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 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 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 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.””