Every finding on record at Heavenly Love Hospice Inc

Upon observation, there was no evidence that the patient has the right: • To exercise his or her rights as a patient of the hospice Patient #1,2,3 upon home visits the LVN photo ID badge had another agency name which was covered with a sticker of a Disney princess.

Upon patient record review, 3 of 14 (Patient #1,2,3) 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 #1,3 both had Amlodipine 2.5mg tablet on their medication profile and plan of care twice. Same medication, dose, frequency and route, this is duplicate drug therapy. Patient #2, medication reconciliation during home visit per surveyor, the label on bottle of Clonidine 0.1mg tablet instructs "Take one tablet by mouth once a day if BP over 160". Patient verifies she checks BP in the morning and only takes this medication if it is over 160 Systolic. The Medication profile and plan of care have instructions stating "one tablet every 6 hours daily as needed for SBP>150".

Upon patient record review, 7 of 14 (Patient #1,2,6,7,8,9,10) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #1 upon record review, 6/25/25, there was no evidence of IDG discussion for recertification #3 that began 5/17/25. Patient #2 upon record review, 6/25/25, there was no evidence of IDG discussion for recertification #4 that began 6/14/25. Patient #6 upon record review, 6/25/25, there was no evidence of IDG discussion since 06/03/25. (22 days). Recertification period #3 began on 6/23/25. No evidence of IDG discussion of Recertification for period #3. Patient #7 upon record review, 6/25/25, there was no evidence of IDG discussion for recertification #2 that began 6/22/25. Patient #8 upon record review, 6/25/25, there was no evidence of IDG discussion for recertification #2 that began 6/21/25. Patient #9 upon record review, 6/25/25, there was no evidence of IDG discussion for recertification #2 that began 6/08/25. Patient #10 upon record review, 6/25/25, there was no evidence of IDG discussion for recertification #2 that began 6/06/25.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #7 Plan of care frequency for LVN is once weekly. Upon review on 6/25/25 the last documented LVN visit was dated 6/11/25. Thus missing a visit for week of 6/15/25.

Upon patient record review, 2 of 14 (Patient #13,14) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #13,14 There were completed Discharge Summaries for these patients that revoked hospice. In the record and the end of the narrative stated, "Discharge summary and plan of care available for fax upon request." No evidence of any records sent to physician.

Upon patient record review 3 of 5 records (Patient #1, #3, #5) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 1: The SOC assessment by RN did not contain the components needed for psychosocial assessment. MSW was declined. There was no evidence of a psychosocial assessment as part of the comprehensive assessment. Patient 3: The SOC assessment by RN did not contain the components needed for psychosocial or spiritual assessment. There was no evidence of a Spiritual or psychosocial assessment as part of the comprehensive assessment. Patient 5: The SOC assessment by RN did not contain the components needed for psychosocial assessment. There was no evidence of a psychosocial assessment.

Upon personnel record review, 1 of 1 applicable (Personnel #5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel 5: Did not have evidence in the personnel file that the required competency assessment was performed by the aide with a patient or Pseudo patient.

Upon patient record review, 1 of 5 records (Patient #5) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient 5: There was no evidence of written certification.

Upon patient client record review, 1 of 5 records (Patient #5) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 5: Document within EMR, has no narrative and no physician signature. There was no evidence of a Physician certification.