Every finding on record at Sacred Passion Hospice Care Inc.

Upon patient record review, 14 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14) 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 Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14: The patient's oxygen did not appear on the medication list. (corrected onsite for all active patients)

Upon patient record review, 2 of 14 (Patient #1, 4) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 1: The patient was admitted for hospice services on 09.04.2022; the initial bereavement assessment was completed on 12.07.2022, which exceeded the 5 day requirement. Patient 4: The patient was admitted for hospice services on 10.11.2021; there is no evidence of an initial bereavement assessment having been completed at any time.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 4: The MSW and chaplain have visit orders written only on a PRN basis, and did not include routine visits. (corrected onsite)

Upon patient record review, 1 of 14 (Patient #3) did not have evidence in the patient record that hospice aide assignments and duties are: • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 3: The hospice aide care plan, dated 01.22.2023, indicated the patient required a bed bath and the hair should be shampooed and brushed; however, the care plan did not specify the frequency for these tasks to be performed. (corrected onsite)