Peoples Hospice and Palliative Care

“It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes the following: for all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles, demonstration of staff knowledge of emergency procedures, EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years, more frequent training occurs if there is a significant update of EP policies and procedures, a periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others, and documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by document review, interview and personnel record review. In 1 of 11 (9%) personnel records reviewed, the agency did not ensure that all staff received training on the agency’s Emergency Preparedness program upon hire. ORIENTATION DOCUMENT: The agency’s orientation documentation form titled “Orientation for hospice employees other than nurses” stated in part, “The orientee will complete [electronic education program] courses regarding but not limited to, Universal Precautions, Advance Directives, Corporate Compliance, HIPAA, Education, and Back Safety, Abuse, and infection control.” PERSONNEL RECORD 11: A review of the Music Therapist’s (date of hire 09/26/2025) personnel record revealed that it contained the form titled “Orientation for hospice employees other than nurses”. There were no transcripts from the electronic education program in the record. No other documents in the record supported the education provided to the Music Therapist included education on Emergency Preparedness. The Administrator (PERSONNEL RECORD 1) and Alternate Administrator (PERSONNEL RECORD 2) were interviewed on 11/20/2025. The Alternate Administrator stated, “Emergency Preparedness is a module assigned in [the electronic education program]. Contracted staff are not given access to [the electronic education program], so no transcripts are available for the Music Therapist” and “We don’t currently provide this education to contracted staff.””

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: Hand hygiene. This standard was not met as evidenced by document review, observation and personnel record review. In 1 of 3 (33%) home visit observations performed, the agency did not ensure that the staff followed accepted standards of practice and the agency’s Infection Control-Home Bag Technique policy. POLICY: The agency’s “Infection Control - Bag Technique” policy (dated 08/08/2022) stated in relevant parts, “The inside of the bag is considered clean; the bag must be closed/zipped when not in use.” and “If you need to return to the bag, you must remove gloves, wash hands before entering the bag.” and “When the visit is completed, reusable equipment will be disinfected as appropriate, wash hands, and return reusable equipment and supplies will be returned to the bag.” HOME VISIT 1: A home visit observation was conducted with the Registered Nurse (RN - PERSONNEL RECORD 3) on 11/18/2025. During the visit, the nurse was observed entering the clinical bag without disinfecting her hands several times. Additionally, the RN’s bag was unzipped (open) throughout the visit as well as after she left the patient’s home. The RN did not follow the agency’s Infection Control-Home Bag Technique policy. The RN was interviewed following the home visit observation. The RN stated that she was knowledgeable about the agency’s Bag Technique policy, and that she “should disinfect [her] hands each time [she] entered the bag.””

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care and documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed where the patient received volunteer services, the agency did not ensure that volunteer visits were provided as written in the volunteer plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit and was admitted to hospice care on 10/06/2025. During the initial comprehensive assessment dated 10/06/2025, documentation indicated that the patient accepted volunteer services. The Plan of Care (POC) dated 10/06/2025 included an order for volunteer services at a frequency of one visit every other week. There were documented volunteer notes dated 10/17/2025 and 11/17/2025. Visits were not provided as ordered on the POC, nor was there documentation in the record indicating that visits were missed or that the missed visits were communicated to the ordering physician or the Interdisciplinary Group. The Administrator (PERSONNEL RECORD 1) was interviewed on 11/19/2025 and confirmed that the visits were not provided as ordered on the POC and stated, “There should be notes written if the visits are not provided.””