Every finding on record at Shore Health Services, Inc

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the initial comprehensive assessment was completed no later than five calendar days after the election of hospice care. CLINICAL RECORD 18: The patient elected the hospice benefit on 12/02/2024 with a terminal diagnosis of intrahepatic cholangiocarcinoma. Clinical record review revealed no documented evidence that a spiritual assessment was completed no later than 5 calendar days after the election of benefit, as part of the initial comprehensive assessment. The Chaplain documented on a clinical note dated 12/09/2025 that the patient passed before he was able to provide a visit and assess the patient. During a joint review of the record and interview on 07/18/2025, the Hospice Agency Manager stated that the comprehensive assessment was not completed within the required time frame.

It is required that the patient’s pain is assessed as part of a comprehensive assessment. The documented assessment of the patient’s pain includes characteristics of the pain, including location, frequency, and intensity. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure the patient’s pain assessment included characteristics of the pain, including location, frequency, and intensity. CLINICAL RECORD 6: The patient elected the hospice benefit on 11/20/2024 with a terminal diagnosis of adenocarcinoma of the rectum. The initial pain assessment dated 11/20/2024 included documentation that the patient reported mild pain. The pain assessment did not include characteristics of the pain, including location, frequency, and intensity. CLINICAL RECORD 8: The patient elected the hospice benefit on 04/28/2025 with a terminal diagnosis of mucinous adenocarcinoma. The Registered Nurse documented on the initial assessment dated 04/28/2025 that the patient had pain in the shoulder and abdomen and patient was prescribed morphine. The pain assessment did not include characteristics of the pain, including frequency or intensity. During joint review of records and interview on 07/17/2025, the Clinical Manager stated the pain assessments did not include documentation of the characteristics of the pain, including location, frequency, and intensity.

It is required that each patient’s individualized written plan of care Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 4 of 19 (21%) clinical records reviewed, the agency did not ensure the individualized written plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 5: The patient elected the hospice benefit on 02/19/2022 with a terminal diagnosis of Parkinson's Disease. The patient has been recertified for multiple episodes of care and is a current patient. The Registered Nurse (RN) documented on the initial comprehensive assessment dated 02/19/2022 that the patient was experiencing dysphagia (difficulty swallowing) with coughing after eating, and difficulty swallowing. The most recent RN comprehensive assessment included documentation that the patient was experiencing chronic aspiration and pocketed food. The plan of care did not include planned interventions related to the patient’s dysphagia and aspiration symptoms identified in the nursing assessments. CLINICAL RECORD 6: The patient elected the hospice benefit on 11/20/2024 with a terminal diagnosis of adenocarcinoma of the rectum. The patient has been recertified for multiple episodes of care and is a current patient. The plan of care included an order for Chaplain services to be provided once a month for supportive presence and spiritual care. The plan of care did not include planned interventions for spiritual care. CLINICAL RECORD 8: The patient elected the hospice benefit on 04/28/2025 with a terminal diagnosis of mucinous adenocarcinoma. The Registered Nurse documented on the initial comprehensive assessment dated 04/28/2025 that the patient had a diagnosis of Clostridioides difficile. The drug profile was reviewed and revealed the patient was treated with Vancomycin (antibiotic) 250 mg on 04/28/2025. Review of the plan of care for the dates of 04/28/2025 through 07/17/2025 revealed the plan of care did not include interventions for the diagnosis of Clostridioides difficile. CLINICAL RECORD 9: The patient elected the hospice benefit on 05/07/2025 with a terminal diagnosis of chronic obstructive pulmonary disease. The plan of care dated 05/07/2025 to 07/17/2025 included an order for Chaplain services to be provided once a month. The plan of care did not include planned interventions for spiritual care. During a joint review of records and interview on 07/17/2025, the Clinical Manager stated that the plans of care were missing interventions for the problems identified in the assessments and that the interventions might have been missing because of the agency’s decision to utilize more point and click documentation and less narrative.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, observation, and interview. In 1 of 4 (25%) home visit observations, the agency did not ensure staff performed hand hygiene as required by agency policy. Agency policy No. DIV-916 Hand Hygiene Policy and Procedure, required in part, "Perform hand hygiene using an alcohol-based hand hygiene product (when the hands are not visibly soiled) or antimicrobial soap and water...immediately after removing gloves." HOME VISIT 1: During the home visit observation on 07/16/2025 with the Hospice Aide (HA) (Personnel Record 1), the HA was observed to sanitize hands and donned (apply) gloves. One of the gloves ripped, so the HA removed the glove and reached into the nursing bag without sanitizing her hands after the glove removal. During a review of the home visit and interview on 07/16/2025, the Clinical Manager stated that the agency policy was to sanitize hands immediately after removing gloves.

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the nursing needs of the patient were met as identified in the comprehensive assessment. CLINICAL RECORD 7: The patient elected the hospice benefit on 12/21/2024 with a terminal diagnosis of endometrial adenocarcinoma. The Registered Nurse (RN) documented on the initial comprehensive assessment dated 12/21/2025 that the patient rated pain at 10/10 (0 being low pain, 10 being high pain) at the time of the visit. The pain was located in the abdomen and was constant and chronic with movement. There was no documented evidence in the clinical record that the RN addressed the patient's pain during the visit. The RN documented on a follow-up nursing visit note dated 12/22/2024 that the patient was comfortable and did not voice any complaints of pain. During an interview and joint review of the clinical record on 07/16/2025, the Clinical Manager stated that the nurse did not document any interventions for the patient's pain at the initial nursing visit.

It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. The hospice advises the patient and family of spiritual counseling services and documents the acceptance or refusal of services. This standard was not met as evidenced by clinical record review and interview. In 1 of 8 (13%) clinical records reviewed with spiritual counseling services provided, the agency did not ensure spiritual counseling services were provided in accordance with the patient’s and family’s acceptance of the services. CLINICAL RECORD 3: The patient elected the hospice benefit on 11/14/2024 with a terminal diagnosis of dementia in Alzheimer's disease with depression. The Registered Nurse (RN) documented on the initial nursing assessment dated 11/14/2024 that the patient had a fear of dying and a need for prayer and accepted chaplain visits. The Chaplain documented a visit on 11/18/2024 and documented a missed visit on 12/02/2024. A review of the clinical record and IDG [interdisciplinary group] notes from 12/02/2024 through 07/16/2025 revealed no documented evidence of chaplain visits or documentation that chaplain visits were declined. During an interview and review of the record on 07/17/2025, the Clinical Manager stated that the agency was in the process of hiring a second Chaplain to provide chaplain services due to the increasing admissions.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent of the total patient care hours Review of the agency’s volunteer program and documentation revealed the agency’s annual hospice volunteer percentage for 2024 was 2.87%. During an interview and joint review of the volunteer program on 07/16/2025, the Hospice Agency Manager confirmed that the agency’s volunteer percentage was less than 5% for 2024. This standard was not met as evidenced by the review of the Volunteer Program documentation and interview with the Volunteer Coordinator and Agency Manager. The agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The annual hospice volunteer percentage for 2024 was 2.87. In an interview with the Hospice Agency Manager on 07/16/2025, it was stated that the volunteer hours did not equal, at a minimum, 5 percent of the total patient care hours of all paid hospice employees and contract staff.

It is required that each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient's clinical record included physician orders. CLINICAL RECORD 8: The patient elected the hospice benefit on 12/21/2024 with a terminal diagnosis of mucinous adenocarcinoma. The Medical Social Worker documented on a visit note dated 06/13/2025 that a urinalysis was obtained. The clinical record included a physician order dated 06/19/2025 for Cipro 250 mg twice a day for seven days for a urinary tract infection. During an interview on 07/18/2025, the Registered Nurse (RN) was asked about the order for the urinalysis. The RN said she spoke with the Hospice Medical Director to obtain the urinalysis but did not document this communication or the order. The clinical record did not include a physician order for the urinalysis. During a joint review of the record and interview on 07/17/2025, the Clinical Manager stated that the order for the urinalysis was not present in the clinical record.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. 10 of 11 (91%) applicable clinical records reviewed revealed that the comprehensive assessment did not include an initial bereavement assessment of the needs of the patient's family and other individuals. The agency's policy #1101 "Bereavement Services" read in part, "Pre-assessment will be performed before patient's death by the admitting registered nurse/social worker/bereavement counselor." Clinical Record #9: was reviewed and identified the patient elected hospice care on 12/10/2021. The review of the clinical record revealed no evidence of an initial bereavement risk assessment completed during the comprehensive assessment. Clinical Record #3: was reviewed and identified the patient elected hospice care on 8/5/2021. The review of the clinical record revealed no evidence of an initial bereavement risk assessment completed during the comprehensive assessment. Clinical Record #1: was reviewed and identified the patient elected hospice care on 1/2/2021. The review of the clinical record revealed no evidence of an initial bereavement risk assessment completed during the comprehensive assessment. Clinical Record #8: was reviewed and identified the patient elected hospice care on 12/30/2021. The review of the clinical record revealed no evidence of an initial bereavement risk assessment completed during the comprehensive assessment. Clinical Record #6: was reviewed and identified the patient elected hospice care on 8/27/2022. The review of the clinical record revealed no evidence of an initial bereavement risk assessment completed during the comprehensive assessment. Clinical Record #7: was reviewed and identified the patient elected hospice care on 8/11/2020. The review of the clinical record revealed no evidence of an initial bereavement risk assessment completed during the comprehensive assessment. Clinical Record #5: was reviewed and identified the patient elected hospice care on 4/2/2022. The review of the clinical record revealed no evidence of an initial bereavement risk assessment completed during the comprehensive assessment. Clinical Record #4: was reviewed and identified the patient elected hospice care on 2/3/2022. The review of the clinical record revealed no evidence of an initial bereavement risk assessment completed during the comprehensive assessment. The telephone visit documented by the Bereavement Coordinator did not include evidence of a bereavement risk assessment. Clinical Record #2: was reviewed and identified the patient elected hospice care on 1/8/2022. The review of the clinical record revealed no evidence of an initial bereavement risk assessment completed during the comprehensive assessment. Clinical Record #10: was reviewed and identified the patient elected hospice care on 1/27/2022. The review of the clinical record revealed no evidence of an initial bereavement risk assessment completed during the comprehensive assessment. The patient expired on 4/7/2022. During an interview, the clinical manager and agency manager confirmed that it is a requirement of the hospice for an initial bereavement risk assessment to be completed on each patient/family and this information incorporated into the plan of care. Agency policy #1101 Bereavement Services states, "Pre-assessment will be performed before patient's death by the admitting registered nurse/social worker/bereavement counselor." Agency Policy # 1102 states its purpose is to "provide a current evaluation of changes in client's bereavement risk assessment as he/she progresses in the grief process." The bereavement risk assessment guidelines are also stated in both policies. Interview with the clinical manager and agency manager confirmed that it is a requirement of the hospice for an initial bereavement risk assessment to be done on each patient/family and this information incorporated into the plan of care.