Every finding on record at Sunshine Care Hospice

Upon patient record review, 2 of 14 (Patient #11, 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 • Drug therapy currently associated with laboratory monitoring Patient #11 - Seroquel 200mg 1 time a day as needed for anxiety and Seroquel 100mg 1 time a day as needed for anxiety both on medication profile - SN did not discontinue Seroquel 100mg when increased to 200mg 1 time a day as needed for anxiety. Patient #14 - Meloxicam 7.5mg 1 tab daily on medication profile twice.

Upon patient record review, 1 of 14 (Patient #13) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #13 - RN completed comprehensive assessment 03/30/25 then again on 04/27/25, exceeds every 15 days.

Upon patient record review, 4 of 14 (Patient #11, 12, 13, 14) 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. Patient #11 - The record indicated the patient is receiving Glucerna but no order noted for Glucerna - diet/nutrition states patient is on Regular DM diet. Patient #12 - The record indicated the patient is receiving Glucerna/Ensure but no order noted for either. Patient #13 - The record indicated the patient is receiving Ensure and to offer supplements as ordered but no order noted for Ensure. Patient #14 - The record indicated the patient is receiving Ensure but no order noted for Ensure - diet/nutrition states patient in on pureed diet.

Upon patient record review, 2 of 14 (Patient #10, 14) 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 #10 - RN documented an Aide supervisory visit on 03/12/25 and 04/09/25 but patient not receiving Aide services. Patient #14 - Nurse documented on 04/26/25 and 05/10 "continues to have poor appetite and remains on a Cardiac Diet" patient is on a Pureed Diet supplemented with Ensure.

Upon patient record review, 2 of 5 records (Patient #1,#3) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component of all involved persons 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. Patient #1: The record indicated that the patient lived with a spouse. The record indicated a bereavement assessment was conducted only on the patient's son who is is also a caregiver. There was not evidence of a bereavement assessment on the spouse. Patient #3: The record indicated that the patient lived with a spouse. The record indicated a bereavement assessment was conducted only on the patient's daughter who is is also a caregiver. There was not evidence of a bereavement assessment on the spouse.