Every finding on record at Peaceway Hospice LLC

Based on record reviews and interviews the agency failed to ensure a patient’s individualized plan of care was followed to ensure a patient’s right to be free from neglect for 1 (Patient 2) of 4 patients’ records reviewed.The failure to provide hospice aide services resulted in the patient’s needs to be unmet, which potentially put the patient at risk for physical and emotional harm. --- Findings:Record review of Patient 2 revealed an RN Initial Assessment and Aide Care Plan dated 5/27/2024 signed by RN B in the agency’s previous EMR system. The Aide Care Plan had a hospice aide frequency of 2 days a week to assist with showering, dressing, hair care, foot care, skin care, nail care, oral care, incontinent (loss of bowel or bladder control) care, ambulation, and bed linen change. Patient 2’s calendar in the agency’s new EMR system from 5/27/2024 to 6/06/2024 did not include scheduled hospice aide visits or a plan of care. Records revealed   Patient 2 called to revoke hospice services on 6/06/2024 and was discharged. An interview was conducted with the ADON on 5/15/2025 at 12:36pm. The surveyor asked about the missing hospice aide schedule and plan of care for Patient 2 in the agency’s new EMR system. The ADON stated, Patient 2’s “admission was during the middle of the crossover from the old system to the new system… In the old system an aide was ordered 2 times a week and was not entered into the new system.” In the new system “there is not a care plan and no frequencies for an aide. I'm sure it just literally got missed.”An interview was conducted with RN B on 5/15/2025 at 1:25pm. The surveyor asked about the agency’s transition process from the old EMR system to the new system. RN B stated the nurses started “moving over the care plan, medications, visit frequencies and aide care plans…two to three weeks before June 1st (2024) which was our (agency’s) go live date.” The surveyor asked about the hospice aide notification process for patients admitted during the last week of May 2024. RN B stated the agency staff were documenting in the old system and were notified of “added patients to their schedule through the “teams” application. RN B stated, the ADON or DON “usually would communicate directly with the aides,” to notify the aides of updated schedules. An interview was conducted with the Alternate Administrator and Alternate Director of Nurses on 5/16/2025 at 12:45pm. The surveyor asked about the agency’s policy on providing hospice aide services. The ADON stated, “the aide services would be provided according to the scheduled frequency on the primary care plan.” The surveyor asked why the agency’s policy was not followed with Patient 2. The ADON stated, “I think it just accidentally did not get added correctly” during the transition from the old EMR system to the new EMR system and “got overlooked.” The surveyor asked how could missed aide visits affect patients? The ADON stated patients “are not able to have the aide services that had been ordered for them. It can affect their well-being, how they feel supported in receiving Hospice services and what they were expecting.”The surveyor placed calls to Patient 2’s son 5/14/2025 at 1:00 pm, 5/15/2025 at 2:33 pm, and 5/16/2025 at 12:16 pm. A voicemail message was left each time requesting a return call.Review of agency’s policy “Implementing Care and Treatment, PC.35, revision 04/14/2023,” reads in part “The Hospice designates a qualified registered nurse (RN), who is a member of the Interdisciplinary Group/Team (IDG/IDT), who will provide coordination of care and to ensure: The implementation of the Interdisciplinary Group/Team (IDG/IDT) Plan of Care (POC) for each patient and family, including but not limited to the principles of the care to be provided…Procedure: The Hospice RN, who is a member or the IDG/IDT, will oversee the assignment of a Hospice (HA) to a particular patient, initiating hospice aide services within time frame to meet identified patient’s needs as identified in the POC and per physician orders.”Review of agency’s policy “Rights and Responsibilities, revision 08/01/2024” reads in part “Each patient has a right to be informed of his or her rights, to exercise his or her rights, as well as have his or her rights protected and promoted. These include the right to: Be free from…neglect…by a Hospice employee.”Review of agency’s policy “Abuse, Neglect and Exploitation-Addendum, PC.15-TX, revision 02/22/2024,” reads in part “Definition: “Neglect means the failure to provide for one’s self the goods or services, including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caretaker to provide such goods or services.”

Based on record reviews and interviews the hospice agency failed to provide all hospice care and services to patients and their families and failed to follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs for 1 (Patient 2) of 4 patients’ records reviewed. The failure to provide hospice aide services resulted in the patient’s needs to be unmet, which potentially put the patient at risk for physical and emotional harm. --- Findings:Record review of Patient 2 revealed a RN Initial Assessment and Aide Care Plan dated 5/27/2024 signed by RN B in the agency’s previous EMR system. The Aide Care Plan had a hospice aide frequency of 2 days a week to assist with showering, dressing, hair care, foot care, skin care, nail care, oral care, incontinent (loss of bowel or bladder control) care, ambulation, and bed linen change. Patient 2’s calendar in the agency’s new EMR system from 5/27/2024 to 6/06/2024 did not include scheduled hospice aide visits or a plan of care. Records revealed   Patient 2 called to revoke hospice services on 6/06/2024 and was discharged. An interview was conducted with the ADON (RN A) on 5/15/2025 at 12:36pm. The surveyor asked about the missing hospice aide schedule and plan of care for Patient 2 in the agency’s new EMR system. The ADON stated, Patient 2’s “admission was during the middle of the crossover from the old system to the new system… In the old system an aide was ordered 2 times a week and was not entered into the new system.” In the new system “there is not a care plan and no frequencies for an aide. I'm sure it just literally got missed.”An interview was conducted with RN B on 5/15/2025 at 1:25pm. The surveyor asked about the agency’s transition process from the old EMR system to the new system. RN B stated the nurses started “moving over the care plan, medications, visit frequencies and aide care plans…two to three weeks before June 1st (2024) which was our (agency’s) go live date.” The surveyor asked about the hospice aide notification process for patients admitted during the last week of May 2024. RN B stated the agency staff were documenting in the old system and were notified of “added patients to their schedule through the “teams” application. RN B stated, the ADON or DON “usually would communicate directly with the aides,” to notify the aides of updated schedules. An interview was conducted with the Alternate Administrator and Alternate Director of Nurses (RN A) on 5/16/2025 at 12:45pm. The surveyor asked about the agency’s policy on providing hospice aide services. The ADON stated, “the aide services would be provided according to the scheduled frequency on the primary care plan.” The surveyor asked why the agency’s policy was not followed with Patient 2. The ADON (RN A) stated, “I think it just accidentally did not get added correctly” during the transition from the old EMR system to the new EMR system and “got overlooked.” The surveyor asked how could missed aide visits affect patients? The ADON stated patients “are not able to have the aide services that had been ordered for them. It can affect their well-being, how they feel supported in receiving Hospice services and what they were expecting.”Review of agency’s policy “Implementing Care and Treatment, PC.35, revision 04/14/2023,” reads in part “The Hospice designates a qualified registered nurse (RN), who is a member of the Interdisciplinary Group/Team (IDG/IDT), who will provide coordination of care and to ensure: The implementation of the Interdisciplinary Group/Team (IDG/IDT) Plan of Care (POC) for each patient and family, including but not limited to the principles of the care to be provided…Procedure: The Hospice RN, who is a member or the IDG/IDT, will oversee the assignment of a Hospice (HA) to a particular patient, initiating hospice aide services within time frame to meet identified patient’s needs as identified in the POC and per physician orders.”

This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 19 (5%) records reviewed revealed that the agency did not ensure that the drug profile included all the patient medications in accordance with the agency policy. Policy # TX.17 titled: Medication List Monitoring" stated " Agency will maintain a current, accurate list of all prescription and over the counter (OTC) medications taken by the patient." Clinical Record 5: The initial comprehensive assessment by the Registered Nurse (RN) dated 08/31/2023 identified that the patient had a diagnosis of senile degeneration of the brain. There was no documented evidence that the medication profile included the physician ordered Oxygen 2L-5L/min per nasal cannula as needed dated 08/31/23. During a joint record review on 11/29/2023 with the Director of Clinical Growth, Staff 2, confirmed that the patients' medication profile did not include documentation of all medications that the patient was receiving, per the agency policy.