Every finding on record at Sunshine Hospice and Palliative Care

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

Upon patient record review, 1 of 14 (Patient 10) 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 10 medication profile includes "Miralax powder 17gm solution 1 packet orally daily prn constipation" with no mixing instructions.

Upon patient record review, 1 of 14 (Patient 10) 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 10 plan of care includes "Miralax powder 17gm solution 1 packet orally daily prn constipation" with no mixing instructions.

Upon patient record review, 1 of 14 (Patient 1) 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 1: The RN comprehensive assessment identifies wheelchair in the home. Patient does require a wheelchair and wheelchair is in the home but the plan of care did not include the DME.

Upon observation, there was no evidence the program must use quality indicator data, including patient care, and other relevant data, in the design of the program. There was no evidence of patient record reviews conducted.

Upon patient record review, 3 of 14 (Patient 12, 13 and 14) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 12, 13 and 14 had evidence of Agency contacting patients family after death but no evidence of the development of a bereavement plan of care noting the kind of bereavement services to be offered and the frequency of service delivery.

Upon observation, there was no evidence the hospice designates a physician to serve as Medical Director which includes: • The Medical Director must be a doctor of medicine or osteopathy who is an employee or is under contract. • When the Medical Director is not available, a physician designated by the hospice assumes the same responsibilities and obligations as the Medical Director. There is no evidence of a current Medical Director Designee. Previous Medical Director Designee resigned 12/12/23.