Every finding on record at Sholom Hospice

Based on interview and document review the hospice agency failed to ensure that the care and services are provided in accordance with the plan of care and that visit order frequencies were followed for 3 of 10 patients (P6, P12 and P14) reviewed for visit frequencies. --- Findings include: P6’s Hospice Plan of Care (POC) printed 5/29/25, indicated P6 was admitted to hospice care on 4/10/25 with a primary diagnosis of hypertensive heart disease with heart failure. P6’s Hospice POC further indicated P6 had an order for Hospice Aide (HA) visits one time a week from 4/13/25 – 7/8/25. P6’s Electronic Medical Record (EMR) indicated P6 had one HA visit since admitted to hospice care on 4/14/25. P12’s Hospice POC printed 5/28/25, indicated P12 was admitted to hospice care on 12/7/24 with a primary diagnosis of severe protein-calorie malnutrition. P12’s Hospice POC further indicated P12 had an order for HA visits one time a week from 3/7/25 – 6/4/25. P12’s EMR indicated P12 missed a HA visit the week of 3/23/25 – 3/29/25, 4/20/25 – 4/26/25, and 5/11/25 – 5/17/25. A missed HA visit report was completed on 4/7/25. P14’s Hospice POC printed 5/29/25, indicated P14 was admitted to hospice care on 8/9/22 with a primary diagnosis of Alzheimer’s Disease. P14’s Hospice POC further indicated P14 had an order for HA visits one time a week from 3/26/25 – 5/24/25 and one time a week from 5/25/25 – 7/23/25. P14’s EMR indicated P14 missed an HA visit the week of 4/13/25 – 4/19/25, 4/20/25 – 4/26/25, 5/11/25 – 5/17/25, and 5/18/25 – 5/24/25. During an interview on 5/29/25 at 1:57 p.m., the Director of Home and Community-Based Services (DHCBS) confirmed P6, P12, and P14 were missing HA visits. The DHCBS stated it would be expected that the visit frequencies were followed, and a missed visit report would be put in if a visit was missed. The DHCBS stated she believed P6 was getting aide visits weekly but could not confirm due to an IT issue that prevented the HA from documenting any visits made since 4/14/25. The DHCBS stated it would be expected that she would know about an IT issue to prevent documentation issues as this can prevent continuity of care.