Every finding on record at A Peaceful Journey Hospice LLC

Upon patient record review, 1 of 14 (Patient #6) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 6: The current medication record indicates an order dated 8/26/25 for Silvadene External Cream 1%, apply 1 inch cream topically to back burn areas twice daily for 14 days (9/8/25). Medication remains an active order. Corrected on site, medication was discontinued.

Upon patient record review, 1 of 14 (Patient #6) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 6: The POC dated 9/3/25 under related "X19.XXA contact with other heat and hot substances, init encntr; Indicates Silvadene External Cream 1% apply 1 inch cream topically to back burn areas twice daily x 14 days" there is no evidence of a completion date and the details of the order is unclear. Corrected on site, IT related issue, POC updated.

Upon patient record review, 1 of 14 (Patient #6) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 6: The POC dated 9/3/25 under related "X19.XXA contact with other heat and hot substances, init encntr; Indicates Silvadene External Cream 1% apply 1 inch cream topically to back burn areas twice daily x 14 days" there is no evidence of a completion date and remains on POC as an active order. Corrected on site, IT related issue, POC updated.

Upon patient record review 2 of 14 (Patient #1,2) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 1: Current POC dated 9/3/25 lists aide frequency of 3x weekly. Aide POC dated 9/3/25 indicates all tasks to be completed 1x weekly. Aide documentation notes all tasks being completed 3x weekly. Corrected on site, IT related issue POC updated. Patient 2: Current POC dated 9/3/25 lists aide frequency of 5x weekly. Aide POC dated 9/3/25 indicates all tasks to be completed 1x weekly with the exception of encourage fluids, safety monitoring & functional limitations. Corrected on site, IT related issue POC updated.

Upon patient record review 2 of 14 (Patient #7,8) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 7: The record indicated that an aide supervisory visit was conducted on 7/14/25 and not again until 7/31/25. (17 days) Patient 8: The record indicated that an aide supervisory visit was conducted on 8/04/25 and not again until 8/19/25. (15 days)

Upon patient record review, 1 of 5 (Patient #4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #4 - Patient medication profile contained O2 at 6L/M per nasal cannula as needed for SOB but patient order was O2 at 2L/M per nasal cannula as needed for SOB.