Every finding on record at Good Shepherd Hospice, Inc.

Based on record review, observation and interview, the agency failed to ensure home oxygen safety precautions were implemented as ordered per the POC for two (#3 and #4) of two (#3 and #4) home visit patients with orders for oxygen. --- Review of the agency "Family Handbook for Hospice Care" provided to patient and families at admission read in part, "Medical Oxygen Safety" information with specific fire safety rules to "Post NO SMOKING and NO OPEN FLAMES" signs in and outside the home to remind people not to smoke." Further review of agency policy # PC. S15 titled, "Safety - Patient/ Caregiver" read in part, "Policy Statement: An evaluation of the safety of the patient/caregiver's home environment is included in the comprehensive assessment of the patient..." " Item 2.a...Fire safety (smoking, smoke detectors, fire escape routes, electric blankets, oxygen therapy, space heaters and cooking safety)..."  "Item 5. Safety issues are reassessed on an ongoing basis..."Patient #3Review of the recertification POC for period 06/12/25 - 08/10/25 showed a primary diagnosis of Chronic Obstructive Pulmonary Disease with orders for Oxygen at 2 liters per nasal cannula PRN and for SN and SW to provide assessment of patient safety and instruction on safety measures including oxygen safety, DME safety and home safety, etc.   During a home observation visit on 07/15/25 at 10:00 AM, oxygen was present in the home. Upon further home observation, no signs were identified to indicate "NO SMOKING" in the home. Patient #4Review of the SOC certification POC for period 06/02/25 - 07/31/25 showed a primary diagnosis of Sarcopenia with orders for Oxygen at 2 liters per nasal cannula PRN and for SN and SW to provide assessment of patient safety and instruction on safety measures including oxygen safety, DME safety and home safety, etc.  During a home observation visit on 07/15/25 at 08:30 AM, oxygen was present in the home. Upon further home observation, no signs were identified to indicate "NO SMOKING" in the home. During an interview on 07/15/25 at 08:30 AM, Patient #4 stated they used oxygen as needed.During an interview on 07/15/25 at 10:00 AM, Patient #3 stated they used oxygen as neededDuring an interview on 07/15/25 at 02:30 PM, Staff A stated the DME company that supplied the oxygen failed to provide 'No Smoking" signs and the agency staff failed to ensure "No Smoking" signs were posted in the home as required for oxygen safety measures for patients #3 and #4.