Gentiva

“Upon patient record review, 1 of 5 (Patient #2) 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 2: RN admission documentation indicated that the patient has altered mobility and uses a walker, wheelchair. No evidence that problems, interventions, and goals related to altered mobility was included in the plan of care.”

“Upon patient record review, 4 of 19 (Patients #3,#6,#9,#10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 3: The medical record contained nursing documentation 11/10/25 identifying patient is on oxygen. There was no evidence of oxygen on the medication profile. Corrected on site with clarification order received and medication profile updated. Patient 6: Upon home visit medication reconciliation the facility and hospice medication profiles did not match. The facility profile contained a lorazepam PRN that was not on the hospice profile. Corrected on site with clarification order received and medication profile updated. Patient 9: Upon home visit medication reconciliation the facility and hospice medication profiles did not match. The facility profile contained supplements including ascorbic acid, chlorthalidone, multi-vitamin and zinc that were not on the hospice profile. Corrected on site with clarification order received and medication profile updated. Patient 10: The medication profile contained two continuous oxygen instructions with differing doses. Corrected on site with clarification order received and medication profile updated.”

“Upon patient record review, 2 of 19 (Patients #8,#14) 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 8: There was no evidence of an RN physical assessment between 10/31/25 and 11/26/25. Patient 14: There was no evidence of an RN physical assessment between 11/6/25 and 11/28/25.”

“Upon patient record review, 3 of 19 (Patients #1,#5,#14) 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: The medical record indicated patient is on Plavix. There was no evidence of problems, goals, and interventions related to the risk for bleeding included in the plan of care. Corrected on site with plan of care update. Patient 5: The medical record indicated patient is on Clopidogrel and contained nursing documentation since admission identifying issues of bed bug infestation. There was no evidence of problems, goal, and interventions related to risk for bleeding and bed bug precautions included in the plan of care. Corrected on site with plan of care update. Patient 14: The medical record contained nursing documentation upon admission identifying patient had previous Tylenol overdose and history of substance abuse. There was no evidence of problems, goals, and interventions related to medication management and substance abuse included in the plan of care. Corrected on site with plan of care update.”

“Upon patient record review, 4 of 19 (Patients #1,#3,#6,#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 1: The medical record contained an order 11/28/25 to place foley catheter. There was no evidence of an order for catheter size, change frequency or maintenance. Corrected on site with order received. Patient 3: The medical record contained nursing documentation 11/10/25 identifying patient is on oxygen. There was no evidence of an order for oxygen rate, frequency, and delivery method. Corrected on site with order received. Patient 6: Upon home visit medication reconciliation the facility and hospice medication orders did not match. The facility contained a lorazepam PRN order that was not in the hospice medical record. Corrected on site with order received. Patient 9: The medical record contained a wound care order 11/12/25 with no location of wound or frequency of wound care to be completed. Upon home visit medication reconciliation the facility and hospice medication orders did not match. The facility contained orders for supplements including ascorbic acid, chlorthalidone, multi-vitamin and zinc orders that were not in the hospice medical record. Corrected on site with orders received.”

“Upon patient record review, 6 of 19 (Patients #3,#5,#7,#9,#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 equipment and supply needs. Patient 3: The medical record contained nursing documentation 11/10/25 identifying patient use of a hospital bed, overbed table, and oxygen. There was no evidence of orders for the DME included in the plan of care. Corrected on site with order received. Patient 5: The medical record contained nursing documentation upon admission identifying patient use of bedrails, low air loss mattress, and nebulizer. There was no evidence of orders for the DME included in the plan of care. Corrected on site with order received. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of a cane. There was no evidence of an order for the DME included in the plan of care. Corrected on site with order received. Patient 9: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair. There was no evidence of an order for the DME included in the plan of care. Corrected on site with order received. Patient 13: The medical record contained nursing documentation upon admission identifying patient use of a nebulizer, wheelchair, and trapeze. There was no evidence of orders for the DME included in the plan of care. Corrected on site with order received. Patient 14: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair, and 10/13/25 identifying use of a walker. There was no evidence of orders for the DME included in the plan of care. Corrected on site with order received.”

“Upon patient record review, 2 of 19 (Patients #8,#9) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient 8: The medical record contained nursing documentation 12/23/25 identifying patient has suffered intermittent nausea and vomiting in the benefit period. There was no evidence the plan of care was updated to include problems, goals, and interventions related to nausea and vomiting. Corrected on site with plan of care update. Patient 9: The medical record contained documentation of wound inactivation for coccyx wound 11/12/25 and right lower leg 12/17/25. The plan of care contained active problems, goals, and interventions related to wound care. There was no evidence the plan of care was updated to reflect the progress of the healed wounds. Corrected on site with plan of care update.”

“Upon client record review, 2 of 19 (Patients #3,#14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: The medical record contained an order for nursing visits twice weekly. There was no evidence of a second visit completed the week of 12/14/25. Corrected on site with late data entry of reason for missed visit. Patient 14: The medical record contained an order for nursing visits twice weekly. There was no evidence of a second visit completed the week of 11/30/25. Corrected on site with late data entry of reason for missed visit.”

“Upon patient record review, 2 of 19 (Patients #5,#9) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient 5: The medical record contained nursing documentation 11/14/25 identifying the patient had former wound care visits weekly from an outside company. There was no evidence of documentation of the company’s wound assessments and visits for collaboration of care. Patient 9: The medical record contained nursing documentation 12/1/25 identifying the facility has wound care provider that oversees wound care orders. There was no evidence of documentation from the facility regarding the wound for collaboration of care.”

“Upon patient record review, 2 of 19 (Patients #16,#17) 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 ofcare • Ensuring that bereavement services reflect the needs of the bereaved Patient 16,17: The bereavement care plans contained tasks of sending sympathy card, holiday letter, and memorial service invitation. There was no evidence of the assigned tasks completed. Corrected on site with late data entry of date tasks completed.”

“Upon patient record review 2 of 19 (Patients #11,#12) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 11: The medical record contained an order for aide visits three times weekly. There was no evidence of a third visit completed the week of 11/23/25. Corrected on site with late data entry of reason for missed visit. Patient 12: The medical record contained an order for aide visits three times weekly. There was no evidence of visits completed the week of 11/9/25 and a third visit missing the week of 11/16/25. Corrected on site with late data entry of reason for missed visits.”

“Upon contract review, 1 of 7 (Priority Wound Care) the agency did not have evidence of an agreement to furnish any services for wound care under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice • Furnished in a safe and effective manner by qualified personnel • Delivered in accordance with the patient’s plan of care Patient 5: The medical record contained uploaded wound care orders Priority Wound Care. There was no evidence of a contract with the wound company.”

“Upon patient client record review, 1 of 19 (Patient #10) 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: The medical record contained nursing documentation upon admission identifying patient use of a ventilator in the DME assessment. There was no further evidence of a ventilator and after agency investigation, the documentation was in error.”

“Based on interview and record review, the agency failed to ensure the right to receive effective pain management for 1 of 6 (Patient #3) patient’s records reviewed. Patient #3 did not receive a refill of her Morphine (opioid pain-relieving medication used to treat moderate to severe pain) medication. This failure caused the patient to not receive adequate pain medication as ordered by the physician which could have led to unmanaged pain and needs being unmet. Findings included: The POC for Patient #3 dated 10/30/25- 11/19/25 indicated she was 87 years old with a SOC date of 10/30/25. Her terminal diagnosis was Parkinson’s disease (a progressive brain disorder which causes tremors, stiffness and slow movement). The Medication Profile for Patient #3 indicated an order for Morphine Concentrate 100mg/5mL (20mg/mL) 0.5 mL every 2 hours. Instructions indicated take 0.25mL for moderate pain or SOB and 0.5mL for severe pain or SOB. The SN Visit Note for Patient #3 dated 11/16/25 indicated the daily visit was completed by RNOC A. MSIR current quantity remaining was indicated as 15mL. The narrative note indicated three doses [of Morphine] since last visit. A Physician Order for Patient #3 dated 11/16/25 indicated an order for Morphine 20mg/mL 0.25-0.5mL every1 hour. The SN Visit Note for Patient #3 dated 11/17/25 indicated the daily visit was completed by RNCM I. Morphine Solution current quantity remaining was indicated as 25mL. The SN Visit Note for Patient #3 dated 11/18/25 indicated the daily visit was completed by Admission Nurse B. Morphine Sulfate current quantity remaining was indicated as 30mL. The note indicated pain palliated with Morphine, no signs of pain and discomfort noted. Medication reviewed, refills sent to the pharmacy. The Coordination Note for Patient #3 dated 11/18/25 indicated on-call note by RNOC A. FM E was concerned she needed a refill. RNCM I reached out to RNOC A for assistance stating FM E was frantic Patient #3 was going to run out of Morphine and RN at visit earlier said it was coming today. RNOC A reviewed chart and could see MSIR was ordered 11/18 for next day delivery. EMR indicated two different orders of MSIR, 0.5mL Q2H PRN and 1mL Q2H scheduled. Pharmacy representative confirmed 60mLs would arrive next day on 11/19. Spoke to FM E over phone regarding next day delivery and she became extremely irate over the phone. FM E stated she was told it would be there today. RNOC A asked FM E at this time how much MSIR she had on hand. RNOC A explained she would reach out to the Director on call for direction. Reached out to the Administrator/ Supervising Nurse and explained situation. She advised we would not be calling out more meds tonight with the amount arriving tomorrow and that 8mLs at Q2H would give patient enough meds to get to 9 or 10 am dependent upon next dose being at 7 or 8 tonight. If patient made it through the night RNCM could track the package at 8 am to reassess situation in the morning. A Complaint Report for Patient #3 dated 11/19/25 indicated 8:50 am ED return call after stand up call reviewed that FM E was upset that medications were not ordered for delivery and her concern that patient might run out of Morphine as she is now receiving hourly administration. ED apologized for any miscommunication, FM E verbalized concern that the admission nurse did not provide education on the medication ordering process and that the RN on call did not have the information she needed to order the meds stating she never counted the amount of meds in the home, how did she know when we would run out. During the call FM E was notified by in home care giver that Patient #3 was not breathing. The Tulip Complaint Investigation Worksheet indicated FM E reported on 11/18/2025, Admission Nurse B asked FM E how much Morphine the patient had. It should be known that the patient was supposed to be getting 1 mL of Morphine every two hours. FM E explained to Admission Nurse B that although the bottle says 8ml of Morphine was left, there was a bit less in the bottle. Admission Nurse B stated that he was going to order it however, FM E later received a call from the main nurse asking questions about this medication. RNOC A stated that no medication could be provided since the agency had the patient already listed with 60 mL of narcotics to be delivered to her. The complainant informed RNOC A that would [not] do since the patient was actively passing. During the night of 11/18/2025, the complainant had to give the patient half of her recommended dose of Morphine since the agency did not want to provide any more. At around 7:00 am, on 11/18/2025, the patient ran out of all her morphine. On 11/19/2025, the patient passed. On 11/20/2025, the agency finally delivered the Morphine that the patient needed. FM E stated that this was too late, and the patient had already passed. During an interview on 12/16/25 at 9:18 am the Administrator/Supervising Nurse said RNOC A was on call when FM E reached out that Patient #3 needed Morphine. The Administrator/ Supervising Nurse said Patient #3 had enough Morphine to get through the night and had 2 bottles being delivered the next day. The Administrator/ Supervising Nurse said FM E wanted some hot shotted out [delivered same day]. The Administrator/ Supervising Nurse said that would be a doctor issue because then there would be too much Morphine in the home. The Administrator/ Supervising Nurse said there was a dosage discrepancy. The Administrator/ Supervising Nurse said the Morphine was ordered every 2 hours. The Administrator/ Supervising Nurse said the patient had enough Morphine to get through 9 or 10 am. The Administrator/ Supervising Nurse said the RNCM was to follow up the next day at 8 am to ensure the new bottles would be there in time. The Administrator/ Supervising Nurse said the narcotic counts were not done consistently at each visit so the [Morphine] count was off. During a telephone interview on 12/16/25 at 3:20 pm FM E said she had trouble with the hospice agency getting Patient #3’s medicine. FM E said the nurse came and they needed Morphine when Patient #3 was actively dying. FM E said when her caregiver would move Patient #3 to change her she was in pain when being rolled to clean her. FM E said they started giving her the Morphine because Patient #3 seemed to be in pain. FM E said on the weekend she told the hospice nurse they were running out of Morphine. FM E said when the nurse had came out the day before in the morning, he picked up the Morphine and shook it. FM E said the nurse said he would order more right away. FM E said he did not check how much was in the bottle just shook it. FM E said and hour or two later another nurse called asked how much Morphine she was giving Patient #3 and told her ok they would send the Morphine out. FM E said by 4:30 pm the Morphine still had not arrived. FM E said the night nurse called back asked how much Morphine was left about. FM E said she told her there was less than 8mL in the bottle but that the amount in the bottle goes down more than 1 each time she gave it. FM E said the nurse said she needed approval for the medication. FM E said when the nurse called back she told her unfortunately they couldn’t have any more because 2 bottles were already ordered. FM E said the nurse said the orders were placed days apart, the first ordered by mail and the second one overnighted. FM E said the nurse said 60mL were already order to be sent but had not arrived. FM E said the medication was not there because it was not ordered correctly. FM E said the nurse told her they would not be sending any. FM E said they decided not to see Patient #3, they just told her on the phone that were not hot shotting any Morphine because it was already on it’s way to arrive the next day. FM E said the nurse said that the morning nurse would call her by 8 am and track the Morphine and by her calculations they had enough to make it until 9 am. FM E said she told the nurse Patient #3 was already due for another dose. FM E said during the night she had to ration the Morphine. FM E said Patient #3 got a smaller dose than what she needed. FM E said overnight she had to give Patient #3 a ½ dose each time so she would not run out completely. FM E said no medication showed up the next morning. FM E said no one called the next morning to make sure the medication was there. FM E said the Administrator/ Supervising Nurse called the next morning after 9 am about her complaint. FM E said the manager said they would get someone to get the Morphine sent out right away. FM E said while they were on the phone Patient #3 passed away. FM E said when Patient #3 passed away there was only a few drops of the Morphine left. FM E said the nurses did not look or check the Morphine amount during their visits only checked to see if she needed a refill. During a telephone interview on 12/17/25 at 8:33 am Admission Nurse B said he went out one time to help with daily visit for Patient #3. Admission Nurse B said FM E said she was giving the Morphine every hour. Admission Nurse B said he instructed FM E to only give the Morphine as needed and not scheduled. Admission Nurse B said he counted the narcotics during his visit and reordered the Morphine. Admission Nurse B said Morphine was already ordered to be delivered the next day but since FM E was adamant he placed another order for Morphine. Attempted a telephone interview on 12/17/25 at 9:04 am with RNCM I. No answer. Voicemail left identifying surveyor and requested a call back. During a telephone interview on 12/17/25 at 9:08 am RNCM I said Patient #3 became active and they began daily visits for her. RNCM I said she saw Patient #3 a couple of days before she passed and that she had ordered more Morphine at the time of her visit. RNCM I said narcotic counts were done during every visit. RNCM I said she received a call from RNOC A that FM E had called and said Patient #3’s Morphine was running very low. RNCM I said Admission Nurse B noticed the Morphine bottle was low and ordered more during his visit. RNCM I said Admission Nurse B said there was not enough on hand so he ordered more. RNCM I said RNOC A asked FM E how much Morphine was left and FM E said there was a couple mLs left. RNCM I said RNOC A said with the Morphine being given every few hours the amount left should last for the night until a certain time the next day so there was a sufficient amount. RNCM I said she believed the amount of Morphine FM E said was on hand matched the agency count. RNCM I said the Morphine she had ordered days before was scheduled to be there by the day following their conversation [11/19]. RNCM I said Admission Nurse B ordered the Morphine through the local pharmacy for delivery the next day [11/19] and she had ordered another non-local pharmacy to be shipped and it was also scheduled to arrive the next day [11/19]. RNCM I said the Morphine was coming but FM E was worried there wouldn’t be enough until it was delivered. RNCM I said when she went to pronounce Patient #3 she destroyed Morphine, but could not remember the amount destroyed. RNCM I said she destroyed a small amount, that there was still some left in the bottle. RNCM I said the destroyed medication would have been noted in the EMR. During an interview and record review on 12/17/25 at 10:40 am the Administrator/ Supervising Nurse said education was done with staff about documenting correct medication counts because they found some were not being done correctly. The Administrator/ Supervising Nurse said narcotic counts should be done at every visit and documented in the note. The Administrator/ Supervising Nurse reviewed the visit note Morphine counts for 11/17/25 and verified the Morphine count was 25mL and the visit note Morphine count for 11/18 verified the Morphine count was 30mL. The Administrator/ Supervising Nurse said according to note the narcotic counts were being done but they were not accurate. The Administrator/ Supervising Nurse said the agency would not be able to get an accurate count based on the visit notes. The Administrator/ Supervising Nurse said RNOC A said there was 8 mL of Morphine left when she called. The Administrator/ Supervising Nurse said she calculated the dosage and there was enough to get her through until 9 or 10 in the morning and she knew there were already 2 bottles on the way. The Administrator/ Supervising Nurse said one bottle was coming from the local pharmacy and another bottle was coming from the shipping pharmacy. The Administrator/ Supervising Nurse said the local pharmacy was used for urgent needs and the shipping pharmacy can take up to 2 days, so it was usually used for routine meds. The Administrator/ Supervising Nurse reviewed the EMR orders and said there was 2 Morphine orders a scheduled 1mL every 2 hours and PRN and another order for 1ml every 2 hours PRN. The Administrator/ Supervising Nurse said there was orders for Morphine 0.5 mL every 2 hours with instructions to take 0.25mL for moderate pain or SOB and 0.5mL for severe pain or SOB. The Administrator/ Supervising Nurse said there was also an order on 11/16 Morphine 0.25-0.5mL every hour. The Administrator/ Supervising Nurse said when the nurse added it to the MAR she entered every 2 hours. The Administrator/ Supervising Nurse said on-call was called on 11/17/25 around 6 or 7 pm. The Administrator/ Supervising Nurse reviewed her phone call log and said it was at 6:13 pm. The Administrator/ Supervising Nurse said Patient #3 was taking 0.5 mL of Morphine. The Administrator/ Supervising Nurse said she was told over the phone the order was every 2 hours so 8mL gave enough doses to get until 10 am with some remaining. The Administrator/ Supervising Nurse said if 0.5 mL was ordered every hour there still would have been enough until 9 am. The Administrator/ Supervising Nurse said the Morphine was already ordered to be delivered. The Administrator/ Supervising Nurse said she told RNOC A to contact the CM first thing in the morning to reach out to the pharmacy to get priority delivery for the Morphine to be dropped off first. The Administrator/ Supervising Nurse said she did not know if RNOC A followed up with the CM the next morning. The Administrator/ Supervising Nurse said this was her first time taking call for this branch and she did not know she needed to follow up. The Administrator/ Supervising Nurse said there was not a drug destruction sheet in Patient #3’s EMR and she would check the paper chart for one. During a telephone interview on 12/17/25 at 11:10 am RNOC A said she was the on-call nurse. RNOC A said she made daily visits on the weekends. RNOC A said she made visit for Patient #3 on Saturday afternoon. RNOC A said she asked about medication. RNOC A said Patient #3 had just received a new bottle of Morphine the day before she went out. RNOC A said Patient #3 was just finishing off her last bottle and had a new bottle there. RNOC A said Patient #3 was well covered with meds through the weekend. RNOC A said she was called on-call on Monday that Patient #3 needed medicine. RNOC A said there was a delivery of 2 bottles of Morphine scheduled for the next day between 9 am-1 pm. RNOC A said she calculated Patient #3 would have enough Morphine to get through till the next morning. RNOC A said they would revisit if the patient made it through the night. RNOC A said she confirmed with Administrator/ Supervising Nurse. RNOC A said narcotic counts were documented in the visit note. RNOC A said when she asked FM E how much Morphine she had on hand FM E told her there was 8 mL left. RNOCA said she did not do a home visit with Patient #3 because FM E hung up on her. RNOC A said she did not call the RNCM the next day to follow up on the refill. During an interview on 12/17/25 at 11:50 am the Administrator/ Supervising Nurse said they could not find the drug destruction form in Patient #3’s paper chart. The Administrator/ Supervising Nurse said RNCM I said the drug destruction was done electronically. The Administrator/ Supervising Nurse said IT tried and could not locate the drug destruction form in the EMR. The Administrator/ Supervising Nurse said she did not know where the drug destruction form for Patient #3 was, but that the form was not where it should be. During an interview on 12/17/25 at 11:54 am the Alternate Administrator/ Alternate Supervising Nurse said supposedly Patient #3 ran out of Morphine. The Alternate Administrator/ Alternate Supervising Nurse said the Morphine was ordered but Patient #3 needed some the night before it was scheduled for delivery. The Alternate Administrator/ Alternate Supervising Nurse said if the narcotic counts were inconsistent the count could be off meaning there could be less on hand than what we have documented and the agency would not be able to accurately tell when the patient was going to run out. The Alternate Administrator/ Alternate Supervising Nurse said if the medication was not delivered timely the patient could run out of medication which could affect pain management. The Alternate Administrator/ Alternate Supervising Nurse said the patient could be negatively impacted if their pain was uncontrolled which could lead to other uncontrolled symptoms. During an interview on 12/17/25 at 11:58 am the Administrator/ Supervising Nurse said if the narcotic counts were off there could be a delay in the patient getting medication refills. The Administrator/ Supervising Nurse said if the nurse thought there was enough medication out there and there was not it could affect the patient’s pain management if the medication was not there when they need it. The Administrator/ Supervising Nurse said if the medication was not delivered timely the patient could run out of medication which could result in the patient starting out with mild pain and end up in uncontrolled pain if the medication was unavailable. The Administrator/ Supervising Nurse said the patient could fall into a cycle of needing more medication to try to chase the pain to get it back under control. Record review of a Patient Bill of Rights policy dated 12/12/25 revealed, “… Policy Each patient will be an active, informed participant in his/her plan of care. To ensure this process, the patient will be empowered with certain rights as described. The rights contained within this policy include the basic rights of the patient. A patient may designate someone to act as his/her representative. The representative, on behalf of the patient, may exercise any of the rights provided by the policies and procedures established by the hospice. … Procedure 1. The Patient Bill of Rights and Responsibilities defines the right of the patient to: … e. Patients have the right to receive effective pain management …” Record review of a Pharmacy Services policy dated 9/12/25 revealed, “Purpose To ensure that pharmacy services are available 24 hours per day. Policy Pharmacy, biological and infusion services needed by hospice patients and families/caregivers and hospice personnel will be available 24 hours a day. Medications will be available through contracts between specific pharmacies and … (the hospice). Controlled substances and other medications will be available through the pharmacy contracts for patients … for those unexpected situations requiring pain and symptom management after normal business hours. Drugs and biologicals related to the palliation and management of the terminal illness and related conditions, as identified in the hospice plan of care, are provided but the hospice while the patient is under hospice care. … All medications are ordered for each individual patient based upon actual or anticipated need. …””