Every finding on record at Heart of Hope Hospice Care, Inc

Upon patient record review, 1 of 14 (Patient #13) 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 13: The medication record recorded, "Polyethylene Glycol 17g powder for solution, 1 powder oral once daily." There was no further evidence of instructions to mix the powder with a diluent.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1: The initial RN assessment dated 09/20/25 indicated the patient self catheterizes multiple times daily due to urinary retention. There is no documented evidence of any problem, interventions, or goals related to the need for self catheterization to include the frequency, education and training to be performed, or any infection control practices.

Upon patient record review, 2 of 14 (Patient #4, 13) 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 4: The initial plan of care effective 09/18/25 records an incomplete wound care order as follows, "Pressure Ulcer on right hip. SN to perform wound care as follows: Cleanse with saline, pat dry, apply A & D ointment, Calmoseptine and cover w/dressing. Change every 2-3 days." There is no further documented evidence of what type dressing should cover the wound, how the dressing should be secured, or what would indicate the need for dressing change every 2 days versus every 3 days. Patient 13: The plan of care effective 10/12/25 recorded, "Polyethylene Glycol 17g powder for solution, 1 powder oral once daily." There was no further evidence of instructions to mix the powder with a diluent.

Upon patient client record review, 3 of 14 (Patient #1,11,13) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1: The Informed Consent and Treatment Authorization form with a signature date of 09/20/25 did not indicate the anticipated disciplines frequency of visits. Patient 11: The Informed Consent and Treatment Authorization form with a signature date of 04/05/25 did not indicate the anticipated disciplines frequency of visits. Patient 13: The Informed Consent and Treatment Authorization form with a signature date of 10/12/25 did not indicate the anticipated disciplines frequency of visits.