Every finding on record at The Evangelical Lutheran Good Samaritan Society

Based on record review, policy and procedure review, and staff interview, the hospice failed to have qualified social worker (SW) as a member of the hospice interdisciplinary group (IDG) which had the potential to affect all 16 current hospice patients. The sample size was 14. --- Findings are: A. Review of the agency policy and procedure titled Social Services, Hospice-Enterprise, last reviewed/revised 10/1/24, revealed:1. Social services are provided by a qualified social worker, licensed in the state. 2. The social worker will be a member of the interdisciplinary group (IDG) and will participate in the development, implementation, and revision of the plan of care. 3. The social worker will contribute to the comprehensive assessment and ongoing updates to the comprehensive assessment based on the needs of the patient. B. Review of the agency policy and procedure titled, Interdisciplinary Group (IDG), Hospice-Enterprise, last reviewed/revised 4/8/25, revealed:1. The hospice provides comprehensive care and services through the efforts of an IDG that established the plan of care (POC). 2. The core members of the IDG include a SW, registered nurse, counselor, and physician.3. The IDG meets at least every 15 days to revise the POC.4. The IDG coordinates care, ensures continuous assessment of the patient and family, implements the POC.  C. Review of hospice's current personnel roster revealed one SW listed. SW-G was to begin employment on 12/1/25. D. During an interview on 12/1/25 at 12:00 PM, the Administrator and the Clinical Manager revealed:1. SW-G began employment 12/1/25.2. Last full-time date of employment, for SW-L (previous SW), was 6/27/253. SW-L became employed as an "as needed" (PRN) employee on 6/28/25 and resigned the PRN position effective 10/2/25.4. SW- L did not regularly participate in the IDG team meetings, in the development, implementation, and revision of the plan of care for hospice patients during the PRN time frame. 5. The hospice did not have a SW employee from 10/3/25 through 11/30/25.

Based on record review, policy and procedure review, and staff interview, the agency failed to ensure new and/or revised medication orders were included on the current Client Medication Report (the form used to list all current and active patient medications) for 2 of 14 (Patient 4 & 5) patient records reviewed. The census was 16. --- Findings are:A. Review of the the policy and procedure titled Provider Orders and Notification, Home Health- Enterprise, reviewed/revised 5/27/25, revealed complete provider orders, including all medication and treatment orders are documented in the electronic medical record.  B. Review of the policy and procedure titled Medication Management, Hospice- Enterprise, reviewed/revised 1/27/25, revealed the Medication Profile/Medication Reconciliation was to include prescription, over- the- counter drugs, herbal remedies, and other alternative treatments. The hospice must ensure the patient's medication list is current at each reconciliation.  C. Review of Patient 4's clinical record revealed:1. A Client Coordination note dated 11/13/25. The note revealed the patient had started an allergy medication (name of medication not specified).2. The current Client Medication Report provided on 11/18/25, did not include any allergy medication in the list of medications.  D. Review of Patient 5's clinical record revealed:1. A Skilled Nurse Visit Note Report dated 11/4/25. The note revealed the patient's Miralax (a bowel management medication) was decreased to three times per week. 2. A physician communication note dated 11/4/25 requesting to change the frequency of Miralax. The physician approved Miralax 17 grams by mouth Monday, Wednesday and Friday.3. The current Client Medication Report provided on 11/18/25, did not include the change in the Miralax frequency. E. During an interview on 11/18/25 at 4:30 PM, the Administrator and the Clinical Manager confirmed updated/revised medications for Patient 4 and 5 were not included on these patient's current Client Medication Report.

Based on record review, policy and procedure review, and staff interview, the hospice failed to ensure the Hospice Aide Plan of Care included patient specific interventions for 4 of 11 (Patient 3, 5, 10, and 12) patients reviewed who received hospice aide (HA) services. The sample size was 14. The census was 16. --- A. Review of the agency policy and procedure titled Aide Services, Hospice-Enterprise, reviewed/revised 9/2/25, revealed:1. The Interdisciplinary Group (IDG) identifies the need for aide services.2. The Registered Nurse (RN) arranges HA services, prepares written instructions, assigns care, and supervises the HA.  B. The hospice did not have a policy specific to the development and revisions to the HA plan of care.  C. Review of Patient 3's clinical record revealed:1. The patient's start of care was 10/30/24.2. The Hospice Certification and Plan of Care Update for the certification periods of 8/26/25 through 10/24/25 and 10/25/25 through 12/23/25 included orders for HA one time per week for assistance with personal care, hygiene, and activities of daily living (ADLs). 3. The Aide Care Plan Report (the HA plan of care/assignment form) for the certification period of 10/25/25 through 12/23/25, included the task of routine catheter cares every visit. 4. A skilled nurse (SN) Visit Note Report dated 9/26/25 revealed the patient's foley catheter was discontinued this date. 5. The HA Care Plan Report was not revised once the patient's foley catheter was discontinued.  D. Review of Patient 5's clinical record revealed:1. The patient's start of care was 4/25/25.2. The Hospice Certification and Plan of Care Update for the certification periods of 7/24/25 through 10/21/25 and 10/22/25 through 12/20/25 included orders for HA one time per week for assistance with personal care, hygiene, and ADLs. 3. The Aide Care Plan Report (the HA plan of care/assignment form) for the certification period of 10/22/25 through 12/20/25, included the task shower every visit. 4. A SN Visit Note Report dated 9/2/25 reveals the patient is bed bound.5. A SN Visit Note Report dated 9/16/25 reveals the patient is only out of bed to be weighed.6. A HA Visit Note Reports dated 9/3/25, 9/8/25, 9/15/25, 10/6/25, and10/20/25 revealed the HA performed a bed bath, not a shower. 7. The Aide Care Plan Report had not been updated to include bed bath.  E. Review of Patient 10's clinical record revealed:1. The patient's start of care was 3/1/25.2. The Hospice Certification and Plan of Care Update for the certification period 10/27/25 through 12/25/25 included orders for HA two times per week for 8 weeks then one time per week for one week for assistance with personal care, hygiene, and ADLs.3. The Aide Care Plan Report for the certification period of 10/27/25 through 12/25/25, included stand by assistance for ambulation to bathroom, toileting assistance as needed. 4. A Client Coordination Note dated 10/28/25, revealed a note by the HA indicated the patient is becoming weaker, more difficulty ambulating to the bathroom, and okayed trying a bedside commode. 5. A Client Coordination Note dated 10/31/25, revealed a note by the HA indicated the patient is reportedly using the bedside commode with the help of the caregiver due to continued weakness and instability to use commode independently. 6. The Aide Care Plan Report had not been updated with the new intervention of the bedside commode or increased assistance with transfers.  F. Review of Patient 12's clinical record revealed:1. The patient's start of care was 2/11/25. 2. The Hospice Certification and Plan of Care for the certification period of 2/11/25 through 5/11/25 included orders for HA one time per week. 3. The Aide Care Plan Report for the certification period of 2/11/25 through 3/31/25, included interventions to transfer client from bed to chair, chair to bed, assist to beside commode every visit, and tub bath/bed bath every visit. 4. The Hospice IDG Comprehensive Assessment and Care Plan Update Report dated 2/19/25, indicated the patient has residual right-sided hemiparesis. 5. A SN Visit Note dated 2/24/25 revealed the patient is a maximal assist using a Hoyer lift (a full body mechanical lift device) for transfers. 6. The Aide Care Plan Report does not include information regarding the patient's maximal assist level, use of a Hoyer lift for transfers or the patient's right-sided hemiparesis.  G. During an interview on 12/1/25, the Administrator and the Clinical Manager confirmed the HA Care Plan for Patient 3, 5, 10, and 12 did not include patient specific interventions to aid the HA in providing services to the hospice patients and also confirmed the hospice did not have a policy specific to developing and updating a hospice aide plan of care.

Based on record review, policy and procedure review, and staff interview, the hospice failed to provide a minimum of 5 percent of the total direct patient care services by volunteers for October 2024 through August 2025 and failed to have available volunteer usage reporting for January 2024 through August 2024. The census was 16. --- Findings are: A. Review of the agency policy and procedure Volunteer Services and Documentation, Hospice-Enterprise, last reviewed/revised 3/6/25, revealed:1. Volunteers provide administrative and/or direct care/support greater than or equal to 5% of the total patient care hours of all paid employees.2. Volunteer hours are compiled on a regular basis.3. The agency determines the time spent by volunteers and estimates the financial savings due to their time and services.  B. Review of the Hospice Volunteer Hours Reports for 2024 and 2025 revealed:1. The 2024 report from January 2024 through August 2024 did not include any total staff visit hours to calculate the volunteer usage percentage.2. The 2024 report from October 2024 through December 2024 did not meet the required 5% of total direct patient care services by volunteers.3. The 2025 report from January 2025 through August 2025 did not meet the required 5% of total direct patient care services by volunteers. C. During an interview on 12/1/25 at 11:00 AM, the Administrator and the Volunteer Coordinator confirmed the hospice failed to provide a minimum of 5 percent of total direct patient care services by volunteers for October 2024 through August 2025 and failed to have available volunteer usage reporting for January 2024 through August 2024.

Based on record review, policy and procedure review, and staff interview, the hospice failed to have a qualified social worker (SW) with a Master of Social Work (MSW) degree and/or a Bachelor of Social Work (BSW) with a supervising MSW. This failure had the potential to affect all 16 of the hospice patients on census. The sample size was 14. --- Findings are: A. Review of the agency policy and procedure titled Social Services, Hospice-Enterprise, last reviewed/revised 10/1/24, revealed:1. Social services are provided by a qualified social worker (MSW, BSW), licensed in the state. 2. The policy does not indicate that if a BSW is employed by the hospice, the BSW will be supervised by a qualified MSW.  B. Review of hospice's current personnel roster revealed one SW listed. SW-G was to begin employment on 12/1/25. SW-G is a BSW. C. Review of SW-G's personnel file revealed:1. Date of hire was 12/1/25.2. SW-G is a licensed SW in the State of Nebraska, and holds a BSW degree.  D. During an interview on 12/1/25 at 12:00 PM, the Administrator and the Clinical Manager revealed:1. SW-G to began employment 12/1/25. SW-G is a BSW.2. SW-L (previous MSW) last full-time date of employment was 6/27/25.3. SW-L became employed on an "as needed" (PRN) employee on 6/28/25 and resigned the PRN position effective 10/2/25.4. The hospice did not have any SW employee from 10/3/25 through 11/30/25.5. The hospice currently does not have a MSW to provide supervision to SW-G.