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, 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, 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 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.”