Every finding on record at Heart to Heart Hospice and Palliative Care, Inc

Upon patient record review, 1 of 5 (Patient #1) 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#1: The medication profile contacted acetaminophen with no parameter for when to take for fever.

Upon patient record review, 1 of 5 (Patient #1) 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#1: The medical record contained an order for acetaminophen. However, there was no parameters for when to take for fever.

Upon patient record review, 1 of 5 (Patient #3) 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 equipment and supply needs. Patient#3:Upon record review the nurse documented the caregiver and patient use of glucometer to monitor blood sugar. However, there is no evidence of glucometer being included on the plan of care.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Upon observation, it was noted that the annual report shows the volunteer hours for 2025 is 0%.

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record in confidential manner. There is no evidence agency is currently retaining records and maintaining patient records in a confidential manner. Agency was unable to produce all records back to previous survey.

Upon observation, there was no evidence that all patient records are retained for a minimum of six years from the date of the most recent discharge or the death of the patient, unless state law stipulates a longer period of time. There is no evidence agency is currently retaining records for 6 years. During survey process we tried to go back to use records from previous survey as a discharge review. Agency unable to produce these records.