Sanctuary Hospice

“Upon patient record review, 1 of 19 (Patient #2) 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 #2: Upon review of medications during patient visit, noted facility medication profile includes Miralax but hospice profile does not.”

“Upon patient record review, 4 of 19 (Patient #1, 3, 11, 15) 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. Patient #1: Patient has Eliquis prescribed 2x daily and is on oxygen continuously with no related problems, goals, interventions related to bleeding or oxygen safety precautions. Patient #3: Patient has oxygen continuously with no precautions/safety related problems, goals interventions. Patient #11: Patient has Plavix and aspirin prescribed with no related problems, goals and interventions for bleeding precautions. Patient #15: Patient has Plavix prescribed with no related problems, goals and interventions for bleeding precautions.”

“Upon patient record review, 3 of 19 (Patient #2, 7, 9) 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 #2: Upon review of medications during patient visit, noted facility medication profile includes Miralax but hospice plan of care does not. Patient #7: The 6/1/26 order for oxygen 3LPM NC continuous. 7/6/26 SN visit noted oxygen at 2.5 LPM. 7/13/26 SN visit noted oxygen at 4LPM. There was no update to the order. Patient #9: 5/19/26 order: GNP Saline Wound wash external solution 0.9%, cleanse wound to left breast every shift and PRN. Xeroform occlusive gauze strip external: Apply to wound bed of left breast after applying anti-fungal powder every night shift and PRN. Antifungal external powder: Apply to wound bed and peri wound to left breast every night shift and PRN. PRN is not quantified on the orders.”

“Upon patient record review, 2 of 19 (Patient # 9, 15) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #9: Patient has fungating breast wound with dressing. No alert/reference for hospice aide care plan. Patient #15: Patient has Plavix prescribed with no bleeding precautions.”

“Upon patient client record review, 2 of 19 (Patient #3, 9) 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 #3: Physician CTI narrative includes “She will also now be pleased on a noninvasive ventilator.” Patient #9: Physician CTI narrative includes “54 year old with dx of breast cancer....” 5/27/26 RN clinical note by RN refers to patient as “94 year old..” DOB listed as 10/11/31, evidence patient is 85 years old.”

“It is required that hospice nursing services, physician services, drugs and biologicals are made routinely available on a 24-hour basis, seven (7) days per week. All covered services are available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed it was revealed that the agency did not ensure that medications were provided timely to meet the needs of the patient. DOCUMENT 1: Agency Policy titled, Medication Management, PC.M45, stated in part, “Medications are provided on a timely basis and are available 24 hours a day and seven days a week as needed. The Hospice monitors the medications dispensed to and used by the patient.” CLINICAL RECORD 2: The patient elected the hospice benefit on 06/27/2023. The Registered Nurse assessments dated 9/27/2024, 10/04/2024, and 10/10/2024 did not include documented evidence of a medication reconciliation. Additionally, those visits did not include any documented evidence that the RN reviewed the medications to see if the patient needed refills. The patient did not have the medication Alprazolam for 3 1/2 days. During a joint record review and interview on 11/03/2025, the Clinical Director stated, “When the patient ran out, we should have had our hospice doc call in the Alprazolam right away.” During a joint record review and interview on 11/03/2025, the Clinical Manager (ADS) stated, “Our Hospice Doc is taking care of the medications now and we have switched her to a different pharmacy. It hasn’t been a problem since the changes.””