Every finding on record at Divine Light Hospice, LLC

Based on review of the policy titled “Emergency Preparedness Policy,” facility documents titled “Emergency Preparedness,” and staff interview, it was determined that the agency failed to conduct annual exercises to test the emergency plan. --- The findings include: Review of agency policy titled “Emergency Preparedness Policy,” revealed the following: II. Policies and ProceduresAdministrationA.     Shall ensure the Agency Emergency Coordinator and senior management (Clinical Director and Administrator) review the emergency preparedness plan and training exercises annually and after each actual emergency. Review of the agency’s binder titled “Emergency Preparedness,” failed to reveal documentation of testing exercises since 2022. On June 11, 2025, at approximately 1:10 p.m., an in-office interview was conducted with the Administrator, and she confirmed that the agency’s Emergency Preparedness program has not been updated or maintained since 2022. The Administrator revealed there is no other documentation available for review.

Based on review of policy titled “IDG Care Planning Process,” clinical records review and staff interview, it was determined the agency failed to develop an individualized plan of care to include all services necessary for the palliation and management of the terminal illness and related conditions for one patient (P) (P#6) of 16 sampled patients. --- Findings include: Review of policy titled “IDG Care Planning Process,” dated 1/4/2021, revealed the following:Procedure:2. The care of plan (sic) specifies the care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions.Record review revealed P#6 had pressure ulcers (localized injuries to the skin and underlying tissue, typically caused by prolonged pressure, often over bony prominences), which were referred to an outside wound care company.   Review of a document from the contracted wound care company titled “Lab Progress Report,” dated 2/13/2025, revealed the wounds had been present for three months. Further review of the clinical record revealed that a care plan addressing the wounds was not entered into the clinical record until 6/11/2025. On June 10, 2025, at approximately 2:15 p.m., an office interview was conducted with the Administrator and Director of Nursing (DON), who revealed P#6 is currently receiving care from a wound care company. The company emails weekly progress reports to the agency. The DON performs wound care for P#6 twice a week, on Wednesdays and Fridays, and the wound care company provides wound care every Monday. The DON and Administrator were unable to explain why there was no care plan reflecting P#6’s wounds.

Based on review of agency policy titled “Coordination of Patient Care,” record reviews, and staff interview, it was determined the agency failed to follow staff frequencies as ordered by the Medical Doctor (MD) for two patients (P) (P#7, P#12) of 16 sampled patient records reviewed. --- Findings include: Review of agency policy titled “Coordination of Patient Care,” dated 1/3/2025, reveals the following:Procedure:1.   Hospice has developed and maintains a system of communication and integration to:      Ensure that the IDG maintains responsibility for directing, coordinating, and supervising    the care and services provided.Ensure the care and services are provided in accordance with the plan of care and are based on all assessments of the patients and family needs.1. Record review revealed P#7, with a start of care (SOC) of 1/29/2025, had skilled nursing (SN) visits ordered for one time a week. The agency failed to provide SN visits during the week of 3/19/2025 through 4/23/25. The agency provided no documentation of missed visits  2. Record review revealed P#12, with a SOC of 4/18/2025, had SN visits ordered for one time a week. The facility failed to provide SN visits during the week of 4/21/2025 through 5/3/2025. The agency provided no documentation for missed visits. On 6/10/2025 at 1:00 p.m., during an office interview, the Administrator acknowledged the SN missed visits, without documented missed visits for P#7 during the week of 3/19/2025 through 4/23/25 and P#12 during the week of 4/21/2025 through 5/3/2025.

Based on review of policy titled “Quality Assessment & Performance Improvement (QAPI) Plan,” review of facility documents titled “Quality Assessment and Performance Improvement Plan,” and staff interview, it was determined that the agency failed to develop, implement, and maintain an effective, ongoing, hospice-wide data-driven quality assessment and performance improvement program (PIP). --- Findings include: On June 11, 2025, at approximately 1:00 p.m., an in-office interview was conducted with the Administrator, who acknowledged that the agency’s QAPI program has not been updated or maintained since 2022. Cross refer to L0562 relating to program scope.Cross refer to L0565 relating to program data

Based on review of policy titled “Quality Assessment & Performance Improvement (QAPI) Plan,” review of facility documents titled “Quality Assessment and Performance Improvement Plan,” and staff interview, it was determined the agency failed to measure, analyze, and track quality indicators of performance. --- Findings include: Review of agency policy titled “Quality Assessment & Performance Improvement (QAPI) Plan,” dated January 8, 2022, revealed the following:Policy:Hospice has established an ongoing program of quality assessment and performance improvement.Responsibility/Accountability:1.   1.   The Governing Body is ultimately responsible for QAPI and implementation of the QAPI plan.2.    2.  The Governing Body has designated responsibility for operating the QAPI program to the Administrator/Director, who, in turn, assigns certain   QAPI activities to other staff members.  The Administrator/Director will be responsible for ensuring adequate resources are available, assigning   adequate number of staff, allowing staff sufficient time to participate in QAPI activities and instituting appropriate information systems (manual   and/or computer for collecting and analyzing data.Data Collection:Data collection will be ongoing, and frequency will be determined by the process improvement activity and approved by the Governing Body.The QAPI program will be evaluated annually by the Governing Body as part of the annual program evaluation.  Review of the agency’s binder titled, “Quality Assessment and Performance Improvement Plan” revealed the agency failed to measure, analyze, and track quality indicators of performance since 2022. On June 11, 2025, at approximately 1:00 p.m., during an in-office interview, the administrator confirmed no other QAPI documents were available for review.

Based on review of policy titled “Quality Assessment & Performance Improvement (QAPI) Plan,” review of facility documents titled “Quality Assessment and Performance Improvement Plan,” and staff interview, it was determined the agency’s governing body failed to develop and approve the detail of data collection related to QAPI. --- Findings include: Review of agency policy titled “Quality Assessment & Performance Improvement (QAPI) Plan,” dated January 8, 2022, revealed the following:Policy:Hospice has established an ongoing program of quality assessment and performance improvement.Responsibility/Accountability1.      The Governing Body is ultimately responsible for QAPI and implementation of the QAPI plan.2.      The Governing Body has designated responsibility for operating the QAPI program to the Administrator/Director, who, in turn, assigns certain QAPI activities to other staff members.  The Administrator/Director will be responsible for ensuring adequate resources are available, assigning adequate number of staff, allowing staff sufficient time to participate in QAPI activities and instituting appropriate information systems (manual and/or computer for collecting and analyzing data.3.      The Administrator/Director is responsible for assigning staff to the QAPI committee. The QAPI committee will be responsible for coordinating all QAPI activities, reviewing collection of data, analyzing data, assisting staff in developing design or improvement activities, planning actions, collecting data, analyzing the effectiveness of actions, and implementing effective actions. The QAPI team includes the social worker, chaplain, licensed nurses, medical director, and volunteers.Data Collection:Data collection will be ongoing, and frequency will be determined by the process improvement activity and approved by the Governing Body. Data collected will be used to monitor the effectiveness and safety of services and the quality of care. Review of the agency’s binder titled “Quality Assessment and Performance Improvement Plan,” revealed the governing body failed to approve data collection related to QAPI. On June 11, 2025, at approximately 1:00 p.m., an in-office interview was conducted with the Administrator who acknowledged that the agency’s QAPI program has not been updated or maintained since 2022.

Based on review of policy titled “Quality Assessment & Performance Improvement (QAPI) Plan,” review of facility documents titled “Quality Assessment and Performance Improvement Plan,” and staff interview, it was determined the agency failed to develop, implement, and evaluate Performance Improvement Projects (PIP) as a part of the agency’s Quality Assurance and Performance Improvement (QAPI) program. --- Findings include: Review of agency policy titled “Quality Assessment & Performance Improvement (QAPI) Plan,” dated January 8, 2022, revealed the following:Policy:Hospice has established an ongoing program of quality assessment and performance improvement.Data Collection:Data collection includes developing indicators, criteria or performance levels for each process determined to be improved.  Data collection will be ongoing, and frequency will be determined by the process improvement activity and approved by the Governing Body.Achieved and Sustained Improvement:Hospice will document what performance improvement projects are being conducted, the reasons for conducting these projects and the measurable progress achieved on them. Review of the agency’s binder titled “Quality Assessment and Performance Improvement Plan,” revealed the agency’s QAPI data did not include a PIP. On June 11, 2025, at approximately 1:00 p.m., an in-office interview was conducted with the Administrator who acknowledged that the QAPI plan has not been updated to include PIPs since 2022.

Based on review of policy titled “Infection Control Surveillance System: Prioritized Risks Defined,” facility documents labeled “Infection Control, and QAPI,” and staff interview, it was determined the hospice failed to maintain a coordinated infection control program to include surveillance and investigation of infections as a part of the hospice’s quality assessment and performance improvement (QAPI) program. --- Findings include: Review of policy titled “Infection Control Surveillance System: Prioritized Risks Defined,” revised 1/5/2022, revealed the following:Procedure:1. Hospice will perform targeted infection control surveillance as follows:Patient infections to be reported while patient is on service: wound infections that develop 30 days or greater after admission which require an antibiotic or identified by lab test or MD that may or may not require an antibiotic; central-line associated bloodstream infections, all infections associated with tubes and lines, and all infections that are identified as infections to be reported at admission.2. Written reporting of infections will occur through documentation on the applicable log (patient or employee). Review of a binder labeled “Infection Control,” failed to reveal infection control surveillance data or infection tracking logs for calendar years 2023, 2024, or 2025. Review of a binder labeled “QAPI” failed to reveal infection control surveillance data or tracking logs for calendar years 2023, 2024, or 2025. On June 12, 2025, at approximately 12:00 p.m., an interview was conducted with the Administrator, who confirmed that infections were not tracked or logged for 2023, 2024, or 2025.

Based on review of policy titled “Bereavement Program Policy and Procedure,” record reviews, and staff interview, it was determined the agency failed to develop a bereavement plan for four patients (P) (P#1, P#2, P#13, and P#14) of 16 sampled patient records reviewed. --- Findings include: Review of the undated policy titled “Bereavement Program Policy and Procedure,” revealed the following:Procedure:2.  A bereavement assessment will be completed by the hospice care team after the patient’s death.  Based on the presence of risk factors, patients will be assessed as needing “direct” or “indirect” contact.3.  Based on the assessed bereavement risk, a plan of care will be developed for the bereaved.6.  The bereavement plan of care on all bereaved patients will be documented in the bereavement database. Record reviews failed to reveal a bereavement plan of care for P#1, P#2, P#13, and P#14. On June 11, 2025, at approximately 1:20 p.m., a phone interview was conducted with the Bereavement Coordinator who confirmed that the bereavement files are incomplete. The Bereavement Coordinator explained that he is new to the Bereavement Coordinator role.

Based on record reviews, review of facility policies, and staff interview, it was determined that the facility failed to ensure the management of all hospice operations as evidenced by failures to ensure:•       An effective, ongoing, hospice-wide data-driven quality assessment and performance improvement (QAPI) program.•       Certified Nursing Assistant (CNA) and services were provided as ordered in the plan of care (POC) for one patient (P) (P#12) of 16 sampled patients.•       A plan of care was developed that included all services and orders necessary for the palliation and management of the terminal illness and related conditions for one patient (P) (P#6) of 16 sampled patients.•       Discharge summaries were not included in the clinical record for 4 four patients (P#1, P#2, P#13, P#14) of 6 discharged patients reviewed. --- Findings include: 1. On June 11, 2025, at approximately 1:00 p.m., an in-office interview was conducted with the Administrator, who acknowledged that the agency’s QAPI program has not been updated or maintained since 2022. 2. On 6/10/2025 at 1:00 p.m., during an office interview, the Administrator acknowledged the SN missed visits, without documented missed visits for P#7 during the week of 3/19/2025 through 4/23/25 and P#12 during the week of 4/21/2025 through 5/3/2025. 3. On June 10, 2025, at approximately 2:15 p.m., an office interview was conducted with the Administrator and Director of Nursing (DON), who revealed P#6 is currently receiving care from a wound care company. The company emails weekly progress reports to the agency. The DON performs wound care for P#6 twice a week, on Wednesdays and Fridays, and the wound care company provides wound care every Monday. The DON and Administrator were unable to explain why there was no care plan reflecting P#6’s wounds. 4. On 6/10/2025 at 11:30 a.m., during an office interview, the Administrator acknowledged P#1, P#2, P#13, and P#14 did not have a discharge summary in the clinical records. Refer to L0559 related to Quality Assessment & Performance ImprovementRefer to L0555 related to coordination of servicesRefer to L0545 related to content of plan of careRefer to L0684 related to discharge or transfer of care

Based on review of policy titled “Certification/Recertification of Terminal Illness, Brief Narrative Statement and Face-to-Face Evaluation,” clinical records review, and staff interviews, it was determined the hospice failed to complete an initial certification of terminal illness for one patient (P) (P#16) of 16 sampled patients. --- Findings include: Review of policy titled “Certification/Recertification of Terminal Illness, Brief Narrative Statement and Face-to-Face Evaluation,” dated 1/3/2025 revealed the following:Procedure:1.         To be eligible to elect Hospice care under Medicare, a patient must be certified as being terminally ill.Hospice will obtain the written certification no later than two (2) calendar days after the period begins.If Hospice cannot obtain the written certification within two (2) calendar days, it will obtain oral certification within two (2) calendar days, and written certification prior to submitting a claim for payment.4.         The Medical Director or physician designee reviews the clinical information and other documentation that supports the medical prognosis for each Hospice patient. This Brief Narrative Statement must accompany the certification and be filed in the patient record. Such information may be provided verbally and will be documented in the patient record. Such information will be included as a part of Hospice's eligibility assessment. The written certification must specify that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination:The primary terminal condition. Related diagnosis(es), if any.Current subjective and objective medical findings. Current medication and treatment orders.8.         Hospice staff must:Make an appropriate entry in the patient's record as soon as they receive an oral certification, and file written certifications in the patient record. Clinical record review for P#16 revealed a document titled “Hospice Certification of Terminal Illness,” dated 9/7/2024. The certification failed to reveal a physician's signature and physician brief narrative statement signed and dated by the certifying physician. On 6/11/2025, at approximately 12:45 p.m., a telephone interview was conducted with the Medical Director, who revealed he is unable to document and sign certifications in the electronic medical record (EMR). The Medical Director further revealed that he completes and signs paper certifications every two weeks; then, the signed documents are returned to the agency and uploaded into the Electronic Medical Record (EMR). On 6/12/2025 at 11:00 a.m., an office interview was conducted with the Administrator, who agreed the clinical record for P#16 lacked a physician-signed/dated certification of terminal illness and did not include a physician brief narrative statement.

Based on review of agency policies, record reviews, and staff interviews it was determined the agency failed to ensure the following:·         maintain patient clinical records to include an updated plan of care with clinical visit notes for three patients (P#6, P#10, P#12) of 16 sampled patients,·         physician’s orders for one patient (P#6 and P#9) of 16 sampled patients,·         physician signature authenticating orders for two patients (P#9 and P#12) of 16 sampled patients, and·         a discharge summary for four patients (P#1, P#2, P#13, and P#14) of 6 sampled patients reviewed for discharge. --- Findings include: 1. On 6/10/2025 at 1:00 p.m., during an office interview, the Administrator and Director of Nursing (DON) acknowledged P#12 had no documentation for CNA visits for the certification period beginning 4/18/2025. Administrator explained all CNA visits notes were located at the patient’s place of residence. On 6/10/2025 at 1:00 p.m., during an office interview the Administrator and DON acknowledged late entry home visit documentation for P#6 and P#10 SN visits. 2. On 6/11/2025 at 2:00 p.m., the Administrator acknowledged orders for P#6 and P#9 was entered late. The Administrator stated the DON was “just now getting around to putting in orders” for P#6 and P#9. 3. On 6/11/2025 at 2:00 p.m., the Administrator acknowledged missing MD signatures on medication orders for P#9 and P#12. The Administrator explained the procedure for the agency MD to sign orders was done through an in-person process, completed on paper, and stored in a notebook. The Administrator explained that after she receives the signed orders from the MD, the documents are scanned into the patient’s chart. The Administrator revealed “I have not gotten around to scanning the paper MD orders into the patient electronic clinical records”. The Administrator added she had misplaced the notebook with signed MD orders. 4. On 6/10/2025 at 11:30 a.m., during an office interview, the Administrator acknowledged P#1, P#2, P#13, and P#14 did not have a discharge summary in the clinical records. Refer to L0672 related to contentRefer to L0678 related to contentRefer to L0679 related to authenticationRefer to L0684 related to discharge or transfer of care

Based on review of policy titled “Hospice Plan of Care Review and Development Policy,” record reviews, and staff interview, it was determined the agency failed to update patient clinical records to include nursing staff visits, specifically the certified nursing assistant (CNA) clinical visit notes for one patient (P#12) of 16 sampled patients, and timely documentation of patient visits for two patients (P) (P#6 and P#10) of 16 sampled patients. --- Findings included: Review of policy titled “Hospice Plan of Care Review and Development Policy,” dated 1/10/2025 revealed the following:Ongoing Review and Revisions:-The POC must be reviewed at least every 15 calendar days.-The review shall evaluate:*Effectiveness of interventions*Patient goals and symptoms*Any changes to the patient’s condition and preferences.*Changes to the POC must be documented promptly and communicated to all relevant providers.Documentation Requirements:-All assessments, POC entries, updates, IDG meeting notes, and communications must be recorded in the clinical record.-The documentation must be dated, signed, and indicate the role of the person making the entry. 1. Review of records revealed P#12 had certified nursing assistant (CNA) visits ordered for three times a week for the certification period beginning on 4/18/2025.  P#12 record reviews failed to reveal CNA documentation for ordered visits during the certification period beginning 4/18/2025. 2. Review of records revealed P#6 had home visits by Director of Nursing (DON) on the following dates:·         on 2/3/2025 with visit entered into clinical record on 5/29/2025,·         on 2/6/2025 with visit entered into clinical record on 5/29/2025,·         on 2/13/2025 with visit entered into clinical record on 5/30/2025,·         on 2/18/2025 with visit entered into clinical record on 5/31/2025,·         on 2/21/2025 with visit entered into clinical record on 6/1/2025,·         on 2/26/2025 with visit entered into clinical record on 6/1/2025,·         on 2/28/2025 with visit entered into clinical record on 6/2/2025,·         on 3/5/2025 with visit entered into clinical record on 6/2/2025,·         on 3/7/2025 with visit entered into clinical record on 6/5/2025,·         on 3/12/2025 with visit entered into clinical record on 6/8/2025,·         on 3/14/2025 with visit entered into clinical record on 6/8/2025.  3. Review of records revealed P#10 had home visits for SN on the following dates:·         on 3/17/2025 with visit entered into clinical record on 4/18/2025,·         on 3/18/2025 with visit entered into clinical record on 4/2/2025,·         on 3/27/2025 with visit entered into clinical record on 4/2/2025,·         on 4/4/2025 with visit entered into clinical record on 4/8/2025,·         on 4/8/2025 with visit entered into clinical record on 4/12/2025,·         on 4/17/2025 with visit entered into clinical record on 5/13/2025,·         on 4/28/2025 with visit entered into clinical record on 5/19/2025,·         on 5/9/2025 with visit entered into clinical record on 5/20/2025,·         on 5/16/2025 with visit entered into clinical record on 6/2/2025,·         on 5/20/2025 with visit entered into clinical record on 6/12/2025,·         on 5/29/2025 with visit entered into clinical record on 6/5/2025. On 6/10/2025 at 1:00 p.m., during an office interview, the Administrator and Director of Nursing (DON) acknowledged P#12 had no documentation for CNA visits for the certification period beginning 4/18/2025. Administrator explained all CNA visits notes were located at the patient’s place of residence. On 6/10/2025 at 1:00 p.m., during an office interview the Administrator and DON acknowledged late entry home visit documentation for P#6 and P#10 SN visits.

Based on review of policy titled “Hospice Plan of Care Review and Development Policy,” record reviews, and staff interview, it was determined the agency failed to maintain patient clinical records with physician orders for services and treatments for two patients (P#6 and P#9) of 16 sampled patient charts reviewed. --- Findings include: Review of policy titled “Hospice Plan of Care Review and Development Policy” dated 1/10/2025 revealed the following:Development of the initial POC:-The initial POC shall be established before the hospice care and services are provided. 1. Review of records revealed the wound care for P#6 was provided starting on 2/13/2025, however Medical Doctor (MD) order for wound care was entered into patient’s clinical record on 5/31/2025. Review of document from the contracted wound care company titled “Lab Progress Report,” dated 2/13/2025, revealed the wounds had been present for three months. 2. Review of records revealed P#9 was admitted on 1/31/2025. Review of physician order dated 1/31/2025 revealed medication order was dated 1/31/2025 however the MD order for medications was not entered into patient’s clinical record until 6/9/2025. On 6/11/2025 at 2:00 p.m., the Administrator acknowledged orders for P#6 and P#9 was entered late. The Administrator stated the Director of Nursing (DON) was “just now getting around to putting in orders” for P#6 and P#9.

Based on review of policy titled “Hospice Plan of Care Review and Development Policy,” record reviews, and staff interview, it was determined that the agency failed to maintain patient clinical records with physician orders signed and dated in accordance with agency policy for two patients (P#9 and P#12) of 16 sampled patients. --- Findings include: Review of policy titled “Hospice Plan of Care Review and Development Policy,” dated 1/10/2025 revealed the following:Documentation Requirements:-All assessments, POC entries, updates, IDG meeting notes, and communications must be recorded in the clinical record.-The documentation must be dated, signed, and indicate the role of the person making the entry. 1. Review of the medication list for P#9 revealed Medical Doctor (MD) ordered medications without MD signature and date for authentication. 2. Review of the medication list for P#12 revealed MD ordered medications without MD signature and date for authentication. On 6/11/2025 at 2:00 p.m., the Administrator acknowledged missing MD signatures on medication orders for P#9 and P#12. The Administrator explained the procedure for the agency MD to sign orders was done through an in-person process, completed on paper, and stored in a notebook. The Administrator explained that after she receives the signed orders from the MD, the documents are scanned into the patient’s chart. The Administrator revealed “I have not gotten around to scanning the paper MD orders into the patient electronic clinical records”. The Administrator added she had misplaced the notebook with signed MD orders.

Based on review of policy titled “Discharge Summary,” record review, and staff interview, it was determined the agency failed to include in a discharge summary for four patients (P) (P#1, P#2, P#13, P#14) of six sampled discharged patients. --- Findings include: Review of agency policy titled “Discharge Summary,” dated 1/4/2021 revealed the following:3. The Hospice discharge summary will include:            A summary of patient’s stay including treatments, symptoms, and pain management.            The patient’s current plan of care.            The patient’s latest physician orders.Any other documentation that will assist in post-discharge continuity of care that is requested by the attending physician of receiving facility. 1. Review of clinical records revealed for P#1 discharged on 10/28/2025. The agency failed to have a discharge summary in the clinical record. 2. Review of clinical records revealed P#2 discharged on 1/8/2025.The agency failed to have a discharge summary in the clinical record. 3. Review of clinical records revealed P#13 discharged on 9/9/2024.  The agency failed to have a discharge summary in the clinical record. 4. Review of clinical records revealed P#14 discharged on 9/16/2024.The agency failed to have a discharge summary in the clinical record. On 6/10/2025 at 11:30 a.m., during an office interview, the Administrator acknowledged P#1, P#2, P#13, and P#14 did not have a discharge summary in the clinical records.

Based on review of policy titled “Coordination of patient Care,” record reviews, and staff interview, it was determined the agency failed to coordinate services, specifically updating medication information specific for current hospice patients for one patient (P) (P#12) of 16 patient records reviewed. --- Findings include: Review of agency policy titled “Coordination of Patient Care,” dated 1/3/2025 reveals the following:4.     Care will be coordinated with other involved external organizations, e.g., home medical equipment providers, infusion therapy/pharmacy companies and community agencies. Staff will:Understand Hospice and organization's responsibilities in providing care or services.Communicate with other individuals or organizations involved in the patient's care when significant changes occur in the patient's overall care.Share relevant information to facilitate appropriate continuity and care coordination. Review of records for P#12 revealed the agency failed to communicate an updated medication profile and reconciled patients’ medication profile with the Assisted Living Facility caring for P#12. Medication profile obtained from ALF revealed P#12 is receiving medications that failed to appear on the hospice agency medication list. The following medications failed to be on the Hospice agency medication list:1.     Atorvastatin (medication for high cholesterol) 20 milligrams (mg) take one tablet by mouth at bedtime for cholesterol,2.     Famotidine (medication for acid reflux) 20 mg tablet take one tablet by mouth daily for stomach,3.     Glucerna Shake Vanilla (liquid nutrition used to control blood sugar levels) drink 1 can by mouth three times daily,4.     Hydralazine HCL (medication for blood pressure) 100 mg tablet take one tablet by mouth three times daily for heart,5.     Menthol & Zinc Oxide ointment (used on the skin for skin irritations) Apply topically to affected area three times daily until cleared,6.     Metformin HCL ER (medication used to control high blood sugar levels) 500 mg tablets take one tablet by mouth twice daily with meals for diabetes,7.     Multivitamin/Minerals tablet take one tablet by mouth daily.8.     Triamcinolone Acet 0.5% cream (medication for skin irritations) apply topically to affected area twice daily for irritation.9.     Vitamin B-12 (vitamin replacement) 1000 MCG (micrograms) tablet take one tablet by mouth daily.10.  Polyethylene Glycol (medication for constipation) mix 17 grams (1capful) in 8 ounces of liquid and drink as needed for constipation.11.  Quetiapine Fumarate (antipsychotic medication) take one tablet by mouth daily as needed for agitation and aggression.12.  Thick It Original Powder (liquid additive used to thicken liquids to avoid aspiration) use as directed to thicken liquids. On 6/12/2025 at 11:00 a.m., during an office interview, the Administrator acknowledged P#12 medications orders were not reconciled with the facility in which the patient lived. Administrator added the hospice agency receives the medication list from the agency for updates on new medication orders.