Every finding on record at Peace and Love Services

Upon patient record review, 1 of 14 (Patient #7) 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 Pt #7: Miralax order does not contain an amount of diluent to be used with the medication or any instructions to mix powder in liquid.

Upon patient record review, 1 of 14 (Patient #7) 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. Pt #7: Miralax medication list does not contain an amount of diluent to be used with the medication or any instructions to mix powder in liquid.

Upon client record review, 1 of 14 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Pt #3: Plan of care has frequency listed for SN 2 x week, LVN 1 x week with no end date but also has another entry for SN 1 x week with a start date in November 2023. There is no clarification as to which frequency is current.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Pt #1: Hospice Aide instructions state, "Supplemental oxygen @ 2LPM via nasal cannula as needed for shortness of breath. May increase to 3LPM if ineffective in managing shortness of breath." There was no directive to call the nurse and report complaint of uncontrolled symptom. The instructions direct the aide to assess the symptom and make care decisions.

Upon contract review, 2 of 6 (Medical Director and Alternate Medical Director contracts) did not have evidence of a contract to fulfill the role of medical director or alternate medical director, if applicable. Surveyor observed both contracts did not specify clear roles and responsibilities as both contracts stated, "Medical Director". corrected on site

Upon patient client record review, 2 of 14 (Patients #7 and #8) 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. Pt 7 and 8: Spiritual care visit was indicated "in-person" during the first sentence of the narrative. Later in the narrative spiritual care provider states, "phone call concluded".

Upon observation, there was no evidence the hospice has the appropriate licenses/permits required by state or local rules and regulations. The state license displayed expired 12/2022. The agency provided proof of payment of renewal fee and state receipt.