Shalom Hospice

“Based on policy review, record review, home visit observation, and interview, the hospice provider failed to develop an individualized plan of care (POC), four of five full records reviewed (Records/Patients #1, #2, #3, and #4). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated policy titled, “;Plan of Care,” showed the plan of care reflects patient and family goals and interventions that are based on the problems identified in the initial, comprehensive, and updated assessments. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice on 12/27/2024 with a primary diagnosis of end stage heart failure (the most advanced stage of heart failure, where the heart is severely weakened and unable to pump blood effectively throughout the body) and resided in a LTCF (Long-Term Care Facility). Review of the IDG (Interdisciplinary Group) Update POC, dated 01/22/2025, showed in part: - A problem of incontinence (involuntary loss of bladder or bowel control), a problem description of incontinent of bowel and bladder, and interventions/outcomes that included in part, foley catheter (a thin, flexible tube inserted into the bladder to drain urine); and - The patient did not have a foley catheter (A pull-up brief was worn for incontinence). RECORD/PATIENT #3: Review of the IDG (Interdisciplinary Group) Update POC, dated 01/22/2025, showed in part: - A problem of skin breakdown, a problem description monitoring skin each visit r/t (related to) increased incontinence of bowel and bladder, and interventions/outcomes that included in part, patient education handout(s) for stomach tube (a thin, flexible tube inserted directly into the stomach to provide nutrition, medication, or drainage) care, anal fissures (a small tear in the lining of the anus), colostomy (a surgical procedure that creates an opening in the abdominal wall through which waste from the large intestine is diverted and collected in a bag), ileostomy (a surgical procedure that creates an opening in the abdominal wall through which waste from the small intestine is diverted and collected in a bag); and - The patient did not have a stomach tube, anal fissure, colostomy, and/or ileostomy (A pull-up brief was worn for incontinence and barrier cream was used to prevent skin breakdown). During an interview, on 01/29/2025 at 11:15 AM, the administrator stated that: - The problem description section of the plan of care allows the staff to make interventions and goals patient-specific; - The plan of care showed interventions that did not apply to the patients because the staff were just checking the box on those interventions instead of selecting the ones that applied to that patient specifically; and - He/she would expect the POC to show patient-specific interventions and goals in the problem description section of the plan of care. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 12/27/2023 with a primary diagnosis of end stage heart failure (the most advanced stage of heart failure, where the heart is severely weakened and unable to pump blood effectively throughout the body) and Parkinsons disease (a disorder of the central nervous system that affects movement, often including tremors) and resided at a private residence. Review of the IDG (Interdisciplinary Group) Update POC, dated 01/22/2025, showed in part: -A problem of anxiety (a common emotional state characterized by feelings of unease, worry, fear or apprehension) and agitation (a feeling or irritability, mental distress or severe restlessness), the goal stated the patient would report understanding of the causes and treatment of anxiety; -A problem with pain (physical suffering or discomfort caused by illness or injury), the goal stated the patient would report that pain is reduced to a desired level, which was not indicated; -A problem with decline in activities of daily living (basic self-care tasks for well-being and independence), the goal stated the patient would report comfort and understanding of assistive devices, which the facility did not name in the plan; -A problem with anticipatory grief (the feeling of grief or loss that occurs before a death), the goal stated the patient would express and share grief and concerns, assist patient in identifying strengths; -A problem with nutrition (obtaining food necessary for health and growth), the goal stated the patient would be in control of what, how much and when to eat, caregiver must feed him/her and give fluids; -A problem with communication (sending or receiving information to express needs and wants), the goal stated the family will verbalize ways to effectively communicate with the patient, assist in methods of communication with no plan; and -The IDG narrative stated the patient was “;alert to self only and unable to voice his/her needs,” and was unable to feed his/herself. Observation on 01/28/2025 at 1:20 PM showed the patient was unable to have a conversation and was unable to answer questions when asked. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice on 12/14/2024 with a primary diagnosis of malignant neoplasm of body of pancreas (cancer with tumors that begins in the organ lying behind the lower part of the stomach and spreads to other parts of the body) and resided in a family residence. Review of the IDG (Interdisciplinary Group) Update POC, dated 12/24/2024, showed in part: - A problem with fatigue or weakness, the goal stated the patient would participate in desired activities, patient would report comfort and understanding of assistive devices. The patients activities and assistive devices were not listed; - A problem with pain (physical suffering or discomfort caused by illness or injury), the goal stated the patient would report that pain is reduced to a desired level, the pain level was not indicated; and - The IDG Narrative indicated the patient is bedbound. Observation on 01/27/2025 at 1:45 PM showed the patient was not able to speak. He/she was able to nod in response to some questions. Findings included: Review of the provider’s undated policy titled, “;Plan of Care,” showed the plan of care reflects patient and family goals and interventions that are based on the problems identified in the initial, comprehensive, and updated assessments. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 12/27/2023 with a terminal diagnosis of end stage heart failure (a decrease in the ability of the heart to pump blood) and Parkinsons disease (a neurological disorder that causes unintended or uncontrollable movements or stiffness) and resided at a private residence. Review of the comprehensive assessment, dated 12/27/2024, showed in part: -According to the onset, progression of symptoms, functional status and response to treatment section: The interview with the patient/family/representative indicated the patient had increased mental status changes; - The patient was in need of total care and unable to make his/her needs known;- In the diagnosis and prognosis assessment: The patient was nonverbal;- In the pain and comfort assessment: The patient was unable to describe pain;- In the neurological status assessment: The patients behavior was hampered by Sundowners syndrome (a complex neurobehavioral disorder that affects people with dementia that worsens in the late afternoon, evening or night) and his/her speech was characterized as garbled (speech that was unclear or confusing making it difficult to understand);- The mental status assessment stated: The patient was confused at all times; - The immediate needs for problem and symptom management indicated a decline in the patients ADL (activities of daily living) and self-care; and- The communication section stated the representative was educated on diet, nutrition, feeding, and fluids. Review of the interdisciplinary group (IDG) update POC, dated 01/22/2025, showed in part: -A problem of anxiety (a common emotional state characterized by feelings of unease, worry, fear or apprehension) and agitation (a feeling or irritability, mental distress or severe restlessness). The goal showed, the patient would report understanding of the causes and treatment of anxiety; -A problem with pain (physical suffering or discomfort caused by illness or injury). The goal showed the patient would report that pain was reduced to a desired level. The POC failed to show the patient’s acceptable level of pain; -A problem with decline in activities of daily living (basic self-care tasks for well-being and independence). The goal showed the patient would report comfort and understanding of assistive devices. The POC failed to show what assistive devices the patient was using); -A problem with anticipatory grief (the feeling of grief or loss that occurs before a death). The goal showed the patient would express and share grief and concerns. Staff would assist the patient in identifying strengths; -A problem with nutrition (obtaining food necessary for health and growth). The goal showed the patient would be in control of what, how much and when to eat. The caregiver must feed him/her and give him/her fluids; -A problem with communication (sending or receiving information to express needs and wants). The goal showed the family would verbalize ways to effectively communicate with the patient and assist in methods of communication. The POC failed to identify the communication methods used; and -The IDG narrative showed, the patient was “;alert to self only and unable to voice his/her needs,” and was unable to feed him/herself. Observation on 01/28/2025 at 1:20 PM, showed the patient was unable to have a conversation and was unable to answer questions when asked. The POC failed to be individualized regarding:-The patient being unable voice his/her needs;-Acceptable level of pain;-Goal of grief (since the patient was unable to have a conversation);-Goal of nutrition (since the patient was unable to have a conversation, how would he/she be in control of what, how much, and when to eat); and-Communication methods. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice on 12/27/2024 with a terminal diagnosis of end stage heart failure and resided in a long-term care facility (LTCF). Review of the IDG update POC, dated 01/22/2025, showed in part, a problem of incontinence (involuntary loss of bladder or bowel control), a problem description of incontinent of bowel and bladder, and interventions/outcomes that included in part, foley catheter (a sterile tube placed in the bladder to drain urine). During observation on 01/27/2025 at 1:00 PM showed the patient did not have a urinary catheter. The POC failed to be individualized and accurate when it showed the patient had a urinary catheter and the patient did not have a catheter. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice on 03/01/2024 with a terminal diagnosis of malignant neoplasm of prostate (prostate cancer) and resided in a LTCF. Review of the IDG update POC, dated 01/22/2025, showed in part, a problem of skin breakdown, a problem description monitoring skin each visit related to r/t increased incontinence of bowel and bladder, and interventions/outcomes that included in part, patient education handout(s) for enternal feeding tube (a tube placed surgically through the abdominal wall into the stomach for the administration of foods, fluids, and medication) care, anal fissures (a small tear in the lining of the anus), colostomy (a surgical procedure that creates an opening in the abdominal wall through which waste from the large intestine is diverted and collected in a bag), ileostomy (a surgical procedure that creates an opening in the abdominal wall through which waste from the small intestine is diverted and collected in a bag). During observation on 01/28/2025 at 9:00 AM showed the patient did not have an enternal feeding tube, anal fissure, colostomy, and/or ileostomy. The POC failed to be individualized and accurate when it showed the patient had an enternal feeding tube, anal fissure, colostomy, and/or ileostomy and the patient did not have any of those. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice on 12/14/2024 with a terminal diagnosis of malignant neoplasm of body of pancreas (cancer with tumors that begins in the organ lying behind the lower part of the stomach and spreads to other parts of the body) and resided in a family residence. Review of the comprehensive assessment, dated 12/14/2024, showed in part: -According to the cardiopulmonary assessment: The patient used oxygen and experienced decreased activity; - The pain and comfort assessment indicated: Generalized pain/undefined location;- The patient was confined to the bed or a chair;- The medical condition impaired the patients ability to ambulate, or move independently; and- The environment assessment stated the patient was non-ambulatory. Review of the IDG update POC, dated 12/24/2024, showed in part:- A problem with fatigue or weakness. The goal showed the patient would participate in desired activities, the patient would report comfort and understanding of assistive devices. The POC failed to include the patients activities and assistive devices.- A problem with pain. The goal showed the patient would report that pain was reduced to a desired level. The POC failed to include the patients acceptable pain level; and- The IDG narrative indicated the patient was bedbound. Observation on 01/27/2025 at 1:45 PM, showed the patient was not able to speak. He/she was able to nod in response to some questions. The POC failed to be individualized and include:-The patients activities and assistive devices;-The patients acceptable pain level;-The patients bedbound status;-The patient being non-verbal; and -How to communicate. During an interview on 01/29/2025 at 11:15 AM, the administrator stated that: - The problem description section of the plan of care allowed the staff to make interventions and goals patient-specific; - The plan of care showed interventions that did not apply to the patients because the staff were just checking the box on those interventions instead of selecting the ones that applied to that patient specifically; and - He/she would expect the POC to show patient-specific interventions and goals in the problem description section of the plan of care.”

“Based on policy review, record review, home visit observation, and interview, the hospice provider failed to develop measurable outcomes in the implemented individualized plan of care (POC) that measured the goals for two of five patients (Records/Patients #1 and #4). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated policy titled, “;Plan of Care, Policy Number: PC, P50,” showed in part, the POC is written by members of the Interdisciplinary Team with measurable goals and outcomes for plans interventions. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 12/27/2023 with a terminal diagnosis of end stage heart failure (a decrease in the ability of the heart to pump blood) and Parkinsons disease (a neurological disorder that causes unintended or uncontrollable movements or stiffness) and resided at a private residence. Review of the interdisciplinary group (IDG) update POC, dated 01/22/2025, showed in part, the facility failed to incorporate measurable data in the plan of care, for reporting pain, comfort, and nourishment, based on the patient’s inability to speak: -A problem of anxiety (a common emotional state characterized by feelings of unease, worry, fear or apprehension) and agitation (a feeling or irritability, mental distress or severe restlessness). The goal showed the patient would report understanding of the causes and treatment of anxiety; -A problem with decline in activities of daily living (basic self-care tasks for well-being and independence). The goal showed the patient would report comfort and understanding of assistive devices; -A problem with incontinence (involuntary loss of bladder or bowel control). The goal showed the patient would report comfort; -A problem with constipation (infrequent or difficult bowel movements). The goal showed the patient would report soft, formed stools; -A problem with anticipatory grief (the feeling of grief or loss that occurs before a death). The goal showed the patient would express and share grief and concerns; -A problem with nutrition (obtaining food necessary for health and growth). The goal showed the patient would be in control of what, how much, and when to eat; -A problem with communication (sending or receiving information to express needs and wants). The goal showed the family would verbalize ways to effectively communicate with the patient; and -The IDG narrative showed in part, the patient was “;alert to self only and unable to voice (his/her) needs” and was unable to self-feed. Observation on 01/27/2025 at 1:45 PM, showed the patient was not able to speak. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice on 12/14/2024 with a terminal diagnosis of malignant neoplasm of body of pancreas (cancer with tumors that begins in the organ lying behind the lower part of the stomach and spreads to other parts of the body) and resided in a family residence. Review of the IDG update POC, dated 12/24/2024, showed in part, the facility failed to include measurable data in the goals for the patient, for activity and pain relief, based on the patient’s inability to move without assistance and being nonverbal: - A problem with fatigue or weakness. The goal showed the patient would participate in desired activities, the patient would report comfort and understanding of assistive devices; - A problem with pain (physical suffering or discomfort caused by illness or injury). The goal showed the patient would report that pain was reduced to a desired level. The POC failed to indicate the patient’s acceptable pain level; and - The IDG narrative indicated the patient was bedbound. The narrative failed to include the pain criteria for when to notify the registered nurse case manager. Observation on 01/27/2025 at 1:45 PM, showed the patient was bedbound and was not able to speak. He/she was able to nod in response to some questions. During an interview on 01/29/2025 at 11:00 AM, the administrator stated that, the goals should be captured in the hospice tools in the problem description. That section was where the nurses should add the personal goals and the measurable data. He/she thought the nurses were leaving it off the plans.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure that the hospice aide written instructions included patient-specific instructions for patient care in four of five records reviewed (Records/Patients #1, #2, #3, and #4). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated policy titled, “;Hospice Aide/Personal Care Services,” showed that the hospice RN (registered nurse) develops a written hospice aide plan of care that provides instructions to the hospice aide of the patient-specific care to be provided. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice on 12/27/2024 with a primary diagnosis of end stage heart failure (the most advanced stage of heart failure, where the heart is severely weakened and unable to pump blood effectively throughout the body) and resided in a LTCF (Long-Term Care Facility). Review of the hospice aide care plan, dated 12/27/2024, showed in part: - Functional limitations: OOB (out of bed) with assist, two-person assist to transfer, poor endurance, and floor mat in place when in bed; - Safety precautions: safety precautions assigned (No further documentation of the safety precautions); and - The hospice aide care plan failed to show patient-specific instructions on how the hospice aide was to conduct the two-person transfer. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice on 03/01/2024 with a primary diagnosis of malignant neoplasm of prostate (prostate cancer) and resided in a LTCF (Long-Term Care Facility). Review of the hospice aide care plan, dated 01/27/2025, showed in part: - Assistive Devices/Equipment Used During Patient Care: Wheelchair; - Senses: Language barrier (Primary language was Spanish); and - The hospice aide care plan failed to show patient-specific instructions on safety precautions, how the hospice aide was to transfer the patient from the wheelchair for showers, and how the hospice aide was to communicate with the patient. During an interview, on 01/29/2025 at 11:00 AM, the administrator stated that: - The functional limitations were care planned by the nurse selecting the task box; and - The aide instructions should have included additional details with patient-specific instructions on how the hospice aide should perform the selected task. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 12/27/2023 with a primary diagnosis of end stage heart failure (the most advanced stage of heart failure, where the heart is severely weakened and unable to pump blood effectively throughout the body) and Parkinsons disease (a disorder of the central nervous system that affects movement, often including tremors) and resided at a private residence. Review of the hospice aide care plan update, dated 06/13/2024, showed in part: - Functional limitations: OOB (out of bed) with assist, two-person assist to transfer, Hoyer assist with two persons (a machine that mechanically lifts a person from one area in a sling device, and allows two people to move the patient to another area, while in mid-air), poor endurance, and side rails up on bed; - Safety precautions: safety precautions assigned (no further documentation of the safety precautions); and - The hospice aide care plan failed to show patient-specific instructions on how the hospice aide was to conduct the two-person transfer. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice on 12/14/2024 with a primary diagnosis of malignant neoplasm of body of pancreas (cancer with tumors that begins in the organ lying behind the lower part of the stomach and spreads to other parts of the body) and resided in a family residence. Review of the hospice aide care plan update, dated 12/14/2024, showed in part: -Functional limitations: bed bound, Hoyer assist with two persons, poor endurance and side rails up on bed; - Safety precautions: safety precautions assigned (no further documentation of the safety precautions); and - The hospice aide care plan failed to show patient-specific instructions on how the hospice aide was to conduct the two-person transfer with the Hoyer lift.”

“Based on policy review, employee file review, and interview, the hospice provider failed to ensure that a criminal background check (CBC) was conducted prior to patient contact in, one of five employee files reviewed (Employee #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated policy titled, “;Personnel Records,” showed in part: - Personnel records are maintained for job applicants, employees, and past employees in accordance with laws and regulations and in order to maintain documentation of the hospices hiring practices and employment related matters; and - Personnel records contain criminal background checks in accordance with organizational policy and procedures and local and/or state law. EMPLOYEE #3: Review of employee #3’s personnel file, showed in part: - Date of hire: 12/18/2024; and - Date of CBC: 01/28/2025 (during the recertification survey). During an interview on 01/28/2025 at 2:30 PM, the administrator stated that: - He/she thought that he/she submitted a Family Care Safety Registry (FCSR) request that checked for the CBC, but he/she did not receive any results back; and - He/she must have overlooked it.”