Every finding on record at Peace Hospice & Palliative Care, Inc.

Observed in Record Review. The organization failed to provide emergency preparedness training to staff regarding their roles and responsibilities. During interviews with 4/4 staff members, the hospice nurse surveyor asked about the organization's emergency operations plan, what role their role they would play and how they would know it was initiated. All 4 staff were unable to speak to the process. This was discussed and reviewed with the Owner and the DON.

Observed in Record Review. In 1 of 1 patient records reviewed, the organization failed to reassess its patients according to policy. During record review for RR#3, the hospice nurse surveyor observed the wound was entered on 3/6 and had measurements. But as of survey date there were no new measurements, documentation of the appearance of the wound bed or drainage per organizational policy which states it will be done every two weeks. This was discussed and verified with the DON.

Observed in Record Review. In 9 of 12 patient records reviewed, the organization Interdisciplinary Group failed to document updates to the comprehensive assessment in collaboration with the attending physician at least every 15 days. During record review for RR#1- RR#9, the hospice nurse surveyor observed missing documentation from multiple IDG meetings. For example in RR#1, IDG meeting minutes and notes were blank for 12/28, 1/11, 1/25, 2/8, 2/22, 3/8, and 3/22. For RR#2, for 1/25 and 2/8 there was no documentation of collaboration notes for SN or MD, and they had not signed in electronically ( although they had signed in on the office form). For 2/22, 3/8, and 3/23 there was no documentation of collaboration for SC or SN, and they had not signed in electronically ( although they had signed in on the office form). For RR#7-#8, the patients were discharged for extended prognosis but there was no documentation of collaboration with the IDG of the discharge process. This surveyor discussed with the DON and asked for documentation internally of said meetings and they were able to provide the sign in sheets and a vague agenda with no patient names or activities. Per the QAPI Coordinator, there has been a known issue with HospiceMD and some IDG meetings do not get saved. This was discussed and reviewed with the DON.

Observed in Record Review. In 12 of 12 patient records reviewed, the organization failed to plan the patient's care. During record review for all records, the hospice nurse surveyor observed that care plans did not contain all needed goals and individualized timeframes to meet those goals. In all records reviewed, timeframes were set at the same date as IDG. There was no individualization per patient. In HV#2, HV#3, RR#1, RR#3, RR#6, RR#7, and RR#8, the hospice nurse surveyor noted items missing related to the palliation and management of the terminal illness and related conditions. . For example in HV#2, the patient had anxiety and insomnia but these items were not addressed on the POC. For HV#3, the patient mentioned weakness, anxiety, choking ( ordered thick-it on 2/28/23) and none of these items were addressed on the POC. In RR#1, the POC was missing items to address weakness, skin and nutrition. In RR#7 and RR#8, the POC did not contain items for discharge although both were discharged for extended prognosis. This was discussed and reviewed with the Owner and the DON.

Observed in Record Review. In 2 of 6 patient records reviewed, the organization failed to plan the patient's care. During record review for RR#2 and RR#4, the hospice nurse surveyor observed incorrect information related to oxygen use on the aide care plan. For example in RR#2, the documentation stated the patient was on continuous oxygen at 2 Liters. But orders for the patient were for 2 Liters NC PRN for shortness of breath. The aide CP also did not address whether the oxygen could be removed for the bath. For RR#4, the documentation on the aide care plan stated both continuous oxygen and PRN oxygen and did not state if it could be removed for bathing. This was discussed and reviewed with the DON.

Observed in Record Review. In 9 of 12 patient records reviewed, the organization failed to have a medical record that reflected the patient's care, treatment, or services. During record review for RR#1-RR#9, the hospice nurse surveyor observed multiple missing IDG meeting notes to show collaboration for patient care. RR#7 and RR#8 were both discharged for extended prognosis but there was no documentation of collaboration with IDG. After discussion with the DON and the contracted QAPI coordinator, they stated that this appears to be an EMR issue and that the notes did not save. The hospice nurse surveyor found IDG notes missing back several months. There was a paper sign in that showed who attended but no specific agenda to show who was discussed. This was discussed with the Owner and the DON.

Observed in HR File Review. In 1 of 10 HR files reviewed, the organization failed to verify staff qualifications upon hire. During HR file review for HR#8, the hospice nurse surveyor observed the HHA had a copy of her certification but there was no primary source verification as required by organizational policy and law. This was discussed and reviewed with the Owner and the DON.