Every finding on record at Saunders Hospice LLC

Upon patient record review, 2 of 14 (Patient #5 and #7) 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 #5-SN notes dated 07/19/25 and 07/25/25/ document patient taking Tylenol 325 mg PO for pain. Tylenol not on medication profile. #7-SN SOC comprehensive assessment documents patient taking Fluconazole 150 mg 2 tablets PO BID. Medication profile document Voriconazole 50 mg PO BID. Also documentation that patient is using Nystatin 100,000 units/g topical daily. These medications are not on the medication profile.

Upon patient record review, 2 of 14 (Patient #5,7) 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 medications and treatments. #5-SN notes dated 07/19/25 and 07/25/25 document patient taking Tylenol 325 mg PO for pain. There is no MD order for Tylenol. #7-SN SOC comprehensive assessment documents patient taking Fluconazole 150 mg 2 tablets PO BID. Also documentation that patient is using Nystatin 100,000 units/g topical daily. These medications do not have an MD order.

Upon patient record review 1 of 14 (Patient #12) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training #12-Aide POC included instruction to assess vital signs each visit. There are no vital signs documented on any aide visit notes throughout episode of care.

Upon observation, there was no evidence volunteers are used in day to day administrative and/or direct patient care roles. There are zero volunteer hours documented on the Volunteer Cost Savings Report.

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.