Every finding on record at Peacehealth

Observed in Tracer Activities. From review of VOL#1 and discussion with the volunteer coordinator it was determined that there was not a process in place to provide emergency preparedness training at least every 2 years as required by the standard or every year as required by organization policy. This was reviewed with the volunteer coordinator.

Observed in Record Review. In 1 of 2 records reviewed of live discharged patients, there was no evidence of the required Medicare Notice of Non Coverage being provided at the time of planned discharge. From the review of RRNHV#2 it was noted that there was no documented Notice of Medicare Non Coverage included in the discharged record at the time of surveyor review. This was confirmed by the accreditation manager who reviewed the record with the surveyor.

Observed in Record Review. In 3 of 12 patient records reviewed, the initial bereavement risk assessment was not conducted within the first 5 days of hospice care. In HV#1, NHV#6, and NHV#9 the initial bereavement risk assessment was not completed as part of the initial comprehensive hospice assessment. This was confirmed by the hospice administrator who reviewed the records with the administrator.

Observed in Record Review. In 4 of 12 patient records reviewed, the hospice plan of care included prn frequency orders without routine ordered visits. In HV#1, HV#3, NHV#1, and NHV#6 the MSW frequency orders only included prn visit orders, there were no routine visits orders for MSW. This was confirmed by the hospice administrator.

Observed in Record Review. In 1 of 12 patient records reviewed, the medication order was incomplete. In HV#1 the Lorazepam order was written as, Lorazepam 1-2 tablets (0.5mg-1 mg) every 4 hours as needed for anxiety or dyspnea without direction for when to take 1 or when to take 2 tablets. This was confirmed by the Administrator who reviewed the record with the surveyor.

Observed in Record Review. In 1 of 12 patient records reviewed, the frequency of visit orders were not followed. In HV#2 there was 1 MSW visit ordered over a 60 day period in January to March 2026 and there were no MSW visits made and no missed visit notes included in the record. This was confirmed by the accreditation manager who reviewed the record with the surveyor.

Observed in Tracer Activities. From review of VOL#1 and from discussion with the volunteer coordinator it was determined that there was not a process to provide the required annual infection control training to the volunteer staff. From review of VOL#1 record the infection control training for 2025 was limited to a hand hygiene question on a written test as reported by the volunteer coordinator

Observed in Competency Session. In 1 of 10 HR files reviewed, it was determined that the competencies required of the volunteer coordinator had not been defined. From review of HR#2, the volunteer coordinator, it was determined that the competencies to be assessed of the volunteer coordinator had not been defined in order for the competency assessments to be documented. This was reviewed with the manager of accreditation.

Observed in Tracer Activities. From discussion with the volunteer coordinator it was determined that the process for documenting volunteer visit notes was for the volunteer coordinator to transcribe their notes into the electronic medical record. There was no authentication of the transcription by the volunteer(s). This process was confirmed from review of NHV#5 volunteer notes that had been transcribed without authentication of the volunteer author.

Observed in Record Review. In 10 of 11 patient records reviewed, the Hospice surveyor noted the goals in patient records were not specific to care provided and were not measurable or time specific. For example, in HSHV/RR #1 the patient had COPD, on oxygen and living alone and goal was that the patient would report an acceptable level on an ongoing basis. And social work was working to get placement on the wait list in an assisted living and the only goal related to this was that patient's psychosocial needs would be addressed through end of life. On review of HSHV/RR #2, the patient has Alzheimer's and is being cared for in her home by husband and the goals were not specific or measurable for the care needs of the patient; for example, patient will demonstrate acceptable bowel/bladder comfort and Patient will receive adequate care in desired setting. On review of HSHV/RR #3, the patient has brain cancer and the goals associated with care were not time specific, one example is that patient will express understanding of comfort regimen with no time measurement for the goal. On review of HHRR #10, the patient had an active wound and there was no goals to reflect the care for that wound. On review of HHRR #5, HHRR, #6, HHRR #7, HHRR #8, and HHRR #9, goals were not measurable. Examples include: Acceptable bowel and bladder control, cardiac comfort at acceptable levels, breathing managed at acceptable levels, all of which were not measurable or time specific. This finding was reviewed and discussed with the Hospice Manager.

Observed in HR File Review. In 6 of 6 HR Files reviewed of employees who were hired in the last three year, the organization had not assessed and documented completion of orientation on hire. In all HR Record there was no documented competency completed as part of orientation. Organization does have the forms developed but has not completed the documentation on their employees. This finding was reviewed and validated with the Hospice Manager.

Observed in Patient Home. In 3 of 3 home visit conducted, the nurse surveyor noted that the organization had not reassessed medications of the patient. On HHHV/RR # 1, the patient had been taking Meclizine and this was not reflected on the medication list. On HSHV/RR #2 the caregiver had stopped giving the patient the calcium with D3 and started vitamin D3 and this was not reflected on the medication list. HSHV/RR #3, during the visit that caregiver told the social worker he was giving the patient ibuprofen daily for discomfort, this was not on the medication record and when I asked the caregiver how long he has been doing this he stated for at least 3 weeks and there had been nursing visits to the patient since that timeframe. This finding was reviewed and validated with the Hospice Manager.

Observed in Tracer Activities. On review of the agency contracts, it was noted there was no provision in the pharmacy contract that the contracted entity obtain a criminal background check. This was reviewed and confirmed with the Hospice Manager.