Shiloh Hospice & Palliative Care, LLC

“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 1 of 14 (7%) clinical records reviewed, it was revealed that the agency did not ensure the plans of care were updated to reflect patient and family goals and interventions based on problems identified in the initial comprehensive and updated comprehensive assessments. Clinical Record 6: The patient elected hospice care on 01/13/2024. The initial nursing assessment dated 01/13/2024 identified the presence of a foley catheter. The individualized written plan of care (POC) dated 01/13/2024 did not include planned goals and interventions related to the foley catheter. During the exit conference on 02/23/2024 with the Director of Nursing, the RN/Administrator, the Licensed Social Worker, the Chaplain/Bereavement Coordinator/Volunteer Coordinator, two registered nurses, and the Nurse Practitioner/Alternate Administrator, it was reviewed and acknowledged that the identified POC did not include goals and interventions related to the foley catheter.”

“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 2 of 14 (14%) clinical records reviewed, it was revealed that the organization did not ensure that the individualized written plan of care (POC) included measurable outcomes anticipated from implementing and coordinating the POC. Clinical Record 7: The patient elected hospice services on 08/09/2023. The individualized written POC effective 09/16/2023 included a goal that stated, “Patient will maintain optimal nutrition and hydration.” The goal did not include a measurable outcome that defined how optimal nutrition and hydration for the patient would be measured. Clinical Record 3: The patient elected hospice services on 08/12/2022. The individualized written POC effective 02/03/2024 included a goal that stated, “[patient name] will maintain optimal nutrition and hydration.” The goal did not include a measurable outcome that defined how optimal nutrition and hydration for the patient would be measured. During a daily wrap up conference on 02/21/2024 with the Director of Nursing, the RN/Administrator, and the Nurse Practitioner/Alternate Administrator, it was reviewed and agreed that the identified POC goals did not include measurable outcomes.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 12 (8%) clinical records reviewed of patients receiving hospice aide services, it was revealed that the agency did not ensure the registered nurse completed written patient care instructions for the hospice aide. Clinical Record 6: This patient elected hospice services on 01/13/2024 and the initial nursing assessment completed the same day indicated the presence of a foley catheter. The aide plan of care dated 01/15/2024 stated in part, “Perineal Care (provide perineal care at every visit and apply patient/caregiver choice of barrier skin lotion at every visit)” and did not include instructions on how to provide care for the foley catheter. During an interview with the RN/Administrator on 02/22/2024, it was stated that they thought the instructions in the aide plan of care included foley care. Upon review it was agreed that the instructions did not include instructions for the hospice aide pertaining to the foley catheter.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days. This standard was not met as evidenced by clinical record review and interview. In 2 of 12 (17%) applicable clinical records reviewed of patients receiving hospice aide services, it was revealed that the organization did not ensure the hospice aide was supervised by a registered nurse by making an on-site visit to the patient’s home no less frequently than every 14 days. Clinical Record 4: The patient elected hospice care 12/27/2023 and was receiving ordered hospice aide services three time weekly per the aide plan of care dated 12/27/2023. The record provided no evidence of an on-site supervisory visit by the registered nurse from 01/21/2024 through 02/21/2024 (31 days). Clinical Record 6: This patient elected hospice services on 01/13/2024 and was receiving hospice aide visits three times weekly per the aide plan of care dated 01/13/2024. The record provided no evidence of an on-site registered nurse supervisory visit of the hospice aide from 01/13/2024 through 02/21/2024 (39 days). During the daily wrap up meeting on 02/22/2024 with the Director of Nursing, the RN/Administrator, and the Nurse Practitioner/Alternate Administrator, it was reviewed and acknowledged that the clinical records were missing hospice aide supervision by a registered nurse no less frequently than every 14 days.”

“It is required that a registered nurse makes an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) personnel record reviewed for the hospice aide, it was revealed that the organization did not ensure that a registered nurse made an on-site visit to the location where the patient was receiving care in order to observe and assess each hospice aide while he or she was performing care. Personnel Record 8: The hospice aide was hired on 10/17/2022. The personnel record provided no evidence of an on-site visit by a registered nurse to observe the aide performing care to date. During an interview with the RN/Administrator on 02/23/2024, it was reviewed and acknowledged that the personnel record provided no evidence of the on-site observation visit. The RN/Administrator stated they were the one to complete this visit with each hospice aide, however she could not recall when the visit was completed with this aide and did not document the observation visit for the personnel record.”

“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. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, interview and personnel record review. In 7 of 10 (70%) personnel records reviewed it was revealed that the organization did not ensure the skills and competencies of all individuals providing care were performed per agency policy. Document 2: Agency policy number 3-001 (Revised October 2019) stated in part, “The organization will establish and annually evaluate a group of specific skills related to patient care/service responsibilities and complexity of care/service provided by personnel. Competencies must be successfully demonstrated before organization personnel complete orientation. After completion of orientation, competency will be monitored annually thereafter as part of the annual performance evaluation process.” Personnel Record 2: This employee was hired 08/04/2022. The personnel record provided no evidence of an initial competency assessment for the social worker role. There was an annual competency assessment skills checklist for the social worker completed on 08/11/2023. Personnel Record 3: The employee was hired 04/28/2022. The record lacked evidence of initial or annual competencies for the chaplain role, the bereavement coordinator role and the volunteer coordinator role. The employee assumed all of these roles. Personnel Record 5: The employee was hired 12/05/2019. The personnel record provided no evidence of an annual competency for the hospice nurse practitioner role for the years of 2022 and 2023. Personnel Record 6: The employee was hired 01/07/2020. The personnel record provided no evidence of an annual competency for the hospice registered nurse role for the calendar years 2022, 2023, or 2024 to date. Personnel Record 7: Thie employee was hired 09/04/2019. The personnel record provided no evidence of an annual competency for the hospice registered nurse role for the calendar years 2021, 2022, or 2023. Personnel Record 8: The employee was hired 10/17/2022 with an initial competency for the hospice aide role completed on 10/21/2022. The personnel record provided no evidence of an annual competency for the hospice aide for the 2023 calendar year. Personnel Record 9: The employee was hired 01/27/2020. The personnel record provided no evidence of an annual competency for the hospice registered nurse role for the calendar years 2022, 2023, or 2024 year to date. During an interview with the RN/Administrator on 02/23/2024, it was reviewed and stated that the organization was unaware of the policy for annual competencies and were only performing competencies at time of hire.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes physician orders. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 14 (7%) clinical records reviewed, it was revealed that the organization did not ensure the clinical record included all physician orders for the care and services provided to patients. Document 1: Agency policy number 2-002 (Revised October 2019), stated in part, “Orders will be obtained from a licensed physician (or other authorized independent practitioner) for care and services to be provided to hospice patients.” Clinical Record 6: This patient elected hospice services on 01/13/2024 and the initial nursing assessment, same date, indicated the presence of a foley catheter. A licensed practical nurse visit note dated 01/23/2024 indicated the nurse changed the foley catheter for the patient. The record provided no evidence of a physician order for removal of the old catheter and the insertion of a new catheter. During the daily wrap up meeting on 02/22/2024 with the Director of Nursing, the RN/Administrator, and the Nurse Practitioner/Alternate Administrator, it was confirmed that the clinical record was missing the physician order for the catheter removal and insertion. The RN/Administrator stated she was the one to take the order from the physician and give the order to the LPN. After review and during an interview on 02/23/2024, the RN/Administrator acknowledged the order was missing from the record at time of review.”