Kind Hearts Hospice Inc.

“Upon patient record review, 2 of 14 (Patients # 1, 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 # 1: During home visit, the patient’s medication included a vial of Ondansetron HCL 4 mg, 1 tab by mouth, as needed every six hours for nausea and vomiting. The patient’s medication list did not contain this medication. The daughter stated that they give this medication to the patient as needed. Patient # 2: During home visit, the patient’s medication included a vial of Ondansetron HCL 4 mg, 1 tab by mouth, as needed every six hours for nausea and vomiting. The patient’s medication list did not contain this medication.”

“Upon patient record review, 2 of 14 (Patients # 1, 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 # 1: During home visit, the patient’s medication contained a vial of Ondansetron HCL 4 mg, 1 tab by mouth, as needed every six hours for nausea and vomiting. The patient’s most recent plan of care did not contain orders for this medication. The daughter stated that they give this medication to the patient as needed. Patient # 2: During home visit, the patient’s medication contained a vial of Ondansetron HCL 4 mg, 1 tab by mouth, as needed every six hours for nausea and vomiting. The patient’s most recent plan of care did not contain orders for this medication.”

“Upon patient record review, 3 of 14 (Patients # 1, 2, 3) 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 # 1: During home visit observation and discussion with nurse, patient had a walker and supplies that included gloves, briefs, and adhesive remover. These items were not listed on the most current plan of care. Patient # 2: During home visit observation and discussion with nurse, patient had a shower chair and supplies that included wipes, briefs, and Tubigrip. These items were not listed on the most current plan of care. Patient # 3: During home visit observation and discussion with nurse, patient had a walker, urinal, over bed table, hospital bed, and supplies that included wipes, briefs and moisture barrier pads. These items were not listed on the most current plan of care.”

“Upon client record review, 8 of 14 (Patient #1,2,3,4,5,6,7,10) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient’s condition requires but no less frequently then every 15 calendar days. Patients # 1, 4, 5, 6, 7: The 6/25/26 IDG minutes did not contain evidence of the MSW signature on the meeting attendance sign in page. The social worker was actively involved with the patient therefore there was no evidence of collaboration since there was no signature to validate participation. Patient # 2: The 5/14/26, 6/11/26, and 6/25/26 IDG minutes did not contain evidence of the MSW signature on the meeting attendance sign in page. The social worker was actively involved with the patient therefore there was no evidence of collaboration since there was no signature to validate participation. Patient # 3: The 5/14/26, 5/28/26, 6/1/26 and 6/25/26 IDG minutes did not contain evidence of the MSW signature on the meeting attendance sign in page. The social worker was actively involved with the patient therefore there was no evidence of collaboration since there was no signature to validate participation. Patient # 10: The 4/2/26 IDG minutes did not contain evidence of the MSW signature on the meeting attendance sign in page. The social worker was actively involved with the patient therefore there was no evidence of collaboration since there was no signature to validate participation.”

“Upon personnel record review, 1 of 12 (Personnel # 8) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel # 8: The hospice aide’s file did not contain evidence of a skill assessment for communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff.”

“Upon personnel record review, 3 of 12 (Personnel # 2, 3, 12) 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 # 2: The employee file did not contain evidence of an initial competency being completed for the position of Administrative Designee. Personnel # 3: The employee file did not contain evidence of an initial competency being completed for the position of DPCS Designee. Personnel # 12: The employee file did not contain evidence of an initial competency being completed for the position of Volunteer.”