Every finding on record at Peaceful Hearts Hospice LLC

Upon patient record review, 7 of 19 (Patients #3,#6,#7,#8,#12,#13,#14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 3: Upon home visit medication reconciliation, the patient's daughter stated that gabapentin was not in use since an acute nerve pain issue that occurred in May 2025. The gabapentin was still active on the medication profile. The profile also contained duplicative lidocaine patch instructions. Corrected on site with removal of invalid medications from the profile. Patient 6: The medication profile contained a topical muscle rub cream and lidocaine patch with no areas defined for administration. Corrected on site with order clarifications received and medication profile updated. Patient 7: The medication profile contained a topical triamcinolone with no area defined for administration. Corrected on site with order clarification received and medication profile updated. Patient 8: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen included on the medication profile. Corrected on site with order received and medication profile updated. Patient 12: Upon home visit medication reconciliation, the assisted living and hospice medication lists did not match. The facility had acetaminophen every 6 hours PRN instead of four times daily PRN per hospice, and dextromethorphan & guaifenesin four times daily PRN instead of every 4 hours PRN per hospice profile. The hospice medication profile also contained Miralax oral powder with no instructions to mix with a diluent. Corrected on site with order clarifications received and medication profile updated. Patient 13: The medication profile contained a former Cipro order listed as still active. Corrected on site with removal of invalid medication from the profile. Patient 14: The hospice medication profile contained Miralax oral powder with no instructions to mix with a diluent. Corrected on site with order clarification received and medication profile updated.

Upon patient record review, 1 of 19 (Patients #12) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 12: There was no evidence of a physical comprehensive RN assessment from 9/29/25 to 10/20/25. All nursing visits within timeframe were completed by an LVN.

Upon patient record review, 1 of 19 (Patient #5) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 5: The medical record contained LVN documentation identifying patient wound 9/22/25, 9/25/25, and 9/29/25. There was no evidence of an RN assessment of the wound.

Upon patient record review, 4 of 19 (Patients #4,#12,#13,#14) 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 4: The medical record identified the patient as diabetic. There was no evidence of problems, goals, and interventions related to endocrine dysfunction included in the plan of care. Corrected on site with plan of care update. Patient 12: The medical record identified the patient is on Eliquis. There was no evidence of problems, goals, and interventions related to risk for bleeding included in the plan of care. Corrected on site with plan of care update. Patient 13: The medical record contained nursing documentation upon admission identifying patient need for straight catheterization. There was no evidence of problems, goals, and interventions related to catheterization included in the plan of care. Corrected on site with plan of care update. Patient 14: The medical record contained nursing documentation upon admission identifying patient is a high fall risk. There was no evidence of problems, goals, and interventions related to fall safety included in the plan of care. Corrected on site with plan of care update.

Upon patient record review, 6 of 19 (Patients #3,#6,#7,#8,#12,#14) 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 3: Upon home visit medication reconciliation, the patient's daughter stated that gabapentin was not in use since an acute nerve pain issue that occurred in May 2025. There was no evidence of an order to discontinue the gabapentin. Corrected on site with discontinuation orders received. Patient 6: The medical record contained orders for topical muscle rub cream and a lidocaine patch with no areas defined for administration. Corrected on site with order clarification received. Patient 7: The medical record contained an order for topical triamcinolone with no area defined for administration. Corrected on site with order clarification received. Patient 8: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen rate, frequency, and delivery method. Corrected on site with order received. Patient 12:Upon home visit medication reconciliation, the assisted living and hospice medication orders did not match. The facility had acetaminophen every 6 hours PRN instead of four times daily PRN per hospice, and dextromethorphan & guaifenesin four times daily PRN instead of every 4 hours PRN per hospice profile. The medical record also contained an order for Miralax oral powder with no instructions to mix with a diluent. Corrected on site with order clarifications received. Patient 14: The medical record contained an order for Miralax oral powder with no instructions to mix with a diluent. Corrected on site with order clarification received.

Upon patient record review, 3 of 19 (Patients #3,#8,#12) 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 3: The medical record contained nursing documentation upon admission identifying patient use of a overbed table, walker, wheelchair and commode. There was no evidence of orders for the DME included in the plan of care. Corrected on site with orders received. Patient 8: The medical record contained nursing documentation upon admission identifying patient use of a shower chair, commode, and oxygen equipment. There was no evidence of orders for the DME included in the plan of care. Corrected on site with orders received. Patient 12: The medical record contained nursing documentation upon admission identifying patient use of a nebulizer. There was no evidence of an order for the DME included in the plan of care. Corrected on site with order received.

Upon patient record review 2 of 19 (Patients #3,#12) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient 3: The aide did not complete all assigned tasks including incontinence care, brushing teeth, nail care, light housekeeping 10/7/25, and brushing teeth and light housekeeping 10/3/25, 10/10/25, and 10/17/25. There was no evidence of communication with the RN. Patient 12: The aide did not complete all assigned tasks including nail care, applying deodorant, lotion, and brushing teeth 10/8/25. There was no evidence of communication with the RN.

Upon patient record review 1 of 19 (Patient #12) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 12: There was no evidence of RN supervision of the aide between 9/29/25 and 10/20/25.

Upon patient record review, 5 of 19 (Patients #1,#4,#6,#10,#11) did not have evidence that each patient record contains Advance Directives. Patients 1,4,6,10: The Health Care Directives on file do not outline the patient wishes regarding resuscitation. Agency utilized their CPR directive process with hospice admission representative to witness and Medical Director DNR order written in record. Patient 11: The Health Care Directive on file contains patient wish for attempt of CPR and treatment if able to communicate, care for self, live without incapacitating pain, and be conscious and aware of surroundings. Agency utilized their CPR directive process with hospice admission representative to witness and Medical Director DNR order written in record.

Upon patient record review, 1 of 19 (Patient #5) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 5: The medical record contained a wound care order 9/24/25 that did not designate facility and hospice responsibilities. Corrected on site with order clarification.

Upon personnel record review, 2 of 16 (Personnel #1,#6) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements. Personnel 1: The personnel did not have an RN license as required per agency job description for alternate DPCS. The personnel was licensed as an LVN. Personnel 6: The personnel did not have an RN license as required per agency job description for on-call nurse. The personnel was licensed as an LVN.

Upon patient record review, 3 of 11 records (Patient #1, #8, #10) 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: Patient #1: The medication profile listed nitroquick 0.4 mg PRN chest pain however, did not contain evidence of complete directions for use. Corrected on site. Patient #8: The medication profile listed aspercreme 10% topical apply three times per day however, did not contain evidence of a specific location. Patient #10: The medication profile listed ativan cream 2 mg topical apply every 6 hours PRN for agitation however, did not contain evidence of a specific location.

Upon patient record review, 11 of 11 records (Patient #1-#11) 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. Patients #1-#11: There was no evidence of problems/interventions/goals for alternative therapies being provided to each patient. Corrected on site for #1-#7. Patient #2: The nurse comprehensive visit identified the patient could not safely administer medications and there was not another caregiver available however, there was not evidence in the plan of care for problems/interventions/goals to address this need. Corrected on site. The nurse noted patient had impetigo and received order for antibiotic however, there was not evidence that plan of care was updated to reflect problems/interventions/goals. Patient #3: Upon home visit observed nurse perform medi-planner refill however, there was no evidence of this included on plan of care. Corrected on site. Patient #4: The patient was ordered on 09/13/2022 calmoseptine to groin and skin folds twice daily and PRN for redness however, there was no evidence of skin integumentary problems/interventions/goals on plan of care. Corrected on site. Patient #7: Initial nurse assessment revealed patient had scab/scrapes however, there was no evidence of skin integumentary on plan of care. Corrected on site.

Upon patient record review, 11 of 11 (Patient #1-#11) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patients #1-#11: There was an order for alternative therapy as PRN however, there was not evidence of specific frequency for each. Corrected on site for #1-#7 only.

Upon patient record review, 3 of 11 records (Patient #1, #8, #10) 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 #1: There was an order for nitroquick 04.mg PRN chest pain however, did not contain evidence of complete directions for use. Corrected on site. Patient #8: There was an order for aspercreme 10% topical apply three times per day however, did not contain evidence of a specific location. Patient #10: There was an order on 09/06/2022 for ativan cream 2 mg topical apply every 6 hours PRN for agitation however, did not contain evidence of a specific location.

Upon patient record review, 4 of 11 records (Patient #3, #4, #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 equipment and supply needs. Patient #3: The nurse comprehensive visit noted patient had bedside commode however, there was not evidence of this on plan of care. Corrected on site. Patient #4: The nurse comprehensive visit noted patient had hospital bed, over bed table, walker, wheelchair, shower chair, and geri chair however, there was not evidence of these on plan of care. Corrected on site. Patient #5: The nurse comprehensive visit noted patient had wheelchair, shower chair, and hoyer lift however, there was evidence of these on plan of care. Corrected on site. Patient #7: The nurse comprehensive visit noted patient had shower chair and over bed table however, there was not evidence of these on plan of care. Corrected on site.

Upon personnel record review, 2 of 10 records (Personnel #5, #9 ) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #5: There was not evidence of skills competency for VC and BC roles. Corrected on site. Personnel #9: The skills check off for PT was completed by an OT.

Upon inpatient contract review, 1 of 1 (Florence) did not have evidence that the inpatient facility has identified an individual within the facility who is responsible for the implementation of the provisions of the agreement. Contract #2: The contract did not have evidence of the individual within the facility who is responsible for the implementation of the provisions in agreement. Corrected on site.

Upon SNF/NF contract review, 1 of 1 (Florence) did not have a provision that the hospice may use the SNF/NF nursing personnel where permitted by state law and as specified by the SNF/NF to assist in the administration of prescribed therapies included in the plan of care only to the extent that the hospice would routinely use the services of a hospice patient's family in implementing the plan of care. Contract #2: The contract did not have evidence that specified hospice may use the SNF/FN nursing personnel where permitted by state law as above. Corrected on site.