Every finding on record at Saint Lucy, Inc.

Upon patient record review, 1 of 16 (Patient #2) 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#2: The record indicates there is evidence of duplicate drug therapy for Clotrimazole 1% to be applied twice a day. The medication profile list these as both active when patient discharged.

Upon patient record review, 1 of 16 (Patient #13) 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#13: The record indicates patient using medication for nebulizer. There is no evidence of a DME order that included nebulizer on the plan of care.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Agency records indicate volunteers at 0% for 2025.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • 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 #11, Aide Plan of care has a direction under exercise stating, equipment as specified in RN instructions. RN additional instructions state, infection control measures, universal precaution, covid19 precautions, aide to follow all assignments once a week. No special instructions noted for equipment. Aide documented as completed and unknown what was completed.