Every finding on record at Peaceful Hope Hospice and Palliative Care LLC

It is required that consistent with current professional standards of practice, licensed professionals actively participate in the coordination of all aspects of patient care including conducting ongoing interdisciplinary comprehensive assessments; developing and evaluating the plan of care; and contributing to patient and family counseling and education. Hospice “core” services are substantially provided directly by hospice employees in a manner consistent with acceptable standards of practice. “Core” services include nursing services, medical social work, and counseling. This standard was not met as evidenced by personnel record review, document review, clinical record, and interview. In 9 of 4 (64%) of clinical records reviewed for patient receiving medical social work services (MSW), revealed the agency was inconsistent with standards of care for hospice and did not ensure the hospice provided core services by direct care employee only. Agency Contract: A contract for Social Work services was signed on 04/08/2022. The contract was for multiple staffing positions, however the agency only had one primary social worker that they used to see their patients. The agency did not have a personnel file for the contracted social worker. CLINICAL RECORD 1: The patient's date of election was 01/08/2025. A review of the record included the comprehensive psychosocial assessment dated 01/11/2025 by the contract MSW. CLINICAL RECORD 3: The patient's date of election was 11/01/2024. A review of the record included the comprehensive psychosocial assessment dated 11/04/2024 by the contract MSW. CLINICAL RECORD 4: The patient's date of election was 03/30/2024. A review of the record included the comprehensive psychosocial assessment dated 04/01/2024 by the contract MSW. CLINICAL RECORD 5: The patient's date of election was 06/10/2023. A review of the record included the comprehensive psychosocial assessment dated 06/13/2023 by the contract MSW. CLINICAL RECORD 6: The patient's date of election was 04/04/2024. A review of the record included the comprehensive psychosocial assessment dated 04/08/2023 by the contract MSW. CLINICAL RECORD 7: The patient's date of election was 01/17/2025. A review of the record included the comprehensive psychosocial assessment dated 01/20/2025 by the contract MSW. CLINICAL RECORD 11: The patient's date of election was 10/21/2024. A review of the record included the comprehensive psychosocial assessment dated 10/22/2024 by the contract MSW. CLINICAL RECORD 12: The patient's date of election was 01/07/2023. A review of the record included the comprehensive psychosocial assessment dated 02/18/2023 by the contract MSW. CLINICAL RECORD 13: The patient's date of election was 01/26/2023. A review of the record included the comprehensive psychosocial assessment dated 02/04/2023 by the contract MSW. This was shared with leadership on 03/06/2025 and in an interview with the Administrator/DON (Personnel Record 1) and the Alternate Administrator/Alternate DON (Personnel Record 2) he stated, "I knew we needed a social worker but was unaware that it had to be an employee not a contracted employee."

It is required that consistent with current professional standards of practice, licensed professionals actively participate in the coordination of all aspects of patient care including Hospice “core” services are substantially provided directly by hospice employees in a manner consistent with acceptable standards of practice. “Core” services include nursing services, medical social work, and counseling. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met, as evidenced by personnel record reviews, contract reviews, and interviews with the Administrator, which revealed that the hospice: Failed to ensure that the Hospice Medical Social Work services were substantially provided by hospice employees in a manner consistent with acceptable standards of practice and the hospice provided core services by direct care employee only. “Core” services include nursing services, medical social work, and counseling {HCDT.2.I/L585/ 418.62(b)}. The cumulative effect of this deficiency has resulted in the hospice organization's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.64: Core Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.

It is required that all hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation and consistent with the hospice aide training. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by a review of clinical records and interviews which revealed the hospice: Failed to ensure that the competency evaluation was completed {HSRM.9. I/L615/ 418.76(c)(1)}; Failed to ensure did not ensure the aide care plan frequency was followed {HCDT.16.I/L626/418.76(g)(2)(i)}; and Failed to ensure an annual on-site visit with the registered nurse to assess the aide while she was performing care {HSRM.27. D/L632/418.76(h)(2)}. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.76, Hospice Aide and Homemaker Services. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

It is required that all hospice aide services must be provided by an individual who has successfully completed a competency evaluation. This standard was not met as evidenced by document review, personnel record review, and interview. In 2 of 2 (100%) personnel records for hospice aides reviewed revealed the agency did not ensure a competency evaluation was completed. POLICY: Agency policy # 4.15.1 staff competency program states in part, "Personal care staff (Home Health Aides) will be competency assessed at least annually (every 12 months). PERSONNEL RECORD 3: The hospice aide’s date of hire was 04/18/2023. A review of the personnel record identified there was no documented evidence of a competency evaluation provided by the hospice at the time of hire. PERSONNEL RECORD 6: The hospice aide’s date of hire was 11/01/2024. A review of the personnel record identified there was no documented evidence of training and competency evaluation provided by the hospice at the time of hire. This was shared with leadership on 03/06/2025 and in an interview with the Alternate DON on the same day, she was unable to produce the document and didn't even know that she had to do one. She stated, " I was unaware of all the requirements on the competency evaluation."

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 6 of 10 (60%) clinical records reviewed for patients receiving hospice aide services revealed the agency did not ensure the aide care plan frequency was followed. CLINICAL RECORD 2: The plan of care dated 09/20/2024 – 11/19/2024, 11/20/2024 – 01/19/2025, and 01/20/2025 - 03/20/2025 included an order for hospice aide five times a week to assist with bathing and dressing. The aide plan of care from 05/31/2023 to present included the task for the aide to assist with bathing and dressing. During the weeks of 10/29/2024, 11/04/2024, 11/18/2024, 11/25/2024, and 01/20/2025, the aide only provided aide services four (4) times a week. During the week of 12/22/2024, the aide only provided care two(2) times. The weeks of January 27, 2025, and February 03,2025, there were no documented aide visits. CLINICAL RECORD 3: The plan of care dated 11/01/2024 – 01//29/2025 and 01/30/2025 – 04/29/2025 included an order for the hospice aide 5 times a week to assist with bathing and dressing. The aide plan of care dated 11/01/2024 to present included the task for the aide to assist with bathing and dressing. During the weeks of 11/18/2024, 11/25/2024, and 01/20/2025, the aide only provided aide services four (4) times a week. The weeks of 01/27/2025 and 02/03/2025 there were no documented aide visits. CLINICAL RECORD 4: The plan of care dated 01/24/2025 – 03/24/2025 and 11/24/2024 – 01/23/2025 included an order for the hospice aide two (2) times a week to assist with bathing and dressing. The aide plan of care dated 03/30/2024 to present included the task to assist with bathing and dressing. The week of 12/03/2024 there was only one (1) aide visit. There was no documented evidence that the patient was seen the rest of the month of December after the visit on 12/03/2024 through the end of December 2024. CLINICAL RECORD 7: The plan of care dated 01/17/2025 – 04/16/2025 included an order for the hospice aide three (3) times a week to assist with bathing and dressing. The aide plan of care dated 01/17/2025 included the task to assist with bathing and dressing. During the week of 01/20/2025 there was only one (1) aide visit. The weeks of 02/17/2025 and 02/24/2025 there were no documented aide visits. CLINICAL RECORD 12: The plan of care dated 05/01/2024 – 06/29/2024 included an order for the hospice aide 5 times a week to assist with bathing and dressing. The aide plan of care beginning 01/07/2023 included the task to assist with bathing and dressing. There were no documented aide visits in the clinical record for 04/04/2024, 04/08/2024, 04/12/2024, 01/29/2025, and 01/31/2025 and no documented evidence as to why th visits were missed. CLINICAL RECORD 13: The plan of care dated 11/16/2024 – 01/14/2025 included an order for the hospice aide 5 times a week to assist with bathing and dressing. The aide plan of care beginning 01/26/2023 included the task to assist with bathing and dressing. There were no documented aide visits in the clinical record for 09/04/2024, 09/05/2024, 09/06/2024, 10/11/2024, 10/28/2024,11/28/2024, and 11/29/2024 and no documented evidence as to why th visits were missed. During interviews on 03/05/2025 and 03/06/2025 with the Alternate Administrator and Alternate Director of Nursing (DON (Personnel Record 2) she stated, "the aides are supposed to upload visits into the electronic medical record if they chart visits on paper."

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 hospice aides eligible for an annual on-site visit revealed the agency did not perform an annual on-site visit with the registered nurse to assess the aide while she was performing care. POLICY: Agency policy # 4.15.1 staff competency program states in part, "Personal care staff (Home Health Aides) will be competency assessed at least annually (every 12 months). PERSONNEL RECORD 3: The hospice aide was hired on 04/18/2023. There was no documented evidence that a registered nurse (RN) performed an annual on-site visit to assess the aide while she was performing care for the year 2024 after the Public Health Emergency (PHE) ended September 30, 2023. This was shared with leadership on 03/06/2025 and in an interview on the same day, the Alternate Administrator/Alternate Director of Nursing (DON) (Personnel Record 2) stated she doesn't know where the documents are and verified, they were missing from the personnel file.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. Documentation includes: The identification of each position that is occupied by a volunteer; The work time spent by volunteers occupying those positions; Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1 and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview which revealed the Agency Volunteer Program did not include any documentation of volunteer hours for the year 2024 that included day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. In an interview with the Administrator (Personnel Record 1) on 03/06/2025 he stated, he did not know that at least 5% of total patient care hours have to done by volunteers. The agency currently does not have any patients receiving volunteers. The agency was also unable to produce the percentage of hours that volunteers provided the agency in the year 2024. In an interview with the Administrator (PR 1) on 03/06/2025 he stated "he did not know that at least 5% of total patient care hours have to done by volunteers."

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. The 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, document review and interview. In 2 of 3 (67%) clinical records reviewed for patients that selected hospice aide services revealed the hospice aide care plan prepared by the registered nurse (RN) lacked specificity for the tasks ordered. Document 1: Policy #PC.H25, "Hospice Aide Assignments and Duties (Dated: 2021)", stated in part, "Procedure: 5. The hospice RN responsible for supervising the hospice aide prepares written patient care instructions that are patient-specific and not generic." Clinical Record 2: The patient elected the hospice benefit on 1/7/23. The RN lacked writing a specific bathing task order on the hospice aide plan of care (POC) dated 1/7/23. The hospice aide POC ordered two bath tasks, "1. Bed Bath; Frequency: As needed during every visit; and 2. Shower; Frequency: As needed and as tolerated." Clinical Record 3: The patient elected the hospice benefit on 11/14/22. The RN lacked writing a specific bathing task order on the hospice aide POC dated 11/14/22. The hospice aide POC ordered two bath tasks, "1. Bed Bath; Frequency: Every visit as tolerated; and 2. Shower; Frequency: As needed and as tolerated."

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over the counter (OTC) drugs; supplements; herbal remedies and other treatments that could affect drug therapy. The effectiveness of drug therapy; drug side effects; actual or potential drug interactions. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects.The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by record review, observation, and interview. 2 of 11 (18%) clinical records reviewed revealed the agency did not ensure the medication profiles were updated and drug regime reviews occurred when new medications were ordered for patients. Record #39720 was reviewed and identified the patient elected hospie care on 5/18/22. The RN documented in a nursing progress note, dated 5/22/22, "advised patient to take his pain medication and Zofran. He was instructed to be taking his Zofran prior to meals for 2 days and see if the condition will improve." Drug profile effective 6/1/22 did not include Zofran as current or discontinued medication. During an interview with the Alternate Director of Nursing (#54720) on 6/2/2022, she confirmed that the patient was taking Zofran and they forgot to add it to the drug profile. Record #79313 was reviewed and identified the patient elected hospice care on 5/28/22. During the home visit on 6/1/22, the patient was observed with a patch present on his right side of chest, the wife questioned the RN about moving the patch to his left leg where he was currently having pain. The RN confirmed that it was a Lidocaine patch while providing education to the wife. Drug profile, effective on 6/1/22, did not contain the Lidocaine patch. During an interview with the Alternate Director of Nursing (#54720) on 6/2/2022, she confirmed that the Lidocaine patch was not on the drug profile.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by observation, clinical record review, and interview. 1 of 11 (9%) clinical records reviewed revealed that the agency did not ensure that the plan of care met the needs of the patient. Record #79313 was reviewed and identifed the pateitn elected hospice care on 05/28/22. During the home visit on 06/01/22, the patient was observed with bilateral heels protector boots, the bed contained an air mattress, and the hospice RN reported that patient had a wound on the right lower leg. The current care plan, effective 5/28/22 and updated on 5/31/22, did not address the wound or have any problems, goals or interventions related to the integumentary system. The alternate director of nursing (#54720) reviewed the care plan and confirmed, during an interview on 6/2/22, that the wound was not addressed in the care plan.

It is required that bags used to carry medical equipment (e.g., BP cuff) or supplies into or out of the care environment are transported and used in a manner consistent with organizational policy to prevent the spread of infections and communicable diseases. This standard was not met as evidenced by observation, documentation review and interview. 1 of 2 (50%) home visit observations revealed the hospice did not ensure adherence to bag technique as defined in hospice policy was performed.  Record #79313 was reviewed and identified the patient elected hospice care on 5/28/22. The RN was observed re-entering the clean area of the bag without cleaning hands prior to. The RN was also observed replacing the blood pressure cuff without disinfecting it. Organizational Policy #5.7A "Bag Technique Procedure/Standard Precautions" (dated 2021) under section #5, stated in relevant part “… hands are to be cleansed before re-entering bag” and under section #10 stated in relevant part “all equipment is cleansed with disinfectant after use and before returning to the bag”. In an interview with the Administrator (#76995) and the Alternate Director of Nursing(#54720), they both confirmed that this policy was not followed.

It is required that a hospice aide provides services by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by record review and interview. 1 of 6 (17%) clinical records, in which the hospice aide services were accepted, revealed the agency did not ensure the hospice aide performed visits in accordance with the plan of care orders. Record #34078 was reviewed and identified the patient elected hospice care on 5/19/22. The initial plan of care, effective 5/19/22, had orders written for the hospice aide to perform three (3) visits per week. The first documented visit by the aide was on 5/24/22. Per the administrator, the agency counted the visit frequency (billing) week as Monday to Sunday. In an interview with the administrator (#56995) and the alternate director of nursing (#54720), conducted on 6/2/22, they reported they could not find any documentation for visits performed prior to 5/24/22, documentation for missed visits, or order changes.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. In the absence of state requirements, criminal background checks are obtained within three (3) months of the date of employment for all states in which the individual has lived or worked during the past three (3) years. This standard was not met as evidenced by record review and interview. In 4 of 7 (57 %) applicable personnel records, in which a criminal background check was required, the agency did not ensure the criminal background checks were completed. The following 4 records did not contain the criminal background checks: Record #31663 (date of hire 1/3/22), Record #35768 (date of hire 3/12/2022), Record #25067 (date of hire 2/7/22), and Record #65532 (date of hire 2/15/22). In an interview with the Administrator (#76995) on 6/2/2022, he stated, “I thought that doing the employment verification, OIG (Office of Inspector General) exclusion list and the license verification was enough."