White Rose Hospice, Inc.

“Upon patient record review, 3 of 14 (Patient #1, 2, 6) 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 tor Patient 1: During home visit, the medication profile on 05/07/26 contains multiple orders for acetaminophen including Oral dose of 500 mg every 4-6 hours prn, Hydrocodone/acetaminophen 5mg/325mg every 6 hours prn and rectal supp 650mg every 4 hours prn with no evidence of a limit to not exceed in 24 hour period. Patient 2: During home visit, the medication profile on 05/19/26 does not contain evidence of two medications caregiver reports client is taking including Aldactone and Ticagrelor. Caregiver reports “His daughter brought them in.” The prescriptions were last refilled in 01/26. Patient 6: The medication profile on 12/11/25 contains multiple orders for acetaminophen including rectal suppository every 4 hours and oral tabs 650 mg every 6 hours prn with no evidence of a limit to not exceed in 24 hour period.”

“Upon patient record review, 3 of 14 (Patient # 1, 2, 6) 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 1: The updated POC on 05/07/26 contains multiple orders for acetaminophen including Oral dose of 500 mg every 4-6 hours prn, Hydrocodone/acetaminophen 5mg/325mg every 6 hours prn and rectal supp 650mg every 4 hours prn with no evidence of a limit to not exceed in 24 hour period. Patient 2: The updated POC on 05/19/26 does not contain evidence of two medications caregiver reports client is taking including Aldactone and Ticagrelor. Patient 6: The Initial POC on 12/11/25 contains multiple orders for acetaminophen including rectal suppository every 4 hours and oral tabs 650 mg every 6 hours prn with no evidence of a limit to not exceed in 24 hour period.”

“Upon patient client record review, 12 of 14 (Patient #1,2,3,4,5,6,7,8,9,10, 13 and 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 1: There is no evidence of aide notes signed and dated on 5/4/26, 5/7/26, 5/11/26 and 5/14/26. Patient 2: There is evidence of Initial Spiritual care note completed by SC on 3/20/26 electronically signed and dated by LVN instead of SC. Patient 3: There is evidence of SN notes 4/27/26 and 5/4/26 not completed with electronic signature and date according to agency Policy WRH-CLN-072 submit and sign all patient-related documentation within 72 hours after actual patient visit. Patient 4: There is evidence of initial comprehensive assessments for visits completed by MSW and SC on 11/30/25 electronically signed and dated by LVN instead of MSW and SC. Patient 5: There is evidence of initial comprehensive assessments for visit completed by SC on 02/23/26 electronically signed and dated by LVN instead of SC. Patient 6: There is evidence of initial comprehensive assessments and initial bereavement assessment for visits completed by MSW and SC on 1/01/25 electronically signed and dated by LVN instead of MSW and SC. Patient 7: There is evidence of initial comprehensive assessments for visits completed by RN on 4/24/25 and SC on 4/25/25 electronically signed and dated by LVN instead of RN and SC. Patient 8: There is evidence of initial comprehensive assessments and initial bereavement assessment for visits completed by RN and MSW on 1/01/25 electronically signed and dated by LVN instead of RN and MSW. Patient 9: There is evidence of initial comprehensive assessments and initial bereavement assessment for visits completed by RN 4/23/25 and SC on 4/24/25 electronically signed and dated by LVN instead of RN and SC. Patient 10: There is evidence of initial RN comprehensive assessments completed by RN 08/18/25 is electronically signed and dated by LVN instead of RN. Patient 13: There is evidence that the initial Bereavement assessment completed by MSW on 5/4/25 is signed and dated by LVN instead of MSW. Patient 14: There is evidence that the initial Bereavement assessment completed by MSW on 4/25/25 is signed and dated by LVN instead of MSW.”