interventions and goals that addressed the hospice diagnosis of leukemia and management of a foley catheter, no hospice aide interventions and goals and showed no communication between the IDG to update the POC. On 05/22/26 at 12:55 p.m., Staff C stated the POC did not have interventions or goals for foley catheter or aide services.

Based on record review and interview, the hospice failed to ensure frequent missed hospice aide visits were communicated and addressed by the IDG for one (Patient #16) of 24 patients. --- Findings: Patient #16A review of a POC dated 03/09/26 to 05/07/26 with IDG updates on 03/19/26, 04/02/26, 04/16/26, 04/30/26 and on 05/14/26 showed a hospice aide visit frequency of one time per week for one week, then two times a week. The clinical record showed hospice aide missed visits on 03/17/26, 03/27/26, 04/14/26, 04/15/26, 04/17/26, 04/23/26, 05/01/26 and 05/07/26. The IDG communication notes showed no discussion about the missed aide visits, no decrease in the hospice aide visits frequency and no change in the physician orders.  On 05/22/26 at 12:27 p.m., Staff C stated the IDG did not address the missed visits.

Based on record review and interview, the hospice failed to ensure a QAPI performance improvement project in calendar year 2025 for all patients and employees. --- Findings: A review of QAPI program records showed no selected performance improvement project that reflected the needs of its patient population in calendar year 2025.  On 05/22/26 at 10:50 a.m., Staff D stated there were no performance improvement projects in 2025.

Based on record review and interview, the hospice failed to ensure measurable goals and outcomes for the performance improvement project in calendar year 2024 for all patients and employees. --- Findings: A review of QAPI records showed no measurable goals and outcomes in the implementation and evaluation of the performance improvement project for calendar year 2024. On 05/22/26 at 10:50 a.m., Staff D stated the performance improvement project in 2024 had no measurable goals and outcomes.

Based on record review and interview, the agency failed to ensure review and update of hospice aide care plans for 10 (Patients #2, 4, 5, 7, 8, 10, 11, 12, 22 and #24) of 24 patients. --- Findings: Patient #2A review of a POC dated 04/13/26 to 06/11/26 and IDG updates to the POC on 03/27/26, 04/10/26, 04/24/26 and 05/08/26 ordered hospice aide visits at a frequency of three visits every week. The clinical record showed no review and update to the hospice aide care plan since 01/12/26. Patient #4A review of a POC dated 04/15/26 to 06/13/26 with IDG updates on 04/10/26, 04/24/26 and on 05/08/26 ordered hospice aide visits at a frequency of three visits every week. The clinical record showed no review and update to the hospice aide care plan since 06/20/25. Patient #5A review of a POC dated 03/11/26 to 05/09/26 with IDG updates on 03/12/26, 03/26/26, 04/09/26, 04/23/26 and on 04/30/26 ordered hospice aide visits at a frequency of three visits every week. The clinical record showed no review and update to the hospice aide care plan since 01/02/26. Patient #7A review of a POC dated 04/13/26 to 06/11/26 with IDG updates on 04/16/26, 04/23/26 and on 05/06/26 ordered hospice aide visits at a frequency of three visits every week. The clinical record showed no review and update to the hospice aide care plan since 02/17/26. Patient #8A review of a POC dated 03/06/26 to 05/04/26 with IDG updates on 03/19/26, 04/02/26, 04/16/26, 04/23/26 and on 05/06/26 ordered hospice aide visits at a frequency of three visits every week. The clinical record showed no review and update to the hospice aide care plan since 11/06/25. Patient #10A review of a POC dated 03/17/26 to 05/15/26 with IDG updates on 03/13/26, 03/27/26, 04/10/26, 04/24/26 and on 05/08/26 ordered hospice aide visits at a frequency of three visits every week. The clinical record showed no review and update to the hospice aide care plan since 01/09/26. Patient #11A review of a POC dated 03/20/26 to 05/18/26 with IDG updates on 03/27/26, 04/10/26, 04/24/26 and on 05/08/26 ordered hospice aide visits at a frequency of three visits every week. The clinical record showed no review and update to the hospice aide care plan since 01/19/26. Patient #12A review of a POC dated 03/11/26 to 05/09/26 with IDG updates on 03/12/26, 03/26/26, 04/09/26, 04/23/26 and on 05/14/26 ordered hospice aide visits at a frequency of three visits every week. The clinical record showed no review and update to the hospice aide care plan since 02/18/26. Patient #22A review of a POC dated 12/11/25 to 02/08/26 with IDG updates on 12/04/25 and on 12/18/25 ordered hospice aide visits at a frequency of three visits every week. The clinical record showed no review and update to the hospice aide care plan since 11/06/25. Patient #24A review of a POC dated 02/23/26 to 04/23/26 with IDG updates on 02/25/26 and on 03/11/26 ordered hospice aide visits at a frequency of three visits every week. The clinical record showed no review and update to the hospice aide care plan since 12/31/25. On 05/22/26 at 11:25 a.m. to 12:55 p.m., Staff C stated the hospice aide care plans were not reviewed for patients #2, 4, 5, 7, 8, 10, 11, 12, 22 and #24 during the recertification visits for continued services.

Based on record review and interview, the hospice failed to ensure personnel records were maintained with employee acknowledged job description for one (Staff H) of three volunteers and six employees. --- Findings: Staff HA review of personnel records showed no signed job description for chaplain role and responsibilities.On 05/22/26 at 11:00 a.m., Staff K stated Staff H did not have a signed job description.

Based on record review and interview, the hospice failed to ensure personnel records were maintained with annual employee performance evaluations for five (Staff E, F, G, I and J) of three volunteers and six employees. --- Findings: Staff EA review of personnel records showed a date of hire of 10/18/17. Documentation showed no annual performance evaluation in 2025.  Staff FA review of personnel records showed a date of hire of 01/06/10. Documentation showed no annual performance evaluations in 2025 and up to 05/22/26.  Staff GA review of personnel records showed a date of hire of 01/12/24. Documentation showed no annual performance evaluation in 2025 and up to 05/22/26. Staff IA review of personnel records showed a date of hire of 08/31/16. Documentation showed no annual performance evaluation in 2025.  Staff JA review of personnel records showed a date of hire of 10/31/22. Documentation showed no annual performance evaluation in 2025.  Additional request for information yielded no results. On 05/22/26 at 11:00 a.m., Staff A stated personnel records for Staff E, F, G, I and J were provided and did not contain annual performance evaluations.

Based on record review and interview, the hospice failed to ensure it completed a discharge summary of care for two (Patients #19 and #20) of 24 patients. --- Findings: Patient #19A review of the clinical record showed the patient was discharged from the hospice on 01/12/26 during an LPN visit. The clinical record showed no discharge summary was completed. Patient #20A review of the clinical record showed the patient was discharged from the hospice on 03/12/26 during an LPN visit. The clinical record showed no discharge summary was completed. On 05/22/26 at 12:40 p.m., Staff C stated:Patients #19 and #29 did not have discharge summaries.The discharge summaries should have been completed by an RN at the time of discharge.

Based on record review and interview, the hospice failed to ensure completion of an initial assessment within 48 hours from receipt of referral for hospice services for four (Patients #1, 4, 6 and 10) of 19 patients. --- Findings: Patient #1 A review of the clinical record showed a referral for hospice services on 10/21/22. Documentation showed an initial / comprehensive assessment dated 11/02/22 (12 days from receipt of the referral). Documentation showed no patient or caregiver refusal or, request to delay hospice services, no communication with the physician and no change in orders. Patient #4 A review of the clinical record showed a referral for hospice services on 12/13/22. Documentation showed an initial / comprehensive assessment dated 12/16/22 (3 days from receipt of the referral). Documentation showed no patient or caregiver refusal or, request to delay hospice services, no communication with the physician and no change in orders. Patient #6 A review of the clinical record showed a referral for hospice services on 05/31/23. Documentation showed an initial / comprehensive assessment dated 06/06/23 (7 days from receipt of the referral). Documentation showed no patient or caregiver refusal or, request to delay hospice services, no communication with the physician and no change in orders. Patient #10 A review of the clinical record showed a referral for hospice services on 10/04/22. Documentation showed an initial / comprehensive assessment dated 10/13/22 (9 days from receipt of the referral). Documentation showed no patient or caregiver refusal or, request to delay hospice services, no communication with the physician and no change in orders. On 07/26/23 from 11:50 a.m. to 1:10 p.m., Staff B stated the initial assessments and subsequent comprehensive assessments for patients #1, 4, 6 and 10 had not been completed within 48 hours from receipt of referral for hospice services.

Based on record review and interview, the hospice failed to ensure: 1. Hospice aide services were provided in accordance with the plan of care for three (Patients #2, 4 and 5) of 19 patients and; 2. Skilled nurse services were provided in accordance with the plan of care for one (Patient #8 and 15) of 19 patients. --- Findings: Patient #2 A review of the plan of care dated 12/03/23 to 03/29/23 and plan of care updates dated 01/05/23, 01/19/23, 02/02/23 and 02/16/23 ordered hospice aide visits at a frequency of three visits every week for 11 weeks. Documentation showed during the week of 01/22/23 to 01/28/23 hospice aide visits were conducted on 01/24/23 and 01/27/23 (3 visits ordered, two visits conducted). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency for the hospice aide. Patient #4 A review of the plan of care dated 03/16/23 to 06/13/23 and plan of care updates dated 03/15/23 and 03/29/23 ordered hospice aide visits at a frequency of one time a week. Documentation showed during the week of 04/01/23 to 04/08/23 no hospice aide visits were conducted (1 visits ordered, no visit conducted). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency for the hospice aide. Patient #8 A review of the plan of care dated 03/31/23 to 06/28/23 and plan of care updates dated 04/06/23, 04/20/23 and 05/04/23 ordered SN visits at a frequency of six times a week, effective week of 04/02/23. Documentation showed during the week of 04/02/23 to 04/08/23 SN visits were conducted on 04/03/23, 04/04/23, and 03/07/23 (six visits ordered, three visits conducted). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency for the SN. Patient #15 A review of the plan of care dated 12/28/22 to 03/27/23 and plan of care updates dated 12/29/23, 01/04/23 and 01/18/23 ordered hospice aide visits at a frequency of three times a week and SN visits at a frequency of four times a week, effective week of 01/22/23. Documentation showed during the week of 01/01/23 to 01/07/23 hospice aide visits were conducted on 01/03/23 and 01/14/23 (three visits ordered, two visits conducted), 01/09/23 and 01/11/23 (three visits ordered, two visits conducted); and during the week of 01/22/23 to 01/28/23 SN visits were conducted on 01/22/23, 01/23/23, 01/24/23, 01/25/23, 01/26/23, 01/27/23 and 01/28/23 (four visits ordered, seven visits conducted). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency for the hospice aide. On 07/26/23 at 1:05 p.m., Staff B stated: 1. Hospice aide frequencies were not followed as ordered for patients #2, 4 and 15 and; 2. Skilled nurse frequency were not followed as ordered for patients #8 and 15.

Based on record review and interview, the hospice failed to ensure the plans of care were fully developed to include intervention goals and/or to update intervention goals for six (Patients #2, 4, 7, 8, 10 and 14) of 19 patients. --- Findings: Patient #2 A review of the plan of care dated 12/03/23 to 03/29/23 and plan of care updates dated 01/05/23, 01/19/23, 02/02/23 and 02/16/23 failed to include intervention goals for the palliation and management of the terminal illness protein deficient malnutrition. Patient #4 A review of the plan of care dated 03/16/23 to 06/13/23 and plan of care updates dated 03/15/23 and 03/29/23 failed to update intervention management of the secondary diagnosis of terminal illness chronic venous stasis ulcer to the right foot. Documentation showed no active wound site to the right foot but continued to include Betadine treatment to toes on the right foot as an active part of the medication profile list. Patient #7 A review of the plan of care dated 03/31/23 to 06/28/23 and plan of care updates dated 04/06/23, 04/20/23 and 05/04/23 failed to include intervention goals for the management of the secondary diagnosis of stage 2 pressure ulcer to the coccyx. Documentation showed treatment interventions of SN to cleanse site with sterile normal saline, apply barrier cream and cover with border dressing every other day. Patient #8 A review of the plan of care dated 03/31/23 to 06/28/23 and plan of care updates dated 04/06/23, 04/20/23 and 05/04/23 failed to include intervention goals for the management of the secondary diagnosis of stage 4 pressure ulcer to the right foot. Patient #10 A review of the plan of care dated 06/10/23 to 08/08/23 and plan of care updates dated 06/15/23, 06/29/23 and 07/13/23 failed to update intervention goals for the management of the secondary diagnosis of pressure ulcer to the left heel. Documentation showed no active wound site and no interventions to the left heel but continued to include goals to prevent infection at the wound site. Patient #14 A review of the plan of care dated 06/05/23 to 09/02/23 and plan of care updates dated 06/07/23, 06/22/23, 07/06/23 and 07/20/23 failed to include intervention goals for the palliation and management of the terminal illness protein deficient malnutrition. Documentation showed interventions to monitor the patients weight. Documentation showed no weight reporting parameters or intervention goals. On 07/26/23 at 11:55 a.m. to 1:00 p.m., Staff B stated the plans of care for patients #2, 4, 7, 8, 10 and 14 failed to include and/or to update intervention goals.

Based on record review and interview, the hospice failed to ensure on-site supervisory visits were completed every 14 days for one (Patient #4) of 19 patients. --- Findings: Patient #4 A review of the plan of care dated 03/16/23 to 06/13/23 showed a home health aide visit frequency of one time per week. Documentation showed home health aide visits were conducted on 04/12/23, 04/19/23 and on 04/26/23. Documentation showed no supervisory visits were made from 04/11/23 to 04/28/23 (17 days between supervisory visits). On 07/26/23 at 12:05 p.m., Staff B stated supervisory aide visits were not conducted every 14 days for patient #4.