Every finding on record at Kind Hearts Hospice LLC

Upon patient record review, 7 of 14 (Patients #4,5,7,8,9,10,11) 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 Patients #4,5,9,10,11: The record reflected patient was using oxygen. This is not listed on med profile or as an order. Corrected on Site. Patients #7.8: Miralax 17 gm powder with no diluent included on med profile. Corrected on Site.

Upon patient record review, 7 of 14 ((Patients #4,5,7,8,9,10,11)) 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. Patients #4,5,9,10,11: The record reflected patient was using oxygen. This is not listed on med profile or as an POC order. Corrected on Site. Patients #7.8: Miralax 17 gm powder with no diluent included on POC order. Corrected on Site.

Upon patient record review, 2 of 14 (Patient #4,8) 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 #4: The record reflected that this patient had an order for Duoneb (8/23/23). There were no DME listed for nebulizer machine on Plan of Care. Corrected on site. Patient #8: The record reflected that this patient had an order for Duoneb (11/17/23). There were no DME listed for nebulizer machine on Plan of Care. Corrected on site.

Upon client record review, 3 of 14 (Patients #2,5,6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: The POC listed Volunteer visit frequency of 2 X's per month. For month of January there were no visits. The visit frequency was not met. Patient #5: The POC listed Spiritual Counselor visit frequency of 2 X's per month. For months of September and December there were only one visit on 9/20/23 and 12/14/23/. The visit frequency was not met. Patient #6: The POC listed Volunteer visit frequency of 2 X's per month. For month of July there were 3 visits on 7/18 and 7/26 x 2 (two went together and both volunteers charted). The visit frequency was not met.

Upon observation, there was no evidence the hospice documented the 2021, 2022 or 2023 cost savings achieved through the use of volunteers. During survey the estimated cost savings for 2023 was generated and reviewed by Governing Body member. Corrected on Site.