Every finding on record at Peaceful Mind Hospice Care, Inc.

Upon patient record review, 1 of 5 (Patient #3) 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 #3: Plan of Care (1-6-23) indicated order for oxygen. Oxygen is not on the medication list.

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: This patient had an over-bed table, bed-rails and a trapeze bar. These items were not included on the Plan of Care.

Upon personnel record review, 2 of 13 (Personnel #2 and #3) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #2 and #3 did not have evidence in their employee file that Hospice Philosophy had been reviewed/taught.

Upon personnel record review, 1 of 13 (Personnel #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 #9: The competency for the MSW was initialed that competencies were complete. However, the signature page did not have the validating personnel name/signature/initial.

Upon patient client record review, 3 of 5 (Patients #1, #2 and #3) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patients#1, #2 and #3: The Election of Benefit (EOB) Effective Date for hospice benefit to begin was not dated in the space provided on the form.

Upon patient client record review, 1 of 5 (Patient #1) 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. Patient #1: In the review/revise medication section, the date was 2-6-22 for assessment of the following: adverse SE's, Interactions, duplicate drug therapy, Pt understanding/instructions and compliance. The patient did not start service until 1-5-23.