United Hearts Hospice Health Services

“Upon patient record review 2 of 14 (Patient #1,#5) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. Patient#1,#5: There is no evidence that a comprehensive spiritual assessment was completed that identified spiritual needs of the patient or family. The admit nurse documents “spiritual assessment completed”. However, the template for spiritual assessment is blank and there is no documentation of what was assessed, any spiritual needs, or any information regarding the spiritual status or preferences of the patient.”

“Upon patient record review, 5 of 14 (Patient #1,#2,#3,#7,#9) 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: The medication profile indicates Amoxicillin ordered 5/14/26 taken 3 times a day for 7 days. However, the medication still shows as active on the medication profile. Also, Prednisone 40mg ordered on 5/14/26 to take 1 daily for 5 days. However, the medication still shows as active on the medication profile. Patient#2: The medication profile indicates patient actively taking Tylenol 325 take 2 every 4 to 6 hours as needed for pain or fever and oxycodone 10-325mg take 1 every 8 hours as needed for pain. There is no indication of a maximum 24 hour dose specified. During home visit it was noted that patient is using Lidocaine 4% patch apply 1 to affected area every 12 hours. There is no evidence of this medication on the medication profile and the instructions on the label in home do not contain a specified area of application. Patient#3: During home visit it was noted that patient had Eliquis 5mg take 1 twice a day and Triamcinolone acetonide 0.1% both filled 7/23/26 in the home and is actively using however, there is no indication of these medications on the active medication profile. The medication profile does indicate active orders for cyclobenzaprine 10mg 1 twice a day and Vitamin A&D ointment. However, these medication are not found in the home. Patient#7: Upon review of medication profile Nitroglycerin is ordered as 1 every 5 minutes take as directed. There is no evidence of instructions specifying max of 3 doses or to contact hospice if pain is unrelieved. Per medication profile the patient is ordered Tylenol 325mg 2 PRN every 4-6 hours and Norco 5-325 PRN every 4-6 hours. There is no evidence of a maximum dose. Patient#9: The medication profile indicates Clobetasol 0.05% topical 2 times a day apply to affected area. There is no evidence of a specified area of application.”

“Upon patient record review, 2 of 14 (Patient #3,#7) 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#3: There is no evidence of problems goals or interventions related to bleeding precautions on the plan of care. Patient is taking aspirin and Eliquis daily for blood thinner. Patient#7: The record indicates patient is ordered oxygen PRN. However, there is no evidence of problems goals or interventions related to use of oxygen on the plan of care Patient is admitted to hospice for terminal diagnosis of COPD.”

“Upon patient record review, 4 of 14 (Patient #2,#3,#7,#9) 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 plan of care indicates patient actively taking Tylenol 325 take 2 every 4 to 6 hours as needed for pain or fever and oxycodone 10-325mg take 1 every 8 hours as needed for pain. There is no indication of a maximum dose of acetaminophen specified. During home visit it was noted that patient is using Lidocaine 4% patch apply 1 to affected area every 12 hours. There is no evidence of this medication on an order and the instructions on the label in home do not contain a specified area of application. Patient#3: During home visit it was noted that patient had Eliquis 5mg take 1 twice a day and Triamcinolone acetonide 0.1% both filled 7/23/26 in the home and is actively using. However, there is no indication of these medications on the plan of care. Patient#7:Upon review of medication order Nitroglycerin is ordered as 1 every 5 minutes take as directed. There is no evidence of instructions specifying Max of 3 doses or to contact hospice if pain is unrelieved. Per medication orders the patient is ordered Tylenol 325mg 2 PRN every 4-6 hours and Norco 5-325 PRN every 4-6 hours. There is no evidence of a maximum acetaminophen dose. Patient#9: The medication order indicates Clobetasol 0.05% topical 2 times a day apply to affected area. There is no evidence of a specified area of application.”

“Upon client record review, 3 of 14 (Patient #2,#3,#6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#2: The RN identified the need to help patient/caregiver and established a plan of care with problems goals and interventions to provide volunteer services. However, there is no evidence these services are being provided. Patient#2,#3: The record indicates there are 2 current frequency orders for nursing. One order states case manager to make 1 visit every 2 weeks. The other active order states skilled nurse to make 1 visit per week. However, there is no evidence that the skilled nurse visit is being made other week the case manager is going. Patient#6: The record indicates MSW frequency order states decline 5/20/26. However per record MSW has visits documented on 5/21/26, 06/21/26 and 07/21/26.”