Every finding on record at Saint Gregory Hospice LLC

Upon patient record review and home visit, 1 of 5 (Patient #1) 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 During home visit, the patient's current prescription bottles were provided in a medication box on patient's table. Upon asking patient about Tramadol and how she is currently taking, the patient reportedly, stated she only uses this medication if she has severe pain and she verified she does not take this medication daily. The medication profile and plan of care list this medication is to be administered "Two times per day".

Upon patient record review, 1 of 5 (Patient #1) 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 had a Bereavement Risk assessment completed by the Social worker on 6/21/25 that only mentioned a "son that lives with patient and is her paid caregiver". Upon surveyor home visit on 6/26/25, the patient and a daughter were present. Those two individuals verified that the daughter is patient's paid caregiver thru a government program and that the daughter lives with this patient. The patient did not mention a son during surveyor visit. The daughter was not included in the Comprehensive Bereavement Assessment.

Upon personnel record review, 1 of 12 (Personnel # 4) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) Personnel#4: The following competencies were not not performed or evaluated. ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(B) Sponge bath ·(C) Shampoo, bed The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient.

Upon patient record review, 2 of 5 (Patient #4,5) did not have evidence that the discharge summary includes all required information. Patient #4 Discharged due to Revocation . Discharge summary did not include the following information: • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current plan of care • The patient's latest physician orders Patient #5 Discharged due to Revocation. Discharge summary did not include the following information: • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current plan of care • The patient's latest physician orders

Upon patient record review, 1 of 5 (Patient #1) did not have evidence in the patient record that the interdisciplinary group, as part of the review of the plan of care, determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home. If the patient and/or family are not capable of safely administering drugs and biologicals in the home, the hospice must address this issue in the patient's plan of care. Patient #1 The patient, and daughter, verified the patient manages and administers her own medications, however; the Plan of care and Medication profile indicate "medications administered by #3" Which correlates to the "key" on medication profile for #3 being "fam/pcg". There is no indication the IDG determined the patient could safely administer her own medications.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence that all drugs and biologicals are labeled in accordance with currently accepted professional practice and include appropriate usage and cautionary instructions, as well as an expiration date, if applicable. Patient #1 Did not have evidence drugs and biologicals are properly labeled to ensure that the patient/family can administer them safely. During observation and medication reconciliation during home visit, the patient's current prescription bottles were provided in a medication box on patient's table. The Tramadol container label was very worn and smeared, unable to read instructions, however, was able to read clearly the label stating "discard by: 01/01/2023".