Every finding on record at Sacred Journey Hospice, LLC

Based on policy titled "Care/Service Coordination," record reviews, home visits, and staff interview, it was determined that the agency failed to coordinate medications and care plan with the Skilled Nursing Facility (SNF) for two patients (P) (P#12, P#14) of three sampled patients. --- Findings Include:Findings Include:Review of Policy titled "Care/Service Coordination," revised October 2019 revealed the following:Purpose: To ensure the coordination of services for each patient and to minimize the potential for missed, conflicting, or duplicated services.Policy: The organization will coordinate care and services with known external providers involved in the care of the patient.Procedure:8. Written evidence of care coordination may be found in the plan of care/service, case conference summary forms, and clinical notes in the patient's clinical record or interdisciplinary group meeting notes. 1. Record review reveals P#12 resides at a SNF and was admitted to hospice on 8/11/2024. Review of the SNF undated document titled “Medication Review Report”, revealed orders for medications and interventions for P#12 to include the following: •    CCD (Consistent Carbohydrate Diet) diet Mechanical Soft texture, Honey consistency, for diet•    Enteral Feed Order two times a day Nutren 2.0 via Peg @ (at) 50ml/hour (On @ 2pm off @noon), H20 flush 100 ml (milliliters) q (every) 4 hours, ideally yield 2000 kcal, 80 gm (gram) protein, 700 ml FW, TV 1700 ml. HOB (head of bed) elevated 30-45 degrees during feeds. Flush tube with 30 ml H20 ac/pc (before meals/after meals). Check residuals•    Change feeding syringe every night shift•    Check residual - If greater than 100 hold feeding for 1 hour. Recheck. If still hold and notify provider. If less than 100 restart feeding every shift•    H2O (water) Med Flush 60 cc before and after each med pass and 10 ML between meds every shift•    PEG site care done with soap and water. Cover with dry protective gauze dressing.•    Albuterol Sulfate Inhalation Nebulization Solution (for wheezing/shortness of breath)  Review of Hospice agency’s undated document titled “Client Medication Report,” failed to include the orders and/or interventions listed above for P#12, The following medications were listed on the “Client Medication Report” for the agency but failed to be listed on the “Medication Review Report” for the SNF.•    Haloperidol (for agitation)On January 7, 2026, at approximately 10:00 a.m., during home visit, review of the agency folder in the facility of residency for P#12, revealed “Hospice IDG Comprehensive Assessment and Plan of Care Update Report,” dated 8/11/2025. 2. Record review reveals P#14 resides at a (SNF) admitted to hospice on  3/22/2023.Review of SNF undated document titled “Medication Review Report”, reveal orders for medications and interventions for P#14 to include the following: •    Cleanse right big toe with normal saline blot dry and Apply skin prep daily and PRN (as needed). Every day shift for protection•     Depakote (for seizures) twice a day•    Amlodipine Besylate Tablet (for blood pressure) once a day•    Linzess (for constipation) Give 1 capsule by mouth before meals for Constipation Give on empty stomach at least 30 minutes prior to first meal of day Review of Hospice agency’s undated document titled “Client Medication Report,” failed to include the orders and/or interventions listed above but listed the following medications or interventions for P#14. •    Depakote (for seizures) 1 tablet daily•    Amlodipine (for blood pressure) 1 tablet 2 times daily•    Humalog Kwik pen (for diabetes)•    Linzess (for constipation)1 tablet daily•    Zoloft (for anxiety)•    Metoprolol Tartrate (for blood pressure)•    Lorazepam (for anxiety)•    Risperidone (for agitation)On January 7,2026, at approximately 11:30 am, during an in-person interview with Administrator, the Administrator confirmed that the Comprehensive Care Plan Report provided was the most recent documentation for P#12 and P#14.

Based on review of policies and procedures, record reviews, and staff interviews, it was determined the agency’s governing body failed to take responsibility for implementing and monitoring patients plan of care to include coordinating services with the Skilled Nursing Facility (SNF),The agency failed to coordinate care with the SNF to include medications and goals and interventions for two patients (P) (P#12, P#14) of three sampled patients. --- Findings included:Cross refer to L0557 related to Coordination of Services