Every finding on record at Peaceful Heart Healthcare LLC

Upon observation, there was no evidence the Emergency Preparedness plan includes a process for cooperation and collaboration with tribal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. There was no evidence of a process for collaboration with Tribal emergency preparedness officials. Tribal area had been marked "NA" and should have included local tribal entities. Corrected on site.

Upon observation, there was no evidence the hospice develops and maintains an emergency preparedness communication plan that complies with federal, state, and local laws and must be reviewed and updated every two years. The emergency communication plan did not include names and contact information for the hospice employees and a process or contact information for the local tribal entities. The tribal sections were marked NA when they did have local tribal authorities that should have been included in the communication plan.

Upon patient record review 6 of 11 (Patient #1, 2, 3, 4, 7, 9) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 1, 2, 7, 9: No evidence of spiritual assessment completed in first 5 days. Completed after day 5. Patient 3 and 4: No evidence of spiritual assessment completed in first 5 days. No evidence of psycho-social assessment completed in first 5 days. Completed after day 5.

Upon patient record review, 4 of 11 (Patient #2, #3, #5, #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 Patient 2: Med profile dated 11/03/2022: 09/21/2022 Lomotil 2.5mg/0.025mg daily. A second order dated, 09/21/2022, Lomotil 2.5mg/0.025mg twice a day. Two conflicting orders for the same medication. Corrected on site. Patient 3: Med profile dated 11/03/2022: Acetaminophen 300mg/Codeine 15mg order dated 05/25/2022 1 tab 2 times a day prn for pain. Acetaminophen 500mg order dated 05/25/2022 1 tab 2 times a day for pain. Conflicting order, no clarity for which should be given at what level of pain. Corrected on site. Patient 5: medication profile included Oxygen 2-4 liters PRN for SOB. Per nurses note: Oxygen to be started for O2 sat less than 90%. Tramadol 50 tab ordered 02/22/2022 1 tab every 6 hours PRN for pain. No clarity on what severity of pain to administer medication no scale within the order. Corrected on site. Patient 7: Med profile dated 11/03/2022: Morphine 10mg/5ml order dated 08/12/2022 10mg q6 hours for pain scheduled dose. Medication should have been entered as a PRN order per nurses note. Also, no clarity on what severity of pain to administer medication, no scale within the order. Hydrocodone 10mg/325mg order dated 08/12/2022, every 4 hours PRN for pain. No clarity for which to be given on what severity of pain to administer medication, no scale within the order. Medication profile included Oxygen 2-4 liters PRN for SOB. Per nurses note to be given for O2 sat less than 90%. Corrected on site.

Upon patient record review, 10 of 11 (Patient #1,#2,#3,#4,#5,#6,#7,#8,#9,#11) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 1: SOC 10-04-2021, Bereavement assessment occurred 01-24-2022. Patient 2: SOC 07-29-2021, Bereavement assessment occurred 08-09-2021. Patient 3: SOC 10-15-2021, Bereavement assessment occurred 01-27-2022. Patient 4: SOC 10-25-2021, Bereavement assessment occurred 12-06-2021. Patient 5: SOC 02-22-2022, Bereavement assessment occurred 03-02-2022. Patient 6: SOC 01-11-2022, Bereavement assessment occurred 03-14-2022. Patient 7: SOC 12-26-2021, Bereavement assessment occurred 01-24-2022. Patient 8: SOC 08-18-2022, Bereavement assessment occurred 9-11-2022. Patient 9: SOC 10-04-2021, Bereavement assessment occurred 01-24-2022. Patient 11: SOC 11-16-2021, Bereavement assessment occurred 01-24-2022.

Upon patient record review, 1 of 11 (Patient #8) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 8: Terminal dx CVA/Post traumatic seizure disorder, a neuro care plan exist with no evidence of problem/interventions for seizures.

Upon patient record review, 4 of 11 (Patient #2,#3,#5,#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. Patient 2: 09/21/2022 Lomotil 2.5mg/0.025mg daily. A second order dated, 09/21/2022, Lomotil 2.5mg/0.025mg twice a day. Two conflicting orders for the same medication. Corrected on site. Patient 3: Acetaminophen 300mg/ Codeine 15mg order dated, 05/25/2022, 1 tab 2 times a day prn for pain. Acetaminophen 500mg order dated, 05/25/2022, 1 tab 2 times a day for pain. Conflicting order, no clarity for which should be given at what level of pain. Corrected on site. Patient 5: Oxygen order dated, 5/23/2022, 2-4 liters PRN for SOB. Per nurses note: Oxygen to be started for O2 sat less than 90%. Tramadol 50 tab, ordered 02/22/2022, 1 tab every 6 hours PRN for pain. No clarity on what severity of pain to administer medication, no scale within the order. Corrected on site. Patient 7: Morphine 10mg/5ml order dated, 08/12/2022 10mg q6 hours for pain, scheduled dose. Hydrocodone 10mg/325mg order dated, 08/12/2022, every 4 hours PRN for pain. No clarity for which to be given on what severity of pain to administer medication, no scale within the order. Oxygen order dated, 07/17/2022, 2-4 liters PRN for SOB. Per nurses note to be given for O2 sat less than 90%. Corrected on site.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 3: LVN observed taking items out of the clean side of the bag with the same gloves that she had previously touch the patient with.

Upon patient record review, 4 of 11 (Patient #1, #2, #5, #8) 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 Patient 1: On SOC SN assessment identified patient as a fall risk. No evidence of fall risk on Aide POC/assignment sheet. Corrected on site. Patient 2: On seizure medications daily. No evidence of seizure precautions on Aide POC/assignment sheet. Corrected on site. Patient 5: Oxygen ordered. Not evidence of oxygen precautions on Aide POC/assignment. Corrected on site. Patient 8: Terminal dx was CVA/Post traumatic seizures, no evidence of seizure precautions on Aide POC/assignment sheet. Corrected on site.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. There is a plan for recruitment and retention, but no evidence of either.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78 No evidence of documentation of cost savings for volunteer program.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family.

Upon observation, there was no evidence the hospice discussed the policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs.

Upon client record review, 11 of 11 (Patient #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11: No evidence of written policies and procedures for managing controlled drugs was provided or discussed.