Good Shepherd Hospice of Ardmore, LLC

“Based on record review and interview, the hospice failed to ensure completion of an initial assessments/plan of care no later than 5 calendar days after the election of hospice benefits for two (Patients #8 and 14) of 19 patients. Findings: Patient #8 A review of the clinical record showed an election of the hospice benefit on 09/22/22 with POC from 09/22/22 to 12/21/22. Documentation showed a psychosocial assessment by the MSW was completed by telephone on 09/28/22 (6 days after the hospice election date) and a spiritual / bereavement assessment by the chaplain was completed by telephone on 10/07/22 (17 days after the hospice election date). Documentation showed no patient or caregiver refusal of assessments and showed no communications or notifications to the physician. On 06/25/24 at 12:00 p.m., Staff A stated the initial POC was not completed within the first five days after the election of the hospice benefit for patient #8. Patient #14 A review of the clinical record showed an election of the hospice benefit on 05/22/24 with POC from 05/22/24 to 08/19/24. Documentation showed no spiritual / bereavement assessment by the chaplain was completed. Documentation showed no patient or caregiver refusal of assessments and showed no communications or notifications to the physician. On 06/25/24 at 12:15 p.m., Staff A stated the initial POC was not completed within the first five days after the election of the hospice benefit for patient #14.”

“Based on record review and interview, the hospice failed to ensure the plan of care was fully developed to include: 1. A hospice diagnosis and; 2. As needed (PRN) visits were designated for use by SN, MSW and Chaplain services necessary for the palliation and management of the terminal illness for 13 (Patients #1, 3, 4, 6, 8, 9, 10, 11, 12, 16, 17, 18 and #19) of 19 patients. Findings: Patient #1 A plan of care dated 05/29/24 to 07/27/24 and plan of care updates dated 05/30/24 and 06/13/24 failed to include a hospice diagnosis. On 06/25/24 at 11:42 a.m., Staff A stated the POC did not include a hospice diagnosis. Patient #3 A plan of care dated 06/15/24 to 08/13/24 and plan of care updates dated 06/13/24 failed to include a hospice diagnosis. Documentation showed PRN visits for SN and MSW did not designate use for services necessary for the palliation and management of terminal illness. On 06/25/24 at 11:45 a.m., Staff A stated the POC did not include a hospice diagnosis and documentation showed PRN visits for SN and MSW did not designate use for services necessary for the palliation and management of terminal illness. Patient #4 A plan of care dated 05/07/24 to 08/04/24 and plan of care updates dated 05/17/24, 05/30/24 and on 06/13/24 failed to include a hospice diagnosis. Documentation showed PRN visits for MSW did not designate use for services necessary for the palliation and management of terminal illness. On 06/25/24 at 11:50 a.m., Staff A stated the POC did not include a hospice diagnosis and documentation showed PRN visits for MSW did not designate use for services necessary for the palliation and management of terminal illness. Patient #6 A plan of care dated 05/02/24 to 07/30/24 and plan of care updates dated 05/17/24, 05/30/24 and on 06/13/24 failed to include a hospice diagnosis. Documentation showed PRN visits for SN, Chaplain and MSW did not designate use for services necessary for the palliation and management of terminal illness. On 06/25/24 at 11:58 a.m., Staff A stated the POC did not include a hospice diagnosis and documentation showed PRN visits for SN, Chaplain and MSW did not designate use for services necessary for the palliation and management of terminal illness. Patient #8 A plan of care dated 05/13/24 to 07/11/24 and plan of care updates dated 05/17/24, 05/30/24 and on 06/13/24 failed to include a hospice diagnosis. Documentation showed PRN visits for SN, Chaplain and MSW did not designate use for services necessary for the palliation and management of terminal illness. On 06/25/24 at 12:00 p.m., Staff A stated the POC did not include a hospice diagnosis and documentation showed PRN visits for SN, Chaplain and MSW did not designate use for services necessary for the palliation and management of terminal illness. Patient #9 A plan of care dated 03/21/24 to 06/18/24 and plan of care updates dated 04/29/24, showed documentation of an order for SN to replace urinary catheter. Documentation showed no catheter type or size. On 06/25/24 at 12:05 p.m., Staff A stated the POC did not include urinary catheter type and size. Patient #10 A plan of care dated 04/19/24 to 06/17/24 and plan of care updates dated 05/02/24, 05/17/24, 05/30/24 and on 06/13/24 documentation showed PRN visits for MSW did not designate use for services necessary for the palliation and management of terminal illness. On 06/25/24 at 11:58 a.m., Staff A stated the POC documentation showed PRN visits for MSW did not designate use for services necessary for the palliation and management of terminal illness. Patient #11 A plan of care dated 06/04/24 to 09/01/24 and plan of care updates dated 06/13/24 documentation showed PRN visits for SN, Chaplain and MSW did not designate use for services necessary for the palliation and management of terminal illness. On 06/25/24 at 12:10 p.m., Staff A stated the POC documentation showed PRN visits for SN, Chaplain and MSW did not designate use for services necessary for the palliation and management of terminal illness. Patient #12 A plan of care dated 04/24/24 to 06/22/24 and plan of care updates dated 05/02/24, 05/17/24, 05/30/24 and on 06/13/24 failed to include a hospice diagnosis. Documentation showed PRN visits for MSW did not designate use for services necessary for the palliation and management of terminal illness. On 06/25/24 at 12:10 p.m., Staff A stated the POC did not include a hospice diagnosis and documentation showed PRN visits for MSW did not designate use for services necessary for the palliation and management of terminal illness. Patient #16 A plan of care dated 02/04/24 to 04/03/24 and plan of care updates dated 02/08/24, 02/22/24, 03/07/24 and on 03/21/24 failed to include a hospice diagnosis. Documentation showed PRN visits for SN, Chaplain and MSW did not designate use for services necessary for the palliation and management of terminal illness. On 06/25/24 at 12:25 p.m., Staff A stated the POC did not include a hospice diagnosis and documentation showed PRN visits for SN, Chaplain and MSW did not designate use for services necessary for the palliation and management of terminal illness. Patient #17 A plan of care dated 01/24/24 to 03/23/24 and plan of care updates dated 02/08/24, 02/22/24, 03/07/24 and on 03/21/24 failed to include a hospice diagnosis. Documentation showed PRN visits for SN, Chaplain and MSW did not designate use for services necessary for the palliation and management of terminal illness. On 06/25/24 at 12:26 p.m., Staff A stated the POC did not include a hospice diagnosis and documentation showed PRN visits for SN, Chaplain and MSW did not designate use for services necessary for the palliation and management of terminal illness. Patient #18 A plan of care dated 12/25/24 to 03/23/24 and plan of care updates dated 01/11/24, 01/25/24, 02/08/24, 02/25/24 and on 03/02/24 failed to include a hospice diagnosis. Documentation showed PRN visits for SN, Chaplain and MSW did not designate use for services necessary for the palliation and management of terminal illness. On 06/25/24 at 12:30 p.m., Staff A stated the POC did not include a hospice diagnosis and documentation showed PRN visits for SN, Chaplain and MSW did not designate use for services necessary for the palliation and management of terminal illness. Patient #19 A plan of care dated 02/07/24 to 04/06/24 and plan of care updates dated 02/08/24, 02/22/24, 03/07/24 and on 03/21/24 failed to include a hospice diagnosis. Documentation showed PRN visits for SN and MSW did not designate use for services necessary for the palliation and management of terminal illness. On 06/25/24 at 12:35 p.m., Staff A stated the POC did not include a hospice diagnosis and documentation showed PRN visits for SN and MSW did not designate use for services necessary for the palliation and management of terminal illness.”

“Based on record review and interview, the hospice failed to ensure individualized plans of care were fully developed to include medical social work and chaplain visit frequencies for two (Patients #9 and #13) of 19 patients. Findings: Patient #9 A review of the plan of care dated 03/21/24 to 06/18/24 with update to the plan of care dated 04/04/24, 04/18/24, 05/02/24, 05/17/24, 05/30/24 and on 06/13/24 showed a Medical Social Work visit frequency of one time a month for one month and one PRN visit for psychosocial support. Documentation showed Medical Social Work visits were conducted on 03/25/24, 04/24/24, 05/31/24 and on 06/17/24 (2 visits ordered, 4 visits conducted). Documentation showed no changes in orders. On 06/25/24 at 12:05 p.m., Staff A stated the individualized POC for Patients #9 did not contain ordered MSW service discipline visit frequencies and durations. Patient #13 A review of the plan of care dated 04/20/24 to 07/18/24 with update to the plan of care dated 05/02/24, 05/17/24, 05/30/24 and on 06/13/24 showed a Chaplain visit frequency of one time a month for one month and two PRN visit for emotional and spiritual support. Documentation showed Chaplain visits were conducted on 05/22/24, 05/30/24, 06/06/24, 06/13/24 and on 06/18/24 (3 visits ordered, 5 visits conducted). Documentation showed no changes in orders. On 06/25/24 at 12:05 p.m., Staff A stated the individualized POC for Patients #13 did not contain ordered Chaplain service discipline visit frequencies and durations.”

“Based on record review and interview, the hospice failed to ensure: 1. Social Work services discipline was ordered in the plans of care or communicated and coordinated through the IDG for one (Patient #4) of 19 patients and; 2. Hospice aide services discipline was ordered in the plans of care or communicated and coordinated through the IDG for two (Patients #5 and #15) of 19 patients. Findings: Patient #4 A review of the plan of care dated 05/07/24 to 08/04/24 and plan of care update dated 05/17/24, 05/30/24 and on 06/13/24 showed an ordered MSW visit frequency and duration one time a month for three months and showed no change in service discipline needs were communicated and coordinated through the IDG. Documentation showed during the weeks of 05/07/24 to 05/31/24 no MSW visit was conducted (one visit ordered, no visit conducted). Documentation showed no changes to the ordered visit frequency for the MSW service discipline needs communicated and coordinated through the IDG. On 06/25/24 at 11:50 a.m., Staff A stated MSW service discipline was ordered in the plans of care for one time a month and there were no changes in the MSW visit frequency communicated and coordinated through the IDG for patients #4. Patient #5 A review of the plan of care dated 05/02/24 to 06/03/24 and plan of care update dated 05/17/24, 05/30/24 and on 06/13/24 showed an ordered aide visit frequency and duration one time a week for one week, then three times a week for eight weeks and showed no change in service discipline needs were communicated and coordinated through the IDG. Documentation showed during the weeks of 05/02/24 to 05/04/24 no aide visit was conducted (one visit ordered, no visit conducted). Documentation showed no changes to the ordered visit frequency for the aide service discipline needs communicated and coordinated through the IDG. On 06/25/24 at 11:55 a.m., Staff A stated aide service discipline was ordered in the plans of care for one time a week for one week, then three times a week for eight weeks and there were no changes in the aide visit frequency communicated and coordinated through the IDG for patients #5. Patient #15 A review of the plan of care dated 12/09/23 to 03/07/24 and plan of care update dated 12/14/23 and on 12/28/23 showed an ordered aide visit frequency and duration three times a week for 12 weeks, then two times a week for one week and showed no change in service discipline needs were communicated and coordinated through the IDG. Documentation showed during the weeks of 12/10/23 to 12/16/23 one aide visit was conducted on 12/11/23 (three visits ordered, one visit conducted), 12/17/23 to 12/23/23 one aide visit was conducted on 12/20/23 (three visits ordered, one visit conducted), 12/24/23 to 12/30/23 one aide visit was conducted on 12/27/23 (three visits ordered, one visit conducted), 12/30/23 to 01/06/24 one aide visit was conducted on 01/01/24 (three visits ordered, one visit conducted). Documentation showed no changes to the ordered visit frequency for the aide service discipline needs communicated and coordinated through the IDG. On 06/25/24 at 12:17 p.m., Staff A stated aide service discipline was ordered in the plans of care for three times a week for 12 weeks, then one time a week for one week and there were no changes in the aide visit frequency communicated and coordinated through the IDG for patients #15.”

“Based on a record review and interview, the agency failed to ensure documentation which showed completion of alternative training requirements to meet the qualifications of a Certified Home Health Aide for one (Staff F) of four employees reviewed. Findings: Staff F A review of personnel records showed certification as a Long-Term Care Aide. Documentation showed no current Home Health Aide certification and showed no documentation which showed completion of alternative training requirements to meet the qualifications of a Certified Home Health [Hospice] Aide. On 06/25/22 at 2:00 p.m., Staff A stated the personnel records were provided in their entirety and did not contain all the required information for Staff F.”

“Based on record review and interview, the hospice failed to ensure continued review and update of the hospice aide care plan for three (Patients #3, 10 and #12) of 19 patients. Findings: Patient #3 A review of the clinical record showed a hospice aide care plan last reviewed and updated on 02/12/24 for the episode of 06/15/24 through 08/13/24 and IDG POC update dated 06/13/24. Documentation showed hospice aide visits were conducted on 06/18/24. On 06/25/24 at 11:45 a.m., Staff A stated the clinical record showed the hospice aide care plan dated 02/16/23 was not reviewed and updated for HA visits beginning 06/15/24 through 08/13/24. Patient #10 A review of the clinical record showed a hospice aide care plan last reviewed and updated on 02/13/24 for the episode of 04/19/24 through 06/17/24 and IDG POC update dated 05/02/24, 05/17/24, 05/30/24 and on 06/13/24. Documentation showed hospice aide visits were conducted on 04/23/24, 04/25/24, 04/30/24, 05/01/24, 05/07/24, 05/09/24, 05/14/24, 05/16/24, 05/21/24, 05/23/24, 05/28/24, 05/30/24, 06/04/24. 06/06/24, 06/11/24 and on 06/12/24. On 06/25/24 at 12:07 p.m., Staff A stated the clinical record showed the hospice aide care plan dated 02/13/24 was not reviewed and updated for HA visits beginning 04/19/24 through 06/17/24. Patient #12 A review of the clinical record showed a hospice aide care plan last reviewed and updated on 02/13/24 for the episode of 04/24/24 through 06/22/24 and IDG POC update dated 05/02/24, 05/17/24, 05/30/24 and on 06/13/24. Documentation showed hospice aide visits were conducted on 04/24/24, 04/29/24, 05/01/24, 05/06/24, 05/08/24, 05/13/24, 05/16/24, 05/21/24, 05/23/24, 05/27/24, 05/29/24, 06/04/24. 06/06/24, 06/11/24, 06/13/24, 06/18/24 and on 06/20/24. On 06/25/24 at 12:07 p.m., Staff A stated the clinical record showed the hospice aide care plan dated 02/13/24 was not reviewed and updated for HA visits beginning 04/24/24 through 06/20/24.”

“Based on record review and interview, the hospice failed to ensure personnel records were maintained with required annual employee performance evaluations for two (Volunteer #1 and 3) of three volunteers and four employees. Findings: Volunteer 1 A review of personnel records showed no annual performance evaluation for 04/23/23 to 04/23/24 employment period. Volunteer 3 A review of personnel records showed no annual performance evaluation for 12/12/22 to 06/25/24 employment period. On 06/25/22 at 2:00 p.m., Staff A stated the personnel records were provided in their entirety and did not contain all the required information for Volunteers 1 and 3.”