Every finding on record at Good Shepherd Hospice, Inc.

Based on record review and interview, the IDG failed to ensure an updated patient specific POC was provided timely to the facility where one (#3) of four (#1 - #4) facility patients visits and records were reviewed. This failed practice had the potential to prevent all 144 facility patients currently on census from receiving care and services to meet their specific needs. --- Patient #3Review of the POC for Patient #3 showed a re-certification period of 05/02/26 - 06/30/26 and a primary diagnosis of Chronic Obstructive Pulmonary Disease with orders for SN visits 3 times a week for 8 weeks and 1 time a week for 1 week, HA visits 2 times a week for 8 weeks and 1 time a week for 1 week.Staff B stated Patient #3 resides at a local facility and a visit was conduct at the facility on 06/03/26 at 11:00AM. The current Aide POC dated 05/05/26 was not identified in the facility communication record for Patient #3. The last Aide POC identified in the facility communication records was dated for the initial SOC date of 07/11/24. During an interview on 06/04/26 at 09:40AM, Staff B stated the agency failed to maintain a current Aide POC in the facility.

Based on administrative record review and interview of the agency Volunteer program, the agency failed to achieve a 5% cost savings for Volunteer activities. This failed practice had the potential to prevent the agency from providing assistance and support to the 208 patients and families currently on service. --- Review of the Volunteer program activity log for 2025 showed a year end average of 1.99 % cost savings The current cost savings log for 2026 year-to-date showed a 2.37% average cost savings.During an interview on 06/03/26 at 4:00 PM, the Volunteer Coordinator stated the Volunteer program did not meet the 5% cost savings for the previous year of 2025 as well as the current year of 2026.

Based on record review and interview, the hospice failed to ensure hospice aide services were provided in accordance with the plan of care for three (Patient #1) of 15 patients. --- Findings: Patient #1 A review of the plan of care dated 12/06/23 to 03/04/24 and IDG plan of care updates dated 12/15/23, 12/29/23, 01/12/24, 01/26/24, 02/09/24 and 02/23/24 ordered hospice aide visits at a frequency of two visits every week for eight weeks, then one time a week for one week. Documentation showed during the week of 01/22/23 to 01/28/23 hospice aide visits were conducted on 01/14/24 and 01/20/24 (two visits ordered, one visits conducted). Documentation showed one visit was missed due to no help. Documentation showed no patient or family refusal of visits and no changes in the ordered frequency for the hospice aide. On 03/05/23 at 2:15 p.m., Staff A stated: 1. The hospice aide frequency was not followed as ordered for patients #2 and; 2. The aide should have called the nurse to assist with the patient.

Based on record review and interview, the hospice failed to ensure patient refusal of hospice aide services was communicated and addressed by the IDG for one (Patient #3) of 15 patients. --- Findings: Patient #3 A review of a POC dated 12/08/23 to 03/06/24 documented a hospice aide visit frequency of two times a week for 12 weeks, then one time a week for one week with IDG meetings to update the POC on 12/29/23, 01/12/24, 01/26/24, 02/09/24 and 02/23/24. Documentation showed patient refusal of hospice aide visits on 12/11/23, 01/02/24, 01/12/24, 01/19/24, 02/14/24 and on 02/19/24. Documentation showed no attempts to reschedule the visits or follow up with the patient, showed no IDG team meeting discussions of patient refusal of hospice aide visits and no changes in hospice aide visit frequency. On 03/05/24 at 2:25 p.m., Staff A stated: 1. IDG documentation showed no discussion of patient refusal of hospice aide services during the IDG team meetings and; 2. The nursing facility where the patient resides wants us (the hospice) to continue to try to shower the patient twice a week.

Based on record review and interview, the hospice failed to establish a hospice aide care plan prior to the provision of aide services for one (Patient #10) of 15 patients. --- Findings: Patient #10 A review of the clinical record showed no hospice aide care plan prior to the provision of aide services for the episode of 06/19/23 through 09/16/23. IDG POC update dated 07/16/23 documented a hospice aide visit frequency of two times a week for seven weeks. Documentation showed a hospice aide care plan dated effective 08/01/23. Documentation showed no hospice aide care plan from 07/16/23 to 07/31/23. Hospice aide visits were conducted on 07/25/23 and 07/28/23. On 03/05/24 at 3:00 p.m., Staff A stated the clinical record showed no hospice aide care plan for hospice aide visits on 07/25/23 and 07/28/23.

Based on record review and interview, the hospice failed to ensure on-site aide supervisory visits were completed every 14 days for one (Patient #7) of 15 patients. --- Findings: Patient #7 A review of the plan of care dated 01/10/24 to 03/09/24 showed a home health aide visit frequency of one time per week for one week then, two times a week for eight weeks. Documentation showed supervisory visits were made on 01/29/24 and on 02/15/24 for period of 01/29/24 to 02/15/24 (17 days between supervisory visits). On 03/05/24 at 2:42 p.m., Staff A stated supervisory aide visits were not conducted every 14 days for patient #7.