Every finding on record at Peaceful Bridge Hospice 3 Inc.

Upon patient record review, 1 of 5 (Patient #2) 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 #2: The medication profile listed on 01/14/2023 neb treatment BID with albuterol 2.5mg/3mL and ipratropium bromide 0.5mg/2.5mL PRN however, there was no evidence of PRN indicator. COS

Upon patient record review, 1 of 5 (Patient #2) 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 #2: The order on 01/14/2023 neb treatment BID with albuterol 2.5mg/3mL and ipratropium bromide 0.5mg/2.5mL PRN however, there was no evidence of PRN indicator. COS

Upon patient record review, 1 of 5 (Patient #2) 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 #2: The nurse notes on 03/31 and 04/27 indicated patient was using low air lost mattress however, this was not included on the plan of care. COS

Upon contract review, 1 of 4 ( Alternate MD contract) did not have evidence of a contract to fulfill the role of alternate medical director, if applicable. There were 2 individuals identified as Medical Director and not one clearly as Alternate Medical Director. COS