Every finding on record at St Sofia Palliative and Hospice Care Inc

Upon patient record review, 1 of 14 (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: The hospice medication profile indicated Nortriptyline 35mg. During med reconciliation in patient home this med was listed as 25mg.

Upon patient record review, 3 of 14 (Patient #1,3,8) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patients #1 and #3: The nursing comprehensive/CTI showed evidence that the patient is a diabetic. The medication profile indicates patient has metformin 500mg BID. There was no evidence of problems, goals, or interventions related to the Endocrine system. Patient #8: The nursing comprehensive/CTI showed evidence that the patient is a diabetic. The medication profile indicates patient has metformin 500mg daily. There was no evidence of problems, goals, or interventions related to the Endocrine system.

Upon client record review, 1 of 14 (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care (POC). Patient #2: The POC listed Spiritual Counselor(SC) visit frequency of, 1 X's per month. There were no visits by the SC in the month of February 2026.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78. The agency "Volunteer Hours and Cost Savings" report provided by agency had included hours only. The report did not include any cost savings data.

Upon patient client record review, 1 of 6 (Patient #2) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #2: Did not have complete date on "Patient Acknowledgement /Orientation Checklist" form. The date read: 3/1 only. The calendar year was not included on this entry

Upon client record review, 1 of 6 (Patient #6) did not have evidence that the discharge summary includes all required information. Patient #6: The Plan of Care was not included in the discharge summary.