Every finding on record at Sacred Heart Enterprises PC

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 8 (12%) clinical records reviewed, the agency did not ensure the individualized written plan of care (POC) included measurable outcomes anticipated from implementing and coordinating the POC. Clinical Record 1: The patient elected the hospice benefit on 07/07/2023. The individualized POC dated 11/09/2023 included a skilled nursing goal that stated, "Patient will maintain optimum level of functioning appropriate for stage of disease process." The goal statement did not include a description of how the achievement of "optimum functioning" by the patient would be measured. During an interview on 11/14/2023, the Administrator and Director of Patient Care Services reviewed the finding and agreed the POC goal was non-measurable.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by personnel record review and interview. In 3 of 10 (30%) personnel records reviewed, the agency did not ensure staff skills and competencies were assessed. Personnel Record 1: Director of Clinical Services, Registered Nurse, Director of Compliance, and Alternate Administrator date of hire 06/27/2023. Personnel record review revealed no documented evidence of an initial competency for the Registered Nurse role. Personnel Record 3: Licensed Clinical Social Worker date of hire 05/02/2023. Personnel record review revealed the competency form for the social worker role was blank. Personnel Record 8: Chaplain and Bereavement Coordinator date of hire 05/01/2023. Personnel record review revealed the competency form for the chaplain role was blank and did not include a competency assessment for the bereavement coordinator role. During review of findings and interview on 11/14/2023, the Administrator and the Director of Clinical Services agreed the personnel records were missing initial competencies assessments.