Every finding on record at Shalom Hospice LLC

It is required that all hospice aide services must be provided by an individual who has successfully completed one (1) of the four (4) training and competency evaluations programs described below. A qualified hospice aide has successfully completed a competency evaluation program that: evaluates the aide’s competency in the following subject areas by observation of the aide’s performance with a patient or pseudo-patient: sponge, tub, and shower bath; [and] hair shampoo (sink, tub, and bed). The competency evaluation is performed by a registered nurse in consultation with other skilled professionals, as appropriate. This standard was not met as evidenced by clinical record review, interview, observation, and personnel record review. In 1 of 2 (50%) personnel records reviewed for Hospice Aides (HA), the hospice did not ensure that HA competency was evaluated for all assigned tasks. PERSONNEL RECORD 7/CLINICAL RECORD 3/HOME VISIT 1: The Hospice Aide was hired on 02/24/2025. A review of the personnel record revealed no documented evidence that the hospice evaluated the HA's competency with a patient or a pseudo-patient in performing a shower and shampoo. A review of Clinical Record 3 revealed that the Hospice Aide visit notes dated 09/23/2025, 10/10/2025, and 11/07/2025.documented that the HA completed the assigned tasks: shower and shampoo. Additionally, the review of Clinical Record 3 revealed that the Hospice Aide Plan of Care dated 09/10/2025 and 11/11/2025 assigned shampoo and shower every visit. During Home Visit 1 with the HA [Personnel Record 7] on 10/11/2025, the HA was observed completing the tasks: bathing/shower and shampoo. There was no documented evidence that the hospice evaluated the HA's competency by observing the HA complete a shower and shampoo. During a joint record review and interview on 11/13/2025, the Clinical Director stated, "We didn't realize it wasn't there. We are working on that skills competency now and will get it done." During a joint record review and interview on 10/13/2025, the Senior Executive Director stated, "It was overlooked by the previous team, and we have updated our process and trained new staff on the requirements ."

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. A review of the Volunteer Binder revealed the hospice did not ensure to demonstrate and document viable and ongoing efforts to recruit and retain volunteers for February 2024 to August 2025. A joint review of the Volunteer Binder with the Senior Executive Director/Volunteer Coordinator on 10/13/2025 revealed no documented evidence of recruitment or retention efforts for the period from February 2024 to August 2025. During an interview on 10/13/2025, the Senior Executive Director/Volunteer Coordinator confirmed the finding and stated, "The national leaders identified gaps in our program, so I stepped in and we started a performance improvement plan (PIP) in August and hired a new Volunteer Coordinator in October. We are on track now." During a joint review of the Volunteer Binder and interview on 10/13/2025, the Executive Director agreed there was no documented evidence of recruitment or retention efforts for February 2024 to August 2025. A review of the Volunteer Binder revealed the hospice did not ensure to demonstrate and document viable and ongoing efforts to recruit and retain volunteers for February 2024 to August 2025.