HP Resource Manual - Hospice Pharmacia

RELEASE DATE: 1/15/15

Dear Partnering Hospice,Hospice Pharmacia is proud to provide you with the online version of the HP Resource Manual.This electronic document was created to provide you with the basic, but essential documentationyou and your staff may need for compliance and survey purposes. Inside you will find copies ofour licensure, insurance certificate, Joint Commission accreditation, along with key policies andprocedures.The electronic HP Resource Manual contains significant advantages over hard copies. The PDFdocument includes bookmarks which can be quickly linked to other relevant parts of the manual.Policies and procedures can be updated without waiting for the printing of an annual supplement,and the most current certificates and licenses are available for your use whether needed forsurveys or other compliance purposes.It is our intent to provide you with a comprehensive and user-friendly resource manual. HP willcontinue to update, make improvements to, and revise the HP Resource Manual. We invite yoursuggestions and comments on the organization, usability, and content of this document. Pleaselet us know how we can continue to assist you in the most proficient and effective way possible.Sincerely,Lisa UrsoAssociate Program ManagerHospice Pharmacia Resource Manual Editor

Hospice Pharmacia Resource ManualTable of ContentsSection I: Partnering with Hospice PharmaciaRM 1.1 Hospice Pharmacia OverviewRM 1.1.1 Patient Welcome LetterRM 1.2 Hospice Pharmacia Contact and Business InformationRM 1.3 Secure Client Access (formerly Xeris ® ), HIPAA, Security and Nurse PINsRM 1.4 Emergency Response and Business InterruptionRM 1.5 Patients’ RightsSection II: Licensing and Certification DocumentationRM 2.1 Hospice Pharmacia Joint Commission Accreditation• Joint Commission Accreditation CertificateRM 2.2 Hospice Pharmacia Pharmacy and Professional Licensure• Pennsylvania Pharmacy and DEA Licenses• Tennessee Pharmacy and DEA Licenses• Certificate of Liability InsuranceRM 2.3 Performance Objectives for Pharmacy StaffSection III: Hospice Pharmacia Billing and PaymentRM 3.1 Monthly Billing ProcedureRM 3.2 Understanding and Printing Your Hospice Pharmacia Billing ReportRM 3.3 Process for Disputing ClaimsRM 3.4 Documenting Related Status of MedicationsRM 3.4.1 LTC Medication Reconciliation ToolRM 3.4.2 Updating Missing Directions and IndicationsRM 3.4.3 Backdated AdmissionsSection IV: Hospice Pharmacia Pharmacy ServicesRM 4.1 Pharmaceutical Care: Adherence to Legal and Ethical Standards of CareRM 4.2 Patient Protected Health Information (PHI)RM 4.3 Admitting Patients to HP and Patient Census ManagementRM 4.4 MUGs ® Development and ReviewRM 4.5 MUGs ® Distribution: Medications Available for DispensingRM 4.6 Determination of Medications Formulary StatusRM 4.7 Provision of Medications that are Outside the FormularyRM 4.8 Safe Medication Dispensing PracticesRM 4.9 Medication MonitoringRM 4.9.1 Anticoagulation TherapyRM 4.10 Class II PrescriptionsRM 4.11 Federal Law Regarding Faxing of Class II PrescriptionsRM 4.12 Prescriptions for Infants and ChildrenRM 4.13 Medication Labeling and Sample LabelRM 4.14 Medication Delivery & Cancelling a Medication RequestRM 4.15 Hospice PaksRM 4.15.1 Hospice Pharmacia SeizurePak UtilizationexcelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2014 excelleRx, Inc – Page 1 of 2RM Table of Contents

Hospice Pharmacia Resource ManualTable of ContentsRM 4.16RM 4.17RM 4.18RM 4.19RM 4.20RM 4.21RM 4.22RM 4.23RM 4.24RM 4.25RM 4.26RM 4.27RM 4.28RM 4.29RM 4.30Medication Expiration and Discard DateOn-call ServicesHours, Operation and Responsibility of HP’s On-call PharmacistUse of HPRxCard for Local Medication AccessMedication Recall and ShortagesAdverse Drug ReactionsDrug Utilization ReviewDangerous AbbreviationsSound Alike/Look Alike MedicationsHigh Risk MedicationsUnit Dosed Prefilled Oral SyringesFall Assessment and PreventionPatient Information LeafletsInfection ControlHospice Clinical and Administrative ReportsSection V: Quality ImprovementRM 5.1 Performance ImprovementRM 5.2 Quality Control Process and ReportingRM 5.3 Performance Improvement PathwayRM 5.4 Medication Waste and DisposalexcelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2014 excelleRx, Inc – Page 2 of 2RM Table of Contents

Hospice PharmaciaResource ManualCopyright © 2012 excelleRx, IncSection I: Partnering with Hospice PharmaciaRM 1.1RM 1.1.1RM 1.2RM 1.3RM 1.4RM 1.5Hospice Pharmacia OverviewPatient Welcome LetterHospice Pharmacia Contact and Business InformationSecure Client Access (formerly Xeris®), HIPAA, Security and NursePINsEmergency Response and Business InterruptionPatients’ RightsexcelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 1Section 1 - Partnering with HP

TITLE:Hospice Pharmacia OverviewDOCUMENT NUMBER:RM 1.1DEPARTMENT:Executive OfficeREVISION DATES:August 1, 2006;March 1, 2008; October1, 2009, January 30,2010; January 10, 2013Welcome to Hospice Pharmacia (HP)Who we areWe believe that hospice patients have the right to effective pain management andsymptom control, because of this, we are devoted to supporting hospices in palliativemedication delivery to offer their patients optimal comfort and care. Hospice Pharmacia(HP), a service of excelleRx, provides pharmaceutical care services, which includesclinical consultation, medication profile reviews, drug information, medication dispensingand access, and customized tools for hospice organizations across the continental USand territories. Through HP’s team of highly skilled specialty pharmacists,MedicationUse Guidelines (MUGs ® ), state of the art technology and custom software,HP cooperates with prescribers and nurses directly to ensure safe and effectivemedication use. Our prospective Medication Therapy Management approach allows ourpharmacists to collaborate with clinicians in the field at the point of care, helping supportthe selection, administration and monitoring of the most appropriate medication the firsttime, thereby reducing time to palliation of symptoms and enhancing patient comfortand quality of life.Prospective Medication Therapy Management (PMTM) integrates prospectivemedication care planning and monitoring with interdisciplinary care management,reducing direct pharmacy costs by 1) identifying untreated symptoms, 2) prospectivelyintervening when potential or actual adverse drug events are detected, and 3)dispensing the most clinically appropriate medication the first time. Indirect hospicecosts, such as unplanned after hours nursing visits, emergency room services, hospitaladmissions and long-term care facility admissions are deferred by reducing adversedrug events and treating symptoms associated with disease progression moreeffectively.The Medication Management Support Center (MMSC)HP’s Medication Management Support Center works directly with hospice nurses toensure optimal pharmacotherapy outcomes for patients. HP provides medication careplanning including documentation and tracking of endpoints, outcomes, and quality oflife markers to ensure appropriate medication use. HP palliative care pharmacistscollaborate with nurses to formulate a cost-effective, clinically appropriate symptommanagement care plan. Utilization of the MUGs during the care planning processenhances the ability to manage medication use and optimize end-of-life outcomes.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2013 excelleRx, Inc – Page 1 of 2RM 1.1 Description of HP.docx

TITLE:DOCUMENT NUMBER:RM 1.1.1Patient Welcome LetterDEPARTMENT:Executive OfficeREVISION DATES:April 1, 2008;May 5, 2009;January 30, 2010April 30, 2010; January10, 2013POLICY:Patients are provided information about HP through the Patient Welcome Letter.The Letter includes information about contacting HP, obtaining medications, howto read the prescription label, ComfortPaks, medication changes, dosage formsand safe medication storage. The Letter invites patients to call HP withmedication-related questions and provide feedback on their satisfaction with HP.PROCEDURE:• The Patient Welcome Letter (attached) is a brochure included in the patient’sfirst shipment of medications from HP.• If the patient is not receiving medication shipments directly from HP (e.g. LTCor IPU) but the hospice wishes to provide them with information on HP, thehospice may print out the attached copy of the Letter.• Distribution of the Patient Notice of Privacy Practices is discussed in policyRM 1.3 HP Online, HIPAA, Security and Nurse PIN.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2013 excelleRx, Inc – Page 1 of 1RM 1.1.1 Patient Welcome Letter.docx

Emergency Medication PaksUpon request from your physician, excelleRx willsend you a pre-packaged box of medication. Youmay receive up to three boxes, depending on yourcondition. The medications in these boxes are foruse in urgent situations, and are only to be usedwhen the nurse/doctor directs you to do so.Some of the boxes offered by excelleRx includethe ComfortPak TM , the CardiacPak TM , and theSeizure ComfortPak TM . Please store these boxesaccording to the directions on the box. Themedications in these Paks are to manage anyemergent symptoms quickly, and keep you ascomfortable as possible.*packaging may vary• Keep out of reach of children.• Use only as directed by your nurse orphysician.FeedbackWe care about your experience with excelleRxPharmacy Services. We are always trying toimprove our service. Do not hesitate to let us knowif we are not meeting your expectations. E-mail usat customerservice@excelleRx.com with yourcomments or ideas.The health care service provided by this business isaccredited by The Joint Commission (TJC). If youhave any safety or quality of care concerns you maycontact: The Senior Director of Compliance andQuality. The mailing address is 1601 Cherry Street,Suite 1700, Philadelphia, PA 19102; or by phone215.282.1735; or, TJC Office of Quality Monitoring at630.792.5600.excelleRx Pharmacy Contact Info1-866-703-1730customerservice@excellerx.comwww.excelleRx.coma TJC accredited organizationCopyright © 2014, excelleRx, Inc.ComfortPak TM , CardiacPack TM , and SeizureComfortPak TM are trademarks of excellerx, Inc.Welcometo excelleRx Pharmacy ServicesUnique Services for HospicePatientsexcelleRx is a specialized mail order pharmacy. Ourteam includes hundreds of specially-trainedpharmacists who help to make your life easier andmore comfortable. We support your nurses anddoctor to assure that you are receiving the mostappropriate and safest medications.Your doctor, nurse, and our pharmacists haverecommended a medication care plan for you.If You Have a Question About YourMedication, We Are Here To HelpIf you have questions regarding your care or anemergency, you should always call your hospiceprovider FIRST. Your hospice nurse willcoordinate your medication needs with the doctor orpharmacist and explain any new changes to yourcare plan.Your hospice provider is available 24/7 to assistyou with your questions and concerns. If you needto speak to someone regarding your care or otherhealth concerns, please call your hospice providerdirectly. A hospice team member can also assist inmaking arrangements to speak to a pharmacist.If you would like to speak to a pharmacist directly,call excelleRx’s toll-free number, 1-866-703-1730.

Medication AccessexcelleRx provides medications as directed byyour physician. Typically, they will arrive the dayafter they are prescribed and be delivered by anational courier service. If you have questions aboutthe medicine delivered to you or you receivemedication you didn’t expect, please contact yourhospice nurse or excelleRx. You may request thatyou sign for all deliveries if you are concernedabout the security of a package that may be left inyour doorway area.If you need your medicines immediately, yourhospice physician will coordinate access through alocal pharmacy. Please let your health care providerknow what pharmacy you use locally for urgentmedications.Medication InstructionsTake your medications according to the instructionson the label. If you have questions or don’tunderstand the instructions, call your health careprovider.Changes in Your Medication PlanIf you are having trouble swallowing a pill, or thinkthat a certain medication might be causingunwanted side effects, talk to your nurse, doctor, orpharmacist. Talking to one of these professionalsFIRST will allow medication changes to be madesafely. Stopping or starting medications on yourown may lead to other problems.Dosage Forms and SpecialInstructionsThere are many “dosage forms” that you might alreadybe taking, or that your health care provider couldrecommend. Some examples are pills, liquids, rectalsuppositories, and topical gels. Talk with your nurse,doctor, or pharmacist about the best dosage forms foryou.• Pills – do not crush or break any pill unless yourhealth care team (nurse, doctor or pharmacist)has told you that it is safe to do so. If you arehaving problems swallowing a pill, contact yournurse or pharmacist. If your medication bottlesays “Dissolve under the tongue” or “Takesublingually,” your medicine is meant to beplaced under the tongue where it will dissolveand be absorbed quickly.• Liquids – it is important to measure liquidscarefully, so that you are taking the right dose.Some medications need a special dropper formeasuring. Be sure to read the droppermeasurement at eye-level.• Suppositories – a suppository is a dosage formthat is meant to be inserted into the rectum (or inspecial cases, the vagina). The medicine iscontained in a waxy, football shaped form that isusually wrapped in foil. Be sure to peel away thewrapper. Once inserted, the suppository meltsand the medication can be absorbed into thebloodstream. Keep suppositories out of directsunlight in a cool, dry place.• Gels or patches – these medications are absorbedthrough the skin and into the bloodstream. Applythe gel or patch to an area of thin, hairless, intactskin (according to instructions). Family membersshould be careful not to get gel on their hands, andshould wear gloves while applying the gel. Washhands before and after applying a gel or a patch.Storing and Disposing ofMedications SafelyAll medications should be stored together in oneplace that is cool and dry unless otherwise directed.When your nurse or doctor visits, he/she should beable to review all the medications that you aretaking to be sure they are working properly.Medications should only be taken by the person forwhom they were prescribed. Be sure to keep allmedications AWAY FROM CHILDREN for safetyreasons. It is best to maintain medications in asecure area to prevent loss or harm. If a child issuspected to have swallowed or applied one of yourmedications, call your Poison Control Centerimmediately and call your health care provider.Your hospice nurse will discuss with you how toproperly dispose of medications that you no longerneed to take.Learn More about Your MedicationsCall us toll-free at 1-866-703-1730 if you have anymedication-related or pharmacy questions. Forgeneral hospice pharmacy information, visitwww.excelleRx.com.

TITLE:Hospice Pharmacia Contact and Business InformationDOCUMENT NUMBER:RM 1.2DEPARTMENT:ITREVISION DATES:August 1, 2006;March 1, 2008;October 2, 2009January 30, 2010April 30, 2010,February 21, 2012August 25, 2014Telephone and Fax• HP Pharmacy Toll-Free: 1-877-882-7820 or 1-800-810-0887• Physician Line: 1-877-AUTH-MED (1-877-288-4633)• Long Term Care Support Service: 1-866-597-3589• In Patient Unit: 1-866-703-1726• Customer Service: 866-670-8162• Local Telephone: 1-215-282-0500• LTC Toll-Free Fax: 1-877-265-6852• CII Prescription Toll-Free Fax: 1-800-530-1565• IPU Fax: 1-866-923-5791• Toll-Free Billing or Administration Support: 1-877-882-7822E-Mail and Web Site• Web Site: www.hospicepharmacia.com and www.excellerx.com• General E-Mail: info@excellerx.com, info@hospicepharmacia.com• MedicationUseGuidelines TM : MUGs@excellerx.com,MUGs@hospicepharmacia.com• TechnicalSupport: support@excellerx.com,support@hospicepharmacia.com• Quality Assurance (QA): QA@excellerx.com, qa@hospicepharmacia.com• Joint Commission: JointCommission@excellerx.com• Resource Manual: resourcemanual@excellerx.com• XerisMobile – renamed to hpMobile: hpmobile@hospicepharmacia.comHours of ServiceMonday through Friday: 8:30am-11:00pm Eastern TimeSaturday, Sunday and Holidays: 9:00am-8:00pm Eastern TimeFor updates, please refer to HP’s websiteAfter Hours AssistanceOn-Call Pharmacist: 1-866-763-2543On-Call Administrator: 1-800-395-2371excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2014 excelleRx, Inc – Page 1 of 1RM 1.2 Hospice Pharmacia Contact and Business Information.doc

TITLE:HP On-line Access (formerly known as Xeris ® ),Security, Nurse PIN & HIPAADOCUMENT NUMBER:RM 1.3DEPARTMENT:Client Relations, ITREVISION DATES:August 1, 2006;March 1, 2008October 7, 2009April 30, 2010February 23, 2011February 2, 2012January 10, 2013HP’s Secure On-line AccessHP offers the following functions through the secure website;www.hospicepharmacia.com:• Admitting patients• Discharging patients• Refilling medications• Discontinuing medications• Tracking packages• Obtaining educational information• Generating reports (clinical, administrative, billing)• Accessing the Medication Use Guidelines (MUGs ® )• Accessing the HP Opioid Conversion Calculator• Reporting Customer Service events• Obtaining patient information leaflets• Communicating comments and suggestions• Managing password administration• Establishing a personal identification number (PIN)Obtaining Access1. To obtain an access code, contact your Hospice Administrator.2. HP provides a monthly on-line orientation for users looking for additionalsupport.3. .System RequirementsIn order to gain access to HP’s website, a computer must have the followinghardware and software:• A color monitor with 1024x768 pixel screen resolution (or higher)• Cable, ViOS, or DSL high speed internet connection (56k Modems are notrecommended)The software is a free browser-based application. Information Technology (IT)staff from the hospice may be needed to verify or update the following:• Acrobat Reader ® 6.0 (or higher) from AdobeexcelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2013 excelleRx, Inc – Page 1 of 2RM 1.3 HP Online Access HIPAA Security Nurse PIN.doc

SecurityEach new user will receive a secure Login ID and Password assigned by thehospice’s Administrator. During the first login, each user is required to:• Read and accept a End User License Agreement (see the Secure ClientAccess (formerly Xeris ® ) RM page 7 – Copy of End User LicenseAgreement)• Select a new secure personal password• Select a 4-digit Personal Identification Number (PIN)HP’s secure access utilizes 128-bit secure socket layer technology to ensuresecure transmission of all patient-related information. All users must comply withHIPAA patient privacy regulations and refrain from viewing sensitive informationin a public area. Open web sessions will be logged out after a period of inactivityand the user will be required to log on again.Each nurse will be prompted to enter a PIN when calling HP. To establish orchange a PIN, a nurse must:1. Log onto HP’s website2. From the toolbar, click 'My User Profile'3. Click 'Edit My Profile'4. Click XXXX next to PINHIPAAHospice Pharmacia is a covered entity under the Health Insurance Portability andAccountability Act (HIPAA), HP’s processes for maintaining and transmittingelectronic health information are in compliance with (HIPAA). HP educates eachteam member about their responsibility regarding the handling and maintenanceof patient information.Complying with Federal HIPAA Privacy Regulations, HP mails a Notice ofPrivacy Practices (NOPP) to each patient upon admission. The NOPPs are sentovernight to the address provided to HP by the hospice for the medicationdelivery. The patient or their designated legal representative is required to reviewthe NOPP and should return the signed acknowledgement of receipt of privacypractices to HP.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2013 excelleRx, Inc – Page 2 of 2RM 1.3 HP Online Access HIPAA Security Nurse PIN.doc

POLICY:Emergency Response and Business InterruptionPOLICY NUMBER:RM 1.4DEPARTMENT:Legal, IT and HRREVISION DATES:August 1, 2006;May 1, 2007;July 10, 2008;December 22, 2008;October 7, 2009February 2, 2012POLICY:HP maintains and routinely tests a plan for enabling patients to accessmedication during business interruption.HP has in place an Emergency Operations Plan, including a Shelter in Placecomponent and components for maintaining business functions duringemergencies, including viral outbreaks. This internal plan is reviewed andupdated on an as needed basis, but no less than once a year. All HP staff istrained on emergency procedures and actions to take to ensure continuity ofservices to partnering hospices.PROCEDURE:In the event of an emergency affecting HP sites:• HP will make every effort possible to communicate situation updates tothe hospice, as necessary.• HP routinely participates in planned fire drills, planned building powershut downs, and other temporary evacuations throughout the year.• HP’s data and phone systems are equipped with built in redundancies.In the event of a disruption (e.g. emergency drill, power failure ornatural disaster) at a given MMSC or CRxP site, calls and prescriptionprocessing can be shifted to another site, so that pharmacy staff andservices remain available. Medication access will be provided by theuninterrupted HP site.• In the event of extreme weather conditions (e.g. blizzards), affected HPstaff are housed as necessary at hotels within walking distance to HP,in order to continue to provide services to partnering hospices. Inaddition, a subset of pharmacy staff members have the ability to workremotely and connect to primary systems.• In the event of extreme viral conditions (e.g. H1N1) HP staff aredeployed at alternate contained sites as necessary to continue toprovide services to partnering hospices. In addition, a subset ofpharmacy staff members have the ability to work remotely and connectto primary systems.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 2RM 1.4 Emergency Response and Business Interruption

• In the extremely rare event of a nationwide failure of HP systems,appropriate senior management level individuals have the ability toopen the HPRxCard to all affected hospices.• Medication access will be provided by community pharmacies usingthe HPRxCard system until directed otherwise by HP.In the event of an emergency affecting partnering hospice sites:• HP leadership monitors national news and weather for warning ofimpending or actual business interruption.• Working with high level FedEx management, HP monitors FedEx’sability to deliver medications during an impending or actual emergency.HP staff is trained in utilizing FedEx package tracking tools.• In the event that a given area may be affected by an emergency (e.g.hurricane), MMSC staff and HP management will attempt to contacthospices and plan for meeting medication needs, according to thesituation.• In the case of isolated events concerning medication access, HPMMSC staff is notified to provide manual authorizations allowingcommunity pharmacies to dispense needed medication in appropriatequantities to meet patient needs throughout the projected interruption.Depending on the situation HP will set up access to medication usingcommunity pharmacies.• Additionally and as warranted, HP will increase days supply and earlyrefills on incoming prescription requests.• HP will make every attempt possible to prioritize processing andfulfillment of medications for hospices in emergency situations.• If given adequate advance notice, the hospice management mayarrange with HP senior management for HP’s participation in thehospice’s emergency preparedness drill.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 2 of 2RM 1.4 Emergency Response and Business Interruption

POLICY:Patient’s RightsREVISION DATES:August 1, 2006;May 18, 2009POLICY NUMBER:RM 1.5DEPARTMENT:Performance Improvement/MMSCPOLICY:HP recognizes and supports a patient’s right to understand the proper use,storage, administration, duration and other considerations of each medication.PROCEDURE:1. The primary responsibility for teaching patients about the medication careplan resides with the hospice nurse and in some cases the long term care(LTC) facility nurse.2. An HP representative may initiate calls to the patient or patient’s caregiver forreasons related to medications dispensed by HP to review proper use,expected outcome, storage, and disposal (if necessary) of the medication.3. Written drug information will accompany each new medication dispensed tohospice patients residing at home.4. HP maintains a toll-free phone number for patient communication to apharmacist 24 hours a day, 7 days a week.5. Multilingual pharmacy staff is available to provide verbal and written patienteducation materials.6. HP respects patients rights including, but not limited to:a. right to privacy. (HP follows strict government regulations regardingsecurity and privacy of protected health information as outlined inHIPAA.)b. right to receive medications that are correctc. right to receive medications that are accurately prepared and labeledd. right to timely access to medications7. Each patient receiving care from HP will be informed of his/her rights andresponsibilities upon receipt of his/her first medication delivery from HP.a. If the patient is not receiving medication shipments directly from HP(e.g. LTC or IPU) the hospice may print out and provide the patientwith the attached copy of the Patient Rights and Responsibilities.b. Further information on the Patient Welcome Letter and Patient Noticeof Privacy Practices may be found in RM 1.1.1 and RM 1.3,respectively.8. Special arrangements may be made for patients who require foreignlanguage labels. HP may print prescription labels in Spanish. Additionalassistance for other languages is available upon request.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 1RM 1.5 Patient's Rights

Hospice PharmaciaResource ManualCopyright © 2012 excelleRx, IncSection II: Licenses and Certification DocumentationRM 2.1 Hospice Pharmacia Joint Commission Accreditation• Joint Commission Accreditation CertificateRM 2.2 Hospice Pharmacia Pharmacy and Professional Licensure• Pennsylvania Pharmacy and DEA Licenses & NPI Number• Tennessee Pharmacy and DEA Licenses• Certificate of Liability InsuranceRM 2.3 Performance Objectives for Pharmacy StaffexcelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 1Section 2 - Licenses and Certification

POLICY:Hospice Pharmacia Joint Commission AccreditationREVISION DATES:August 1, 2006; August8, 2008; October 5,2009, January 28, 2012POLICY NUMBER:RM 2.1DEPARTMENT:Corporate Compliance, LegalPOLICY:The Joint Commission (JC) periodically conducts an accreditation survey of HP.The purpose of each survey will be to evaluate HP’s compliance with nationallyestablished Joint Commission standards. This survey process is similar to thesurveys your organization may periodically undergo for your state or otheraccreditation agencies.Any questions regarding how HP complies with JC standards should be sent viaemail to JointCommission@excellerx.com.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 1RM 2.1 JC Accreditation.doc

POLICY:Pharmacy and Professional LicensurePOLICY NUMBER:RM 2.2DEPARTMENT:Corporate Compliance/LegalREVISION DATES:August 1, 2006;May 9, 2007;March 1, 2008;December 1, 2008;September 1, 2009April 30, 2010;December 2010POLICY:HP pharmacies operate as licensed pharmacies in compliance with the rules andregulations of the states in which they are located. HP maintains active and ingood standing all licenses, permits and certificates necessary to practicepharmacy. All health professionals (nurse, pharmacist, physician, certifiedtechnician, etc.) who practice their profession while in HP’s employment willretain valid licenses, permits and certificates as required by their profession.PROCEDURE:Copies of all appropriate pharmacy licenses (e.g. state pharmacy permit, DEAlicense, etc.) shall be conspicuously displayed within the pharmacy.Facilities1. All out-of-state pharmacy permits must be obtained. These permits areoften required in states to which HP delivers pharmaceutical products, butthe pharmacy has no physical presence in that particular state. It is theresponsibility of the partnering hospice in collaboration with the pharmacymanager to make certain all appropriate license have been procured andthat on an annual basis requirements of any states to which shipments aremade are reviewed. (Frequently the rules governing shipment into aparticular state by an out-of-state pharmacy change, usually becomingmore stringent).2. Ready access (law book or internet access) to state pharmacy regulationsfor the state in which the pharmacy is located and any states in which HPis a registrant for shipping purposes is provided to all appropriate teammembers.Professionals1. The Pharmacist of Record, or a designee under his or her supervision, willmaintain corporate Pharmacy documents governing the practice ofpharmacy as required by the laws of the jurisdiction(s) of practice.2. Team members of HP who practice pharmacy will be certified, licensedand/or registered and in good standing, as required by the profession andthe jurisdiction(s) of practice.3. Any team member who is in a waiting period for licensing or registrationwill perform duties in accord with regulation, under direct supervision of aexcelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 2RM 2.2 Pharmacy and Professional Licensure

licensed practitioner. This applies to student interns, graduate healthprofessionals and out-of-state licensed professionals.4. Team members are required to submit original licenses, permits, andcertificates to the Pharmacist of Record, or his or her designee, upon hireor any change or update of licensure. All health professional licenses,certificates or registrations will be verified at the time of hire and annuallyvia a secure electronic source from the primary source of information. Forexample, accessing the state’s board of pharmacy website and printingthe screen that lists the team member by name and verification of acurrent license.5. The professional licenses of all registered pharmacists and pharmacytechnicians (in states for which technician registration is required) are tobe maintained in good standing and the original or copy kept on site.For the convenience of our partnering hospice clients, the following documentsare provided and available on-line:o Pennsylvania Board of Pharmacy license for excelleRx-PA d.b.a. HospicePharmacia and National Provider Identifier (NPI) Numbero DEA Controlled Substance Registration for excelleRx-PA d.b.a. HospicePharmaciao Tennessee Board of Pharmacy license for excelleRx, Inco DEA Controlled Substance Registration for excelleRx, Inco Certificate of Liability InsuranceAdditional pharmacy licenses or copies of the pharmacist in charge licenses areavailable upon request from the Legal/Corporate Compliance Department or HPCustomer Service (1-866-670-8162).The Hospice Pharmacia Resource Manual posted online in Secure Client Access(formerly Xeris ® ) contains the most current licenses and certificates available.Upon receipt of a renewed or more current document the Resource Manual willbe updated for immediate availability to all partnering hospices. If a hospicecannot access the Manual and require an additional or updated license, theyshould contact the Legal/Corporate Compliance Department or HP CustomerService (1-866-670-8162).excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 2 of 2RM 2.2 Pharmacy and Professional Licensure

PRODUCERINSUREDCONTACTNAME:PHONE(A/C, No, Ext):E-MAILADDRESS:INSURER A :INSURER B :INSURER C :INSURER D :INSURER E :INSURER F :COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:FAX(A/C, No):DATE (MM/DD/YYYY)ACORDTM CERTIFICATE OF LIABILITY INSURANCE 1/15/2015THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THISCERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIESBELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZEDREPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject tothe terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to thecertificate holder in lieu of such endorsement(s).Marsh & McLennan Agency LLCOne Executive DriveSomerset, NJ 08873THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIODINDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THISCERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.INSRLTRTYPE OF INSURANCEADDL SUBRINSR WVDPOLICY NUMBERPOLICY EFF POLICY EXP(MM/DD/YYYY) (MM/DD/YYYY)LIMITSAGENERAL LIABILITYZDY916352104 06/10/2014 06/10/2015 EACH OCCURRENCE $ 1,000,000X COMMERCIAL GENERAL LIABILITYDAMAGE TO RENTEDPREMISES (Ea occurrence) $ 1,000,000AB XUMBRELLA LIABX OCCUR MFX0020420814 08/15/2014 08/15/2015 EACH OCCURRENCE $ 10,000,000CXEagle Rx Holdings, LP1480 Imperial WayWest Deptford, NJ 08066EXCESS LIABGEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $PRO-POLICY$JECT LOCAUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT(Ea accident)$DED RETENTION $ $WORKERS COMPENSATIONWC STATU- OTH-13WEBT793412/31/2014 12/31/2015 XAND EMPLOYERS' LIABILITYTORY LIMITS ERY / NANY PROPRIETOR/PARTNER/EXECUTIVEE.L. EACH ACCIDENT $OFFICER/MEMBER EXCLUDED? N N / A(Mandatory in NH)E.L. DISEASE - EA EMPLOYEE $If yes, describe underDESCRIPTION OF OPERATIONS belowE.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)INSURER(S) AFFORDING COVERAGE NAIC #CLAIMS-MADE OCCUR MED EXP (Any one person) $ANY AUTOALL OWNEDAUTOSHIRED AUTOSXXSCHEDULEDAUTOSNON-OWNEDAUTOSsomersetclsupport@mma-ne.comMassachusetts Bay Insurance ComHomeland Insurance Company of NHartford Underwriters InsurancePERSONAL & ADV INJURY $GENERAL AGGREGATE $BODILY INJURY (Per person) $BODILY INJURY (Per accident) $PROPERTY DAMAGE(Per accident)CLAIMS-MADE AGGREGATE $$$22306344523010410,0001,000,0002,000,0002,000,000ZDY916352104 06/10/2014 06/10/2015 1,000,000B Professional Liab MFL0042060814 08/15/2014 08/15/2015 $1,000,000 each claim$3,000,000 aggregateDedt: $25,000 per claimEvidence of InsuranceClient#: 99621EAGLERX10,000,0001,000,0001,000,0001,000,000CERTIFICATE HOLDERExcelleRx1601 Cherry St, #1700Philadelphia, PA 19102CANCELLATIONSHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED INACCORDANCE WITH THE POLICY PROVISIONS.AUTHORIZED REPRESENTATIVEACORD 25 (2010/05)1 of 1#S1108549/M1108545The ACORD name and logo are registered marks of ACORD© 1988-2010 ACORD CORPORATION. All rights reserved.NSKAB

TITLE:Performance Objectives for Pharmacy StaffPOLICY NUMBER:RM 2.3DEPARTMENT:PerformanceImprovement/EducationREVISION DATES:August 1, 2006March 1, 2009September 9, 2009April 30, 2010February 13, 2012POLICY:HP team members will be provided initial hospice-focused orientation andongoing staff development using performance objectives.Corporate Performance Objectives:• Describe the history of Hospice Pharmacia.• Recite the mission and core values for Hospice Pharmacia.• Describe the employee’s job responsibilities as they relate to the company’smission.• Demonstrate proficiency in navigating and using HP Internal Software® ®(formerly Xeris ) , Microsoft Outlook , and the excelleRx iNet.• Discuss the training and performance markers for the employee’s position.• Define the role and the employee’s responsibility of HIPAA, JointCommission, OSHA, and Corporate Compliance in the excelleRx workplace.• Describe the philosophy of hospice and its approach to end-of-life care.• Describe the services provided by HP and how they involve care planningand access to medications.• Review the care process from the point of client call to the delivery ofmedication to the patient.Medicat ion Management Support Center (MMSC) Performance Objectives:• Answer the phone and identify oneself and position in a pleasant andcourteous manner.• Apply principles of good customer service and behaviors to meet clientexpectations.• Listen to the caller’s needs and process the call in an efficient manner.Technicians:• Collect and enter patient demographic information into HP Internal Software(formerly Xeris ® )• Enter physician demographics into HP Internal Software (formerly Xeris ® )• Admit and discharge patients from HP Internal Software (formerly Xeris ® ).• Change the status or location of patients in HP Internal Software (formerlyXeris ® ).• Enter new medication requests for the pharmacists review• Process refill requests.• Process FedEx-related calls.• Assist community pharmacies with adjudicating prescription claims.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 2RM 2.3 Performance Objectives for Pharmacy Staff

Pharmacists:• Discuss patient assessment data.• Provide clinical, patient-specific recommendations for symptom managementbased on the Hospice Pharmacia Medication Use Guidelines.• Design goals and monitoring plans for pharmacotherapeutic regimens.• Modify pharmacotherapeutic regimens based on patient outcomes.• Review medication requests for appropriateness and accuracy.• Accept verbal prescription requests.• Answer medication-related questions and provide drug information andclinical consultation.• Adhere to applicable laws and regulations.• Review medications profile in compliance with the Medicare Conditions ofParticipation• Review profile and make recommendations related to drug-drug interactionsand food to drug interactions.Central Prescription Processing (CRxP) P erformance Objectives:• Select the correct medication, strength and formulation to complete theprescription request.• Measure or count the specified quantity for the prescription request.• Check accuracy of the prescription, including patient information, medication,strength, formulation, directions, quantity and refills.• Pack medications for shipping to ensure safe delivery.• Pack patient informationleaflets, refill reminder and other literature asapplicable in the patient’s medication package.• Adhere to applicable laws and regulations.• Adhere to USP-797 regulations for sterile compounding preparation.• Practice proper aseptic technique for non-sterile compounding preparation.• Adhere to HP infection control processes to maintain a safe medicationdispensing environment.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 2 of 2RM 2.3 Performance Objectives for Pharmacy Staff

Section III: HP Billing and PaymentHospice PharmaciaResource ManualCopyright © 2012 excelleRx, IncRM 3.1RM 3.2RM 3.3RM 3.4RM 3.4.1RM 3.4.2RM 3.4.3Monthly Billing ProcedureUnderstanding and Printing Your Hospice Pharmacia Billing ReportProcess for Claims ReviewDocumenting Related Status of MedicationsLTC Medication Reconciliation ToolUpdating Missing Directions and IndicationsBackdated AdmissionsexcelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 1Section 3 - HP Billing and Payment

POLICY:POLICY NUMBER:RM 3.1Monthly Billing ProcedureDEPARTMENT:FinanceREVISION DATES:August 1, 2006;March 1, 2008;October 14, 2009,January 25,2011February 28, 2011August 2, 2011POLICY:HP will prepare an accurate invoice and provide it to the hospice client inaccordance with contract specifications. The partnering hospice client will remitpayment in full to HP in accordance with agreed upon terms.PROCEDURE:1. The hospice provides accurate census information (admission, discharge, patientinactivation, service transfer and patient death) to HP within 5 days of patientstatus change using XerisBilling or the automated refill and discharge system(ARDS).2. The HP Finance Department collaborates with the hospice’s designee to prepareand provide an accurate monthly invoice. The hospice’s designee will beresponsible for reviewing the HP Billable Days Report for accuracy.Documentation of the hospice’s monthly admission and discharge data is neededfor quality purposes. The hospice will remit either a census or the reviewed BillableDays Report via fax (215-282-1594) to the attention of their designated HP BillingRepresentative per contract agreement. Data required are: patient name, patientsocial security number, admission and discharge (or change in status) dates.3. HP reserves the right to inspect hospice records for the accuracy of reportedcensus information.4. All invoices are available in an electronic format. The hospice is responsible forprinting their invoices from the HP website.5. The hospice will remit payment in full (the hospice is not permitted to makeinvoice deductions, including disputed claims) within the agreed upon terms asprinted on the invoice.6. All invoice disputes must be submitted as outlined in HP’s Process for DisputingClaims (see policy RM 3.3). Credits will be applied to the following month’sinvoice.IMPORTANT BILLING DATES1st- 5th of the month – Print Billable Days Report for the month prior. Faxcorrections and a copy of hospice census to HP Billing Representative.15-17th of the month – Print invoice.For questions contact the Finance/Billing Department at 215-282-1600 ext. 7357 ore-mail billing@excellerx.com.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 1RM 3.1 Monthly Billing Procedure

POLICY:Understanding and Printing YourHospice Pharmacia Billing ReportPOLICY NUMBER:RM 3.2DEPARTMENT:FinanceREVISION DATES:August 1, 2006;March 1, 2008;October 14, 2009April 30, 2010February 28, 2011POLICY:Invoices are available online and will not be sent to the partnering hospice clientby mail. The invoice is available by the 15 th of each month.PROCEDURE:Visit www.hosp icepharmacia.com to check the date of when the invoice will beavailable. It is displayed on the right side of the HP screen below “HP OnlineBilling.”To Print An Invoice:Step 1: Go to www.hospicepharmacia.com.Step 2: Type in the Username and Password given to you by your Secure ClientAccess (formerly Xeris ® ) Hospice Administrator (XHA).Step 3: Select “Report Options” on the left side of the screen.Step 4: Scroll down and select “Billing Reports”.Step 5: Select Billing Period and use the dropdown to select the month of theinvoice you wish to review.Step 6: Do not select a Report. Simply scroll down to the bottom of the screenand select Print All Billing Reports.Step 7: A PDF file containing the invoice will appear after a few minutes. Printthe invoice.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 1RM 3.2 Understanding and Printing HP Billing Report

POLICY:POLICY NUMBER:RM 3.3Claim Review PolicyDEPARTMENT:Performance Improvement/CustomerServiceREVISION DATES:August 1, 2006;March 1, 2008;September 1, 2009April 30, 2010, January25, 2011, February 14,2012POLICY:The partnering hospice client must initiate claim reviews in accordance with contractspecifications by using Secure Client Access (formerly Xeris ® ).PROCEDURE:The preferred and most efficient method of submitting a claim review is through SecureClient Access (formerly Xeris ® ). To submit a claim review using Secure Client Access(formerly Xeris ® ):1. Enter www.hospicepharmacia.com.2. Type in Username and Password given to you by your Secure Client Access(formerly Xeris ® ) Hospice Administrator (XHA).3. Look up the patient’s profile for whom the claim needs to be reviewed.4. Select the “CS” icon on the left hand side to proceed.5. Complete all required fields. The system automatically enters the Patient’s nameand the user name (person submitting the dispute). Choose the appropriateType.6. For Category of Event select “Not related to an order”. Select the Date of Incidentand click submit.7. This form is submitted directly to Hospice Pharmacia’s Customer Servicedepartment who will respond to claim reviews submitted by the hospice withintwenty (20) business days of receipt, and will inform the hospice designee of theresolution of the claim.8. Credits will be applied to the next month’s invoice.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 1RM 3.3 Process for Claims Review

POLICY:Documenting Related Status of MedicationsREVISION DATES:POLICY NUMBER:RM 3.4DEPARTMENT:Client RelationsPOLICY:Documenting a medication’s related status to the terminal hospice diagnosis isan important step in ensuring that medications are accurately billed.PROCEDURE:1. HP Pharmacists will document the hospice’s determination of themedication’s related status in HP’s medication profile for all facility-basedpatients.2. The decision about related status is solely the responsibility of the hospice;however, the HP pharmacist can provide the nurse with information about themedication’s indications along with other information to assist the hospice inmaking a determination.3. If the related status information is not communicated to the pharmacist or isnot documented on the faxed medication profile, HP will document themedication as “Not Specified”.4. It is the hospice’s sole responsibility to notify HP of the related status for all“Not Specified” medications within 12 days to ensure that the LTC FacilityPharmacy bills the medications to the appropriate payer.5. If related determinations are not communicated to HP within a reasonabletime frame, the hospice may be at risk for inaccurate billing of medications.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 1RM 3.4 Documenting Related Status of Medications

POLICY:LTC Medication Reconciliation ToolREVIEWED DATES:POLICY NUMBER:RM 3.4.1DEPARTMENT:Client RelationsPOLICY:HP recognizes the challenges that hospices face in consistently being included inthe plan of care for hospice patients who reside in LTC facilities. When thehospice is not aware of medication orders, it places the hospice and the LTCPharmacy at risk of inaccurate billing. Determining the related status ofmedications is an important step in ensuring that medications are billedaccurately at the LTC Pharmacy. HP’s online LTC Medication Reconciliation Toolnotifies hospices of new medication orders, which allows the hospice to specifythe related status of the medication and provides the LTC Pharmacy withaccurate billing information as reported by the hospicePROCEDURE:1. Hospices must sign up to access the LTC Medication Reconciliation Tool.This is accomplished by sending an email to LTCMedRec@ExcelleRx.com.Hospice must provide the hospice name, city/state, and names and emails ofthe hospice staff who will be utilizing the LTC Tool. HP recommends that onlymanagers, directors, team leaders, etc. utilize this resource.2. HP sends an email to all designated users every Monday as a reminder toaccess the LTC Tool. The email contains a link to the online LTC Tool and itis also available via the LTC Med Rec icon once the user has logged in tohospicepharmacia.com.3. Hospices should access the online LTC Tool weekly (at a minimum) to viewthe medication information and document related determinations.4. To ensure accurate billing and coordination of benefits at the LTC Pharmacy,hospices must make all determinations within 12 days.5. The LTC Tool is comprised of three different sections. In order to loadpatients and medications into each section, click the + icons.6. The first section, “Medications Imported from Facility Pharmacy”, displaysmedications that the LTC Pharmacy dispensed and tried to bill to the HP Rxcard, but the medication was not on the HP profile. The hospice user clicksthe ‘Complete Med Details’ link, then clicks ‘Related’ or ‘Not Related’ basedon the hospice’s determination, enters the directions and indication ifavailable, then clicks ‘Save’.7. In addition to presenting the hospice with these medications in the firstsection of the LTC Tool, HP also automatically adds the medications to thepatient’s HP profile.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2013 excelleRx, Inc – Page 1 of 2RM 3.4.1

8. The second section, “Related Medications Not Authorized”, displaysmedications that the hospice profiled as related to the terminal diagnosis, butthey were never authorized for payment due to hospice-specific authorizationpolicies. These medications are generally outside per diem medications. If themedication is related and should be authorized for payment, the hospice usermust click ‘Authorize’. If the medication is not related and should not beauthorized, the hospice user clicks ‘Not Related/Not Authorized’. The ‘Update’button must be clicked after each determination.9. The third section, “Not Specified Medications”, displays medications that donot yet have a related status documented. These medications are noted as“Not Specified”. If the hospice determines that the medication is related to theterminal diagnosis, the hospice user must click ‘Related’ and then ‘Update’. Ifthe medication is determined not to be related to the terminal diagnosis, thehospice user clicks ‘Not Related’ and then ‘Update’.10. Throughout the LTC Tool, when the hospice user clicks ‘Related’, themedication is automatically authorized for billing and a notification fax is sentto the LTC Pharmacy. If the hospice user clicks ‘Not Related’, the medicationis not authorized and when the LTC Pharmacy rebills the medication to HP,they will receive a notification that the ‘medication is not covered’. Thismessage signals that the LTC pharmacy should bill a secondary payer.11. Click ‘Logout’ when finished.12. All changes made in the LTC Tool are immediately applied to the patient’s HPprofile.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2013 excelleRx, Inc – Page 2 of 2RM 3.4.1

POLICY:Updating Missing Directions and IndicationsREVISION DATES:POLICY NUMBER:RM 3.4.2DEPARTMENT:Client RelationsPOLICY:HP’s online LTC Medication Reconciliation Tool displays medications that theLTC Pharmacy dispensed and attempted to bill to the HP Rx card, but themedications were not listed on the patient’s HP profile. These medications areimported to the LTC Tool and onto the patient’s HP profile with default directionsand indication. The hospice then documents the related status to ensureaccurate billing. The hospice should also update the directions and indication toensure that the medication profile is accurate.PROCEDURE:1. Refer to the LTC Medication Reconciliation Tool Policy for specific informationregarding the procedure for utilizing the LTC Medication Reconciliation Tool.2. HP’s online LTC Medication Reconciliation Tool displays medications that theLTC Pharmacy dispensed and attempted to bill to the HP Rx card; however,the medications were not listed on the patient’s HP profile. These medicationsare imported to the LTC Tool and onto the patient’s HP profile with defaultdirections and indication. The hospice can then document related status toensure accurate billing. The default directions state “Hospice to providedirections” and the default indication is “Indication Not Specified”.3. Importing these medications onto the HP medication profile also helpsreconcile the different pharmacy records and allows HP to perform a moreaccurate drug utilization review (DUR).4. These default directions and indications should be updated by the hospiceteam, within a reasonable time frame, to reflect the actual medicationdirections and indications.5. The preferred methods for updating are: the online LTC MedicationReconciliation Tool, faxing the LTC Medications Missing Directions/IndicationReport (available in the Clinical Reports section), or faxing the updatedmedication profile.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 1RM 3.4.2 Updating Missing Directions and Indications

POLICY:Backdated AdmissionsREVISION DATES:POLICY NUMBER:RM 3.4.3DEPARTMENT:Client RelationsPOLICY:If the hospice does not admit a patient to HP on the date of admission to hospice, HPwill back admit the patient to the hospice admission date. If the patient’s hospiceadmission date was during the current open billing month; HP will back admit thepatient, per diem will be charged, and medications will be billed to PBM Plus per thestandard process. If the patient's hospice admission date was prior to the current openbilling month; the hospice will pay the fee-for-service pricing for the related/authorizedmedications that were dispensed to the patient during the hospice coverage period thatis prior to the current open billing month and per diem will not be charged retroactively.This policy applies to both alive and deceased patients.PROCEDURE:1. RM Policy 4.3, Admitting Patients and Census Management, describes thepolicy for admitting patients to HP and notifying HP of patient status changes.It states that patients must be admitted to HP on the date of admission tohospice.2. RM Policy 3.1, Monthly Billing Procedure, describes the process forcommunicating census changes to HP’s finance representative.Census/status changes should be communicated on the date they occur andcorrections for the previous month must be communicated to the HP financerepresentative between the 1 st - 5 th of each month.3. If the hospice does not admit a patient to HP on the date of admission tohospice, HP will back admit the patient to the hospice admission date.4. If the patient’s hospice admission date was during the current open billingmonth (ie, invoice for the month of the admission date is not final); HP willback admit the patient, per diem will be charged, and medications will bebilled to PBM Plus per the standard process.a. For example, nurse calls HP on September 10 th to admit patient JaneSmith with an admission date of August 3 rd . August invoice is not final, soHP back admits patient to August 3 rd and hospice is charged for per diemdays on August and September invoice and medications are billed to PBMPlus.5. If the patient’s hospice admission date was prior to the current open billingmonth (i.e., invoice for the month of the admission date is final); the hospicewill pay the fee-for-service pricing for the related/authorized medications thatwere dispensed to the patient during the hospice coverage period prior to theexcelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2013 excelleRx, Inc – Page 1 of 3RM 3.4.3 Backdated Admissions

current open billing month and per diem will not be charged retroactively. Theper diem will begin as of the 1 st of the current open billing month and themedications will be billed to PBM Plus per the standard process.a. For example, nurse calls HP on September 20 th to admit patient JaneSmith with an admission date of August 23 rd . HP will admit patient withAugust 23 rd admission date, but since the August invoice is final, anyrelated/authorized medications dispensed during the month of August willbe billed to the hospice as fee-for-service via the HP invoice. The hospiceis not billed for August per diem days. The per diem and standard billingprocess will start on September 1 st .6. This policy applies to both alive and deceased patients.7. If the patient has already been discharged or has expired, the hospice mustfax the backdated admission information and medication profile to the LTCFax Department at 877-265-6852. The Medication Management SupportCenter technicians and pharmacists will not be able to assist withdischarged/expired backdating requests.8. This backdating policy also applies to readmissions.9. The date that the invoice is finalized may vary from month to month, but isgenerally on the 15 th . This means that before the 15 th of the month, theprevious month’s invoice is still open. On/after the 15 th of the month, thecurrent month is the only open invoice/billing month.a. For questions on the date that a specific month’s invoice will be final,contact your HP finance representative or go to the Billing Notice sectionof www.hospicepharmacia.com.10. The following information applies to invoice disputes regarding admission ordischarge date changes.a. If a hospice reviews the invoice and determines that a patient’s admissiondate should have been an earlier date during that invoice month and thereview is conducted within the contractually agreed upon dispute periodtimeline as found at Exhibit 4 Billing of the Pharmacy Services Agreement,the hospice may communicate this adjustment to the HP financerepresentative. HP will adjust the admission date, charge per diem dayson the next invoice, and assist the LTC Pharmacy adjudicate anyrelated/authorized medications per the standard process. This also appliesto discharge dates that should have been after the original discharge datethat was provided by the hospice. Please note specific admission dateexamples below.b. Example 1: On November 21, 2011 the hospice reviews its October 2011invoice and realizes that patient Ms Smith’s admission date should havebeen 10/13/11 as opposed to 10/16/11 which is what the billable daysreport shows. Hospice contacts HP finance representative to correct theadmission date it originally provided. 11/21/11 is within the 30 day disputeperiod and dates may be adjusted.c. Example 2: On November 21, 2011 hospice reviews its August 2011invoice and realizes that it should have admitted patient Ms Smith to HPon 8/13/2011 rather than 8/16/2011. This review falls outside of theexcelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2013 excelleRx, Inc – Page 2 of 3RM 3.4.3 Backdated Admissions

contractual dispute period, so HP is unable to modify the originaladmission date provided by hospice. Hospice will not be billed at the perdiem rate for the three days in question. If needed, HP will be able toassist the LTC Pharmacy adjudicate related/authorized medications forthat three day period and Hospice will be billed FFS for those medications.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2013 excelleRx, Inc – Page 3 of 3RM 3.4.3 Backdated Admissions

Hospice PharmaciaResource ManualCopyright © 2012 excelleRx, IncSection IV: Hospice Pharmacia Pharmacy ServicesRM 4.1 Pharmaceutical Care: Adherence to Legal and Ethical Standards ofCareRM 4.2 Patient Protected Health Information (PHI)RM 4.3 Admitting Patients to Hospice Pharmacia and Patient CensusManagementRM 4.4 MUGs ® Development and ReviewRM 4.5 MUGs ® Distribution: Medications Available for DispensingRM 4.6 Determination of Medications Per Diem StatusRM 4.7 Provision of Medications that are Outside the Per DiemRM 4.8 Safe Medication Dispensing PracticesRM 4.9 Medication MonitoringRM 4.9.1 Anticoagulation TherapyRM 4.10 Class II PrescriptionsRM 4.11 Federal Law Regarding Faxing of Class II PrescriptionsRM 4.12 Prescriptions for Infants and ChildrenRM 4.13 Medication Labeling and Sample LabelRM 4.14 Medication Delivery & Cancelling a Medication RequestRM 4.15 Hospice PaksRM 4.15.1 Hospice Pharmacia SeizurePak UtilizationRM 4.16 Medication Expiration and Discard DateRM 4.17 On-call ServicesRM 4.18 Hours, Operation and Responsibility of Hospice Pharmacia On-callPharmacistRM 4.19 Use of HPRxCard for Local Medication AccessRM 4.20 Medication Recall and ShortagesRM 4.21 Adverse Drug ReactionsRM 4.22 Drug Utilization ReviewRM 4.23 Dangerous AbbreviationsRM 4.24 Sound Alike/Look Alike MedicationsRM 4.25 High Risk MedicationsRM 4.26 Unit Dosed Prefilled Oral SyringesRM 4.27 Fall Assessment and PreventionRM 4.28 Patient Information LeafletsRM 4.29 Infection ControlRM 4.30 Hospice Clinical and Administrative ReportsexcelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2014 excelleRx, Inc – Page 1 of 1Section 4 - HP Pharmacy Services

POLICY:Pharmaceutical Care: Adherence toLegal and Ethical Standards of CarePOLICY NUMBER:RM 4.1DEPARTMENT:Performance Improvement, LegalREVISION DATES:August 1, 2006;October 2, 2009POLICY:HP adheres to the code of professional and vocational standards as outlined inTitle 49, Chapter 27 for the Commonwealth of Pennsylvania, set forth by thedepartment of State Bureau of Professional and Occupational Affairs, StateBoard of Pharmacy. HP recognizes applicable established legal and ethicalstandards for pharmaceutical care and provides services accordingly. HPadheres to its own policies and does not discriminate or deny services to patientson the basis of race, creed or medical condition.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 1RM 4.1 Pharmaceutical Care - Adherence to Legal and Ethical Standards

POLICY:Patient Protected Health Information (PHI)REVISION DATES:August 1, 2006;September 1,2009;March 9, 2011POLICY NUMBER:RM 4.2DEPARTMENT:ITPOLICY:A profile is created and maintained for every patient served by HP. All data ismaintained, used, and transmitted in accordance with HIPAA regulations forsecurity, privacy and transmission. Employees of excelleRx receive mandatoryHIPAA compliance training during orientation and on a yearly basis.PROCEDURE:1. All pharmacy team members have access to PHI including patientdemographic data in the HP system as necessary to perform their job relatedduties.2. All electronic files (and any necessary hard copy notes) are secured andaccessible only to designated HP personnel and authorized hospicepersonnel for the purpose of providing care, billing or performing operationalfunctions directly related to care or billing.3. Patient-specific data remains the property of HP and may be reviewed by thehospice (or governing bodies and patients) upon written request filed by thehospice or patient.4. Patient-specific data is converted to population-based data by removing allpatient identifiers and is used by HP for outcome tracking without notificationto the hospice or the patient.5. Data is maintained as long as necessary or as required by law.6. Breeches in patient privacy must be reported to legal affairs at excelleRx,.After review the compliance department will notify the Hospice and patientwhen it is determined, that a HIPPA violation occurred.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 1RM 4.2 Patient PHI

POLICY:Admitting Patients to HP andPatient Census ManagementPOLICY NUMBER:RM 4.3DEPARTMENT:MMSC/FinanceREVISION DATES:August 1, 2006;October 1, 2009;January 30, 2010; April30, 2010;April 30, 2011POLICY:Patients must be admitted to HP on the date of admission to the hospice byphone, through HP’s Online Tools or through hospice software that interfaceswith HP. Once a patient has been admitted, a palliative care pharmacist willcollaborate with the nurse to create an appropriate medication care plan and anefficient medication access plan. When patients have a change in status (e.g.,are discharged, expire, move into/out of a facility, or move between teams withina hospice), it is important to notify HP by phone or through HP’s Online Toolswithin 3 days of the status change.A patient may be referred to HP and provided medication access up to 3 daysbefore the actual hospice admit date. This enables medication to be provided atthe home when a patient is discharged from the hospital or facility. If the patientis not admitted, medications can be destroyed and the partnering hospice isbilled fee-for-service for medications dispensed.PROCEDURE:1. Admitting a Patient to HPOption 1: By phone.Call HP and verbally relay demographic information to a MMSC pharmacytechnician.Option 2: Through HP’s Online Tools.Enter the demographic data online accessing www.hospicepharmacia.com.Option 3: Through Hospice Interface (HPConnect).HPConnect is an automatic transfer of data from your hospice’s system toHospice Pharmacia. Interfaces transfer patient demographic data. (Medicationscan be profiled online by the hospice or through verbal communication with HP).Hospice admissions are added to HP as referrals, not active HP admissions. Toactivate the referral, please contact HP upon patient admission.Patient InformationPlease have the following information available when enrolling a patient:1. Patient’s first and last name, mailing address (no PO Boxes), phonenumber, date of birth, social security number, and ethnicity2. Patient location (Home Care or Facility)3. If applicable, name of facility (ALF/LTC)excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 1RM 4.3 Admitting Pts to HP and Pt Census Mgmt

4. Name of pharmacy dispensing hospice medications (HP or FacilityPharmacy)5. Primary hospice qualifying (admitting) diagnosis (including ICD-9 code ifavailable)6. Secondary diagnoses and/or sites of metastases for patients with cancer7. Detailed allergy history (including medications, type of reaction, andseverity)8. Primary physician’s first and last name, phone/fax numbers9. Names of the primary and admitting nurses10. Hospice Team (e.g., North, South)11. Prescriber to contact for Schedule II medications (first and last name,phone/fax numbers)12. Special requests (bubble packing/signature required/Spanish directions)Once the demographic data is entered into HP’s system, the certified pharmacytechnician will enter the following:1. Complete list of medications (hospice/non-hospice, OTC, herbals)a. Indication for useb. Indication for hospice coverage2. Non-pharmacologic therapies (e.g., oxygen therapy, wound care)The palliative care pharmacist will then collaborate with the nurse to verify anddocument the following:1. Complete list of medications (hospice/non-hospice, OTC, herbals)a. Indication for useb. Indication for hospice coverage2. Non-pharmacologic therapies (e.g., oxygen therapy, wound care)3. Patient assessment information4. Medication administration issues, such as the presence of an IV line,feeding tube, or ostomy5. Patient-specific data regarding end-of-life statusThe pharmacist will document this information in the patient’s Hospice Pharmaciarecord. The hospice nurse is strongly encouraged to document the sameinformation in the patient’s hospice record.Setting Patient ExpectationsOnce the patient is admitted to HP, the hospice should explain the pharmacyservices to the family/caregiver. The hospice should inform patients residing athome that most medications will arrive via national courier, but urgentmedications may be obtained from a community pharmacy. It is recommendedthat the patient/family select a preferred community pharmacy from the HPFlagship Pharmacy Network created specifically for your hospice. Identify theperson who will pick up medications from the community pharmacy when needed(that person should know the pharmacy’s hours), and establish a back-up plan incase of emergency. Communicate this plan to HP.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 2 of 2RM 4.3 Admitting Pts to HP and Pt Census Mgmt

2. Changes in StatusTransferring PatientsWhen patients transfer teams within a hospice, it is important to notify HP. Teamtransfers (e.g., from team 953 to 954 or from the North Team to the South Team)may be communicated by:a. Contacting HP to verbally relay the transfer to an HP pharmacy technicianb. Transferring on Secure Client Access (formerly Xeris ® ) by entering thepatient’s profile and clicking the ‘T’ icon to the left of the patient’s name.Discharging PatientsThe status of a patient often changes during the hospice enrollment period. HPmust be notified of these changes. Hospices must communicate with HPwhenever a patient moves. Examples include:• Changes of address• Moves from home care to a facility• Hospitalizations• Respite care• Revoking or discharging from hospice service• DeathsTimely transmission is important. Patients remain active in Secure Client Access(formerly Xeris ® ) from the time of admission to the time of discharge, whichdirectly impacts patient census and per diem charges.Please enter discharge data within 3 days of the date of discharge from thehospice. The hospice is responsible for all per diem charges and outside perdiem medication costs if patients are not discharged from HP’s service.The options for discharging patients include the Automated Refill & DischargeSystem and Secure Client Access (formerly Xeris ® )a. Automated Refill & Discharge System (ARDS)1. Use the ARDS from the phone menu (touch-tone caller’s select option 2).2. Enter the patient’s Social Security number or telephone number (includingarea code).3. Enter your 4-digit PIN4. Choose option 2 to discharge a patient5. Enter the 8-digit month, day, and year of discharge (e.g., 01/25/2005).6. Press zero for an operator or “#” to disconnect.b. Secure Client Access1. Search for the patient by entering his/her name or social security numberusing the Find Patients linkexcelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 3 of 3RM 4.3 Admitting Pts to HP and Pt Census Mgmt

2. Select the patient from the resulting list.3. Click on the Discharge/Deceased icon (to the left of the patient’s name)4. Select either “discharge” or “deceased.”5. Select the correct date from the calendar.6. Click “update” to save.If a patient has already been discharged, and he or she expires, please updatethe profile in Secure Client Access (formerly Xeris ® ) by clicking the Deceasedicon in the patient profile. Please do not readmit the patient in Secure ClientAccess (formerly Xeris ® ) to then perform a discharge/decease notification.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 4 of 4RM 4.3 Admitting Pts to HP and Pt Census Mgmt

POLICY:MUGs ® Development and Review ProcessPOLICY NUMBER:RM 4.4DEPARTMENT:Clinical SupportREVISION DATES:August 1, 2006September 30, 2009October 12, 2009January 30, 2010POLICY:The Medication Use Guidelines (MUGs ® ) are an ever-changing clinical and costreference source for hospice pharmaceutical care. Content of the MUGs isdeveloped and reviewed continuously through a Pharmacy and Therapeutics(a.k.a. MUGs Development) Committee.PROCEDURES:1. Content of the MUGs is selected for development by members of the MUGsDevelopment Committee, including the Editor-in-Chief of the MUGs, based ona compilation of input received from Hospice Pharmacia (HP) staff andhospice partners, medication utilization data obtained from HP dispensingreports, patient demographic data obtained from HP administrative reports,and constant review of the biomedical literature.2. Once the content has been selected for development, HP clinical pharmacists(a.k.a. Development Clinicians) are contracted to systematically review thecontent, which may be a general topic (e.g., management of insomnia) or aspecific medication (e.g., zolpidem), and produce a summary of their findingsas well as their recommendation(s).3. Members of the MUGs Development Committee review the findings andrecommendation(s) of the Development Clinicians and subsequentlydetermine whether additional information is needed to make a decisionregarding the topic or medication. If additional information is needed, theDevelopment Clinician is asked to continue his/her review until sufficientinformation is provided. If additional information is not needed or oncesufficient information is provided, a summary of the Development Clinician’sfindings is sent out to HP hospice partners for peer review.4. Peer reviewers include administrators, medical directors, physicians, andnurse practitioners, directors of nursing, staff nurses and consultantpharmacists practicing in hospice and palliative care who express an interestin participating in the development of the MUGs. Peer reviewers arecontacted by the Editor-in-Chief of the MUGs and asked to critically reviewthe Development Clinician’s findings and provide comments andrecommendation(s). The peer review process is completed in-kind.5. Members of the MUGs Development Committee subsequently review thecomments and recommendations of the peer reviewers.6. Based on the findings the Development Clinician as well as the commentsand suggestions of the peer reviewers, members of the MUGs DevelopmentCommittee make a recommendation regarding the topic or medication. Therecommendation may include, but is not limited to, updating the topic in theexcelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 1RM 4.4 MUGs Development and Review Process

MUGs, adding a medication to the MUGs, or removing a medication from theMUGs. The final decision regarding a specific topic is made by the Editor-in-Chief of the MUGs. The final decision regarding a specific medication is madeby the MUGs Executive Committee.7. To aid in the decision-making process for medications, the Editor-in-Chief ofthe MUGs prepares a summary of the MUGs Development Committee’srecommendation along with other pertinent information such as medicationutilization and cost data for the MUGs Executive Committee. The MUGsExecutive Committee reviews the information provided by the Editor-in-Chiefand either requests additional information or makes a final decision.Additional information is subsequently provided by the Editor-in-Chief of theMUGs.8. Once final decisions regarding topics and medications have been approved,the Editor-in-Chief updates the content of the MUGs. The content issubsequently disseminated to HP staff and hospice partners.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 2 of 2RM 4.4 MUGs Development and Review Process

POLICY:MUGs ® Distribution: MedicationsAvailable for DistributionPOLICY NUMBER:RM 4.5DEPARTMENT:Clinical SupportREVISION DATES:August 1, 2006April 30, 2010April 20, 2012POLICY:The Medication Use Guidelines (MUGs ® ) are an ever-changing clinical and costreference source for hospice pharmaceutical care. HP provides online (i.e.,electronic) access to the MUGs to each of its partnering hospices.PROCEDURES:1. The MUGs are specifically designed to assist clinicians in determining themost appropriate and cost-effective pharmacotherapies to manage pain andpalliate symptoms frequently experienced by hospice patients. Theinformation presented in the MUGs is derived from medical literature and fromprescribing trends in patient medication utilization data over millions of patientdays.2. The MUGs are continuously reviewed for content and periodically updated.See the MUGs Development and Review Policy (see policy RM 4.4 – MUGsDevelopment and Review) for more information.3. The MUGs are available to all HP pharmacy personnel and all partneringhospice’s healthcare staff. Training is available for all staff and hospicepersonnel on how to use this resource.4. Included in the MUGs is a list of medications included in the HP per diem (ifrelated to the patient’s terminal diagnosis) and available for dispensing. Formedications not on the list, refer to the Medication Authorization Process (seepolicy RM 4.6 – Medication Authorization Process).5. A more detailed list of medications, strengths and dosage forms that areavailable for dispensing is located in Secure Client Access (formerly Xeris ® ).6. If a medication is not available to be dispensed due to medication shortages,the pharmacy staff will inform the hospice nurse and/or patient of the shortageand send a limited quantity of a supply, if available. The remaining amount ofthe prescription will be dispensed to the patient when the medication supply isobtained by HP. If no medication is available to dispense, the MMSC and thehospice nurse will determine an alternate way of obtaining the medicationuntil HP can obtain a supply.7. If a medication is unavailable from a wholesaler or manufacturer, allpharmacy personnel and hospice partners are notified by broadcast faxand/or email. They are notified of the medication outage and provided withalternative medications, formulations or other means for obtaining themedication until HP is able to obtain the medication.8. In the event of a disaster and HP is unable to provide access to medications,HP will always provide access to medications at community pharmaciesthrough the HPRxCard. The HPRxCard is a prescription card to be used atexcelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 2RM 4.5 MUGs Distribution- Medications Available for Dispensing

community pharmacies for billing hospice-related medications to HP. Moreinformation may be found in policy RM 1.4 Emergency Response andBusiness Interruption.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 2 of 2RM 4.5 MUGs Distribution- Medications Available for Dispensing

POLICY:Determination of Medication Per Diem StatusPOLICY NUMBER:RM 4.6DEPARTMENT:Clinical SupportREVISION DATES:August 1, 2006;June 26, 2007;September 30, 2009October 12, 2009POLICY:Medications are included in the Hospice Pharmacia (HP) per diem based on thepatient’s primary diagnosis (a.k.a. hospice-qualifying terminal diagnosis).Confirmation of the primary diagnosis and determination of which medicationsare related to the primary diagnosis are the responsibilities of the hospice.Determination of medication per diem status for an individual patient is theresponsibility of HP.PROCEDURES:1. Upon admission of a patient to the HP system and as warranted thereafter,the hospice informs HP staff of the patient’s primary diagnosis and whichmedications are related to the primary diagnosis.2. The patient’s primary diagnosis is entered into the HP system using theInternational Classification of Diseases, Ninth Revision, Clinical Modification(ICD-9-CM) codes. The hospice’s decision about which medications arerelated to the primary diagnosis is documented in the patient’s electronicmedical record.3. Hospice Pharmacia determines which medications are included in the HP perdiem based on the following diagnosis-related inclusion codes:A: All symptoms related to the patient’s hospice-qualifying terminaldiagnosis as determined by the hospice.C: Cancer and HIV/AIDS diagnoses, defined as ICD-9-CM codes 042 or140-239.H: Heart (cardiac) diagnoses, defined as ICD-9-CM codes 391-429 or440-459.L: Lung diagnoses, defined as ICD-9-CM codes 460-519.O: Other diagnoses that do not fall into one of the other diagnosis-relatedinclusion codes (e.g., cerebrovascular disease, defined as ICD-9-CMcodes 430-438; cystic fibrosis, defined as ICD-9-CM code 277).4. In addition, some medications in the Medication Use Guidelines (MUGs ® )have criteria that must be met to be included in the HP per diem. Thesecriteria are specified in the MUGs.5. Based on the diagnosis-related inclusion codes and, in some cases, thecriteria specified in the MUGs, medications may fall into one of threecategories:• Related to the patient’s primary diagnosis and medication is included inthe HP per diem; or,• Related to the patient’s primary diagnosis but medication is outside theHP per diem; or,excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 1RM 4.6 Determination of Medication Per Diem Status

• Not related to the patient’s primary diagnosis and, therefore,medication is outside the HP per diem.6. Hospice Pharmacia staff communicates the medication per diem status tohospice staff and collaborates with hospice staff to identify the patient’smedication needs as outlined in RM 4.8. If the medication is outside the HPper diem but needed as determined by the hospice, HP provides themedication as outlined in RM 4.7.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 2 of 2RM 4.6 Determination of Medication Per Diem Status

POLICY:Provision of Medications that areOutside the Per DiemPOLICY NUMBER:RM 4.7DEPARTMENT:Clinical SupportREVISION DATES:August 1, 2006;September 30, 2009April 30, 2010April 12, 2011POLICY:The hospice determines the patient’s primary diagnosis (a.k.a. hospice-qualifyingterminal diagnosis) and which medications are related to the primary diagnosis.Hospice Pharmacia (HP) determines medication per diem status as outlined inRM 4.6. Hospice Pharmacia dispenses medications outside the per diem butrequires prior authorization from the hospice. Medications authorized to bedispensed outside the per diem are charged directly to the hospice. The chargefor the medication is the responsibility of the hospice and HP does not adjudicateclaims for medications outside the per diem through third-party insuranceproviders.PROCEDURES:A medication may be related to the patient’s primary diagnosis, as determined bythe hospice, but outside the HP per diem for three main reasons: (1) themedication is included in the Medication Use Guidelines (MUGs ® ) under adiagnosis-related inclusion code that does not match the code assigned to thepatient’s primary diagnosis, (2) the medication is included in the MUGs but it isprescribed in a manner that does not follow the specified criteria, or (3) themedication is not included in the MUGs. According to federal regulations, thehospice is responsible for covering all medications that are needed to care for thepatient’s primary diagnosis and related conditions. These regulations are apartfrom the hospice’s contractual arrangement with HP. Hospice Pharmacia followsthe procedure outlined below for providing medications related to the patient’sprimary diagnosis but outside the HP per diem.Medications Related to the Patient’s Primary Diagnosis1. Upon initial request to dispense a medication that is related to the patient’sprimary diagnosis but outside the per diem, an HP pharmacist assists hospicestaff in selecting an alternative medication that is included in the HP per diem.If there is no alternative medication included in the HP per diem for aparticular symptom or condition that the hospice has determined is related tothe patient’s primary diagnosis, an HP pharmacist assists hospice staff inselecting the most cost-effective and clinically appropriate medicationavailable.2. If hospice staff requests a medication to be dispensed outside the per diem,an HP pharmacist will request prior authorization. Prior authorization may begranted by hospice staff making the request or pre-determined hospice staffwith authority to request that a medication is dispensed outside the per diem.In either case, determination of personnel with prior authorizationaccountability is the responsibility of the hospice. The hospice communicatesexcelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 1RM 4.7 Provision of Outside of Per Diem Medications

the name(s) of personnel with prior authorization accountability to HP throughtheir Client Relations Liaison (CRL) and updates the name(s) as necessary.3. Prior authorization may be granted for a one-time dispense of the medicationor for continual dispensing of the medication.4. When an HP pharmacist receives prior authorization to dispense a medicationoutside the per diem, he/she will document the name of the requestor in thepatient’s electronic record; if the requestor is not the pre-determined hospicestaff with authority to request that a medication is dispensed outside the perdiem, the pharmacist will also document the name of the person granting priorauthorization. The pharmacist will document whether prior authorization hasbeen granted for a one-time dispense of the medication or for continualdispensing of the medication.5. Once a medication is dispensed, defined as picked up by U.S. courier servicefrom an HP dispensing facility, the charge for the medication and any otherassociated charges is final; HP does not credit the hospice for refused orreturned packages.6. Hospice Pharmacia provides a report of medications dispensed and chargedoutside the per diem to the hospice with every invoice or bill. These reportsare also available to the hospice through HP’s proprietary system, SecureClient Access (formerly Xeris ® ).Medications that are not related to the patient’s primary diagnosis, as determinedby the hospice, are outside the HP per diem. The hospice is not responsible forcovering medications that are not needed to care for the patient’s primarydiagnosis and related conditions. Hospice Pharmacia follows the procedureoutlined below for providing medications not related to the patient’s primarydiagnosis.Medications Not Related to the Patient’s Primary Diagnosis1. Upon initial request to dispense a medication that is not related to thepatient’s primary diagnosis as determined by the hospice, an HP pharmacistinstructs hospice staff to contact the patient’s local (community) pharmacy toobtain the medication.2. Hospice Pharmacia makes every reasonable effort to support the needs ofthe patient. Therefore, if the patient is unable to obtain the medication throughhis/her local pharmacy provider, HP dispenses the medication outside the perdiem but requires prior authorization from the hospice.3. At this point, the steps for providing a medication not related to the patient’sprimary diagnosis are the same as steps 2 through 6 outlined above forproviding a medication related to the patient’s primary diagnosis but outsidethe HP per diem.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 2 of 2RM 4.7 Provision of Outside of Per Diem Medications

POLICY:Safe Medication Dispensing PracticesPOLICY NUMBER:RM 4.8DEPARTMENT:MMSC and CRxPREVISION DATES:August 1, 2006;December 22, 2008;October 12, 2009April 30, 2010July 30, 2010POLICY:HP staff adheres to medication dispensing guidelines, including the review ofeach prescription for accuracy and appropriateness; to maintain patient safety.PROCEDURES:1. The pharmacy technician affirms the identity of the patient with the healthcareprovider (i.e. hospice nurse or prescriber) and transcribes the request. Newrequests are transferred to a pharmacist.2. The pharmacist verifies the name and address from the patient profile alongwith the patient’s primary diagnosis and allergies to ensure the correct patientand delivery location.3. The healthcare provider and pharmacist prepare a medication care plan forthe patient.4. Prior to dispensing, prescription requests taken verbally from a licensedhealthcare provider are verified by a licensed pharmacist. The pharmacistreads back the medication request to the healthcare provider to confirmaccuracy.5. When required, the pharmacist verifies the authenticity of the prescription withthe prescriber.6. A Drug Utilization Review (DUR) is performed when verifying the prescriptionrequests. Additional information on DURs can be found in RM 4.22: DrugUtilization Review.7. If an issue is identified with the request, the healthcare provider (i.e. hospicenurse or prescriber, as appropriate) is contacted for clarification prior todispensing.8. Based on the patient’s status, the healthcare provider and pharmacistdetermine the appropriate supply of medication to dispense for the patient.Generally, the days supply ranges from 7-15 days based on the patient’sstatus.9. Other precautionary measures are in place to ensure safe medicationdispensing:a. “Signature required” is available for delivery of medication where there iscause for concern in leaving the package without documented acceptanceat the delivery location. This is used if there is concern regardingdiversion, access to the package by children or pets, or other risks topublic health and safety.b. Bubble packing is available for facilities and/or patients needingassistance with keeping track of quantities/inventories.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 1RM 4.8 Safe Medication Dispensing Practices

c. A diversion indicator flag is set in a patient’s profile if the nurse,pharmacist or other healthcare provider believes there is or may besuspicion of medication diversion. If the diversion flag is in a patient’sprofile, the pharmacist will proceed with precautionary measures fordispensing, such as limiting the days supply of medication, shipping themedication to an alternate location or another procedure decided upon bythe nurse, pharmacist and/or supervisor.10. All prescription dispensing information including shipping status is read backto the caller to confirm accuracy of the care plan. Then, the medicationrequest is processed and shipped.11. If Hospice Pharmacia (HP) is unable to dispense the full expected quantity ofa medication to fulfill a prescription, the hospice nurse will be notified. Oncethe medication is in stock, HP will dispense the medication as written in theprescription. If it takes longer than 2 days to procure the medication, an HPpharmacist will review the patient's medication profile in Secure ClientAccess (formerly Xeris ® ) prior to dispensing to verify that the prescription isstill active and has not been discontinued.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 2 of 2RM 4.8 Safe Medication Dispensing Practices

POLICY:POLICY NUMBER:RM 4.9Medication MonitoringDEPARTMENT:MMSCREVISION DATES:August 1, 2006;December 22, 2008;October 12, 2009,July 22, 2013POLICY:HP staff collaborates with the hospice nurse and prescriber to ensure that eachpatient’s symptoms and medication response are monitored.PROCEDURES:1. Upon admission and with each change in clinical status of a patient, ahospice nurse completes an assessment.2. The nurse communicates the assessment to an HP pharmacist. Based onthe nurse’s assessment of the patient’s needs, the HP pharmacist reviews thesymptoms, symptom severity, symptom frequency, amount of medicationtaken (if applicable) and the effectiveness of pharmacologic and nonpharmacologicinterventions.3. Based on the information from the assessment and the patient’s medicalhistory, the pharmacist and nurse will collaborate to formulate a medicationcare plan after consideration of hospice and palliative care literature andevidence-based guidelines. The nurse is responsible for communicating thecare plan to the prescriber. Once the care plan is accepted or modified by theprescriber, the nurse will in turn relay the prescription request to thepharmacist for dispensing.4. The prescription request is reviewed for accuracy, completeness andappropriateness, per procedure, prior to dispensing. More information on thisreview can be found in policy RM 4.22: Drug Utilization Review.5. The pharmacist provides any medication education or monitoring parametersto the nurse, as necessary.6. If the medication is ineffective or causes an adverse event, the nurse will orshould relay the information to the pharmacist. The pharmacist will care planwith the nurse and determine an appropriate course of action based on theadverse event, which may include discontinuing the medication. When anadverse event is recorded, the severity and reaction is documented. See theAdverse Drug Reaction policy (RM 4.21) for more detail.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2013 excelleRx, Inc – Page 1 of 1RM 4.9 Medication Monitoring .doc

POLICY:POLICY NUMBER:RM 4.9.1Anticoagulation TherapyDEPARTMENT:MMSC/Performance ImprovementREVISION DATES:December 1, 2008;December 22, 2008;May 5, 2009;October 12, 2009May 28, 2010;July 20, 2010POLICY:HP is committed to collaborating with its partnering hospices to ensure the safeuse of anticoagulation therapy. All anticoagulant orders entered in thedispensing system and products selected and labeled must be verified foraccuracy prior to dispensing and delivery to the patient. As a part of a completereview of all of the patient’s medications, pharmacists will advise the hospicenurse of any suggested laboratory monitoring for patients prescribedanticoagulation therapy, regardless of the therapy’s relation to the hospicequalifying diagnosis.PROCEDURE:I. INR Monitoring and Warfarin Therapya. For patients prescribed warfarin, the hospice nurse will be asked toconvey the INR value to the pharmacist at the start of warfarin therapy andat a minimum, every 4 weeks thereafter. Warfarin dispensed without anINR will be billed outside per diem.b. The HP pharmacist will document the INR in the patient’s HP clinicalrecord.c. HP pharmacists will confer with the nurse about abnormal INR values (e.g.outside of target range). The hospice nurse is responsible for conveyingthe abnormal value to the attending physician and obtaining anddocumenting follow-up orders in the hospice clinical record.II. Other Anticoagulants: The hospice shall ensure appropriate monitoring for allother anticoagulants, as clinically indicated.III. HP pharmacists will perform a drug utilization review and interactionscreening as outlined in policy RM 4.22.IV. Dispensinga. In the CRxP, all warfarin doses 5 mg and higher per day will be verified by2 pharmacists and compared to original prescription prior to dispensing.b. Enoxaparin doses higher than 40 mg per day and dalteparin doses higherthan 5000 International Units per day will follow this same procedure.c. When available, HP will dispense anticoagulation therapy in pre-filledsyringes. Pre-loaded syringe products specifically designed for pediatricpatients, when available, will be used for children.d. Warfarin is dispensed in a unit dose form for IPU patients.e. The hospice should obtain anticoagulation pre-mixed infusion bags fromtheir infusion provider.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 1RM 4.9.1 Anticoagulation Therapy

f. Additional information on preventing wrong product selection can be foundin policy RM 4.24 List of Look-Alike/Sound-Alike Drugs, section 3.V. Educationa. HP pharmacists are educated on anticoagulation safety.b. Patient information leaflets (PILs) will accompany the first dispensedprescription for all anticoagulants to inform the patient, caregivers, andstaff of the importance of follow-up monitoring, compliance issues, dietaryrestrictions, and potential for adverse drug reactions and interactions.c. Hospice Pharmacia has provided the Warfarin Patient Information Leaflet(PIL) for your convenience and as referenced in this policy. For additionalPILs information or further assistance please see policy RM 4.27 PatientInformation Leaflets, or email PILs@excellerx.com.VI. Quality Improvement Monitoringa. Anticoagulation safety practices, such as documentation of patient INRvalues, will be evaluated on at least a yearly basis by HP’s PerformanceImprovement team.b. Corrective action will be taken to improve practices as indicated.c. Information on HP’s Performance Improvement program can be found inRM Section 5 policies.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 2 of 2RM 4.9.1 Anticoagulation Therapy

POLICY:POLICY NUMBER:RM 4.10Class II PrescriptionsDEPARTMENT:Corporate ComplianceREVISION DATES:August 1, 2006;March 1, 2008;September 1, 2009June 30, 2012POLICY:Creating a care plan often involves CII medications which require an authorizedvalid prescription prior to dispensing a new or renewed medication. HP willdispense the medication with a valid prescription in accordance with applicablestate and federal regulationsPROCEDURE:Class II Prescriptions Dispensed by a Community Pharmacy for HP1. It is the responsibility of the prescribing physician to provide thedispensing pharmacy with a verbal prescription, faxed prescription and/orhard copy prescription for the C-II medication prior to dispense. State andfederal laws and regulations must be followed. The hospice nursecontacts the physician’s office to request a prescription to be attainable atthe designated pharmacy for dispensing.Class II Prescriptions Dispensed by Hospice Pharmacia1. HP will dispense a limited quantity of C-II medications in 15-day supplyincrements as outlined in the partnering agreement. This partial filling ofmedication will continue until the prescription quantity is depleted.2. Released C-II medications cannot be returned to the pharmacy even incases where the medication is not used or the patient has expired.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 1RM 4.10 C-II Prescriptions.doc

TITLE:Federal Law Regarding Faxing of C-II PrescriptionsTitle 21 CFR Section 1306.11REVISION DATES:August 1, 2006September 1, 2009DOCUMENT NUMBER:RM 4.11DEPARTMENT:Corporate ComplianceCode of Federal RegulationsCONTROLLED SUBSTANCES LISTED IN SCHEDULE IISection 1306.11 Requirement of prescription.(a) A pharmacist may dispense directly a controlled substance listed in Schedule II,which is a prescription drug as determined under the Federal Food, Drug, andCosmetic Act, only pursuant to a written prescription signed by the practitioner, exceptas provided in paragraph (d) of this section. A prescription for a Schedule II controlledsubstance may be transmitted by the practitioner or the practitioner's agent to apharmacy via facsimile equipment, provided that the original written, signed prescriptionis presented to the pharmacist for review prior to the actual dispensing of the controlledsubstance, except as noted in paragraph (e), (f), or (g) of this section. The originalprescription shall be maintained in accordance with Sec. 1304.04(h) of this chapter.(b) An individual practitioner may administer or dispense directly a controlled substancelisted in Schedule II in the course of his professional practice without a prescription,subject to Sec. 1306.07.(c) An institutional practitioner may administer or dispense directly (but not prescribe) acontrolled substance listed in Schedule II only pursuant to a written prescription signedby the prescribing individual practitioner or to an order for medication made by anindividual practitioner which is dispensed for immediate administration to the ultimateuser.(d) In the case of an emergency situation, as defined by the Secretary in Sec. 290.10 ofthis title, a pharmacist may dispense a controlled substance listed in Schedule II uponreceiving oral authorization of a prescribing individual practitioner, provided that:(1) The quantity prescribed and dispensed is limited to the amountadequate to treat the patient during the emergency period (dispensingbeyond the emergency period must be pursuant to a written prescriptionsigned by the prescribing individual practitioner);(2) The prescription shall be immediately reduced to writing by thepharmacist and shall contain all information required in Sec. 1306.05,excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 2RM 4.11 Fed Law Regarding Faxing of CII Prescriptions

except for the signature of the prescribing individual practitioner;(3) If the prescribing individual practitioner is not known to the pharmacist,he must make a reasonable effort to determine that the oral authorizationcame from a registered individual practitioner, which may include acallback to the prescribing individual practitioner using his phone numberas listed in the telephone directory and/or other good faith efforts to insurehis identity; and(4) Within 7 days after authorizing an emergency oral prescription, theprescribing individual practitioner shall cause a written prescription for theemergency quantity prescribed to be delivered to the dispensingpharmacist. In addition to conforming to the requirements of Sec.1306.05, the prescription shall have written on its face "Authorization forEmergency Dispensing," and the date of the oral order. The writtenprescription may be delivered to the pharmacist in person or by mail, but ifdelivered by mail it must be postmarked within the 7 day period. Uponreceipt, the dispensing pharmacist shall attach this prescription to the oralemergency prescription which had earlier been reduced to writing. Thepharmacist shall notify the nearest office of the Administration if theprescribing individual practitioner fails to deliver a written prescription tohim; failure of the pharmacist to do so shall void the authority conferred bythis paragraph to dispense without a written prescription of a prescribingindividual practitioner.(5) Central fill pharmacies shall not be authorized under this paragraph toprepare prescriptions for a controlled substance listed in Schedule II uponreceiving an oral authorization from a retail pharmacist or an individualpractitioner.(g) A prescription prepared in accordance with Sec. 1306.05 written for aSchedule II narcotic substance for a patient enrolled in a hospice care programcertified and/or paid for by Medicare under Title XVIII or a hospice program whichis licensed by the state may be transmitted by the practitioner or thepractitioner's agent to the dispensing pharmacy by facsimile. The practitioner orthe practitioner's agent will note on the prescription that the patient is a hospicepatient. The facsimile serves as the original written prescription for purposes ofthis paragraph (g) and it shall be maintained in accordance with § 1304.04(h) ofthis chapter.[36 FR 7799, Apr. 24, 1971, as amended at 36 FR 18733, Sept. 21, 1971.Redesignated at 38 FR 26609, Sept. 24, 1973 and amended at 53 FR 4964, Feb. 19,1988; 59 FR 26111, May 19, 1994; 59 FR 30832, June 15, 1994; 62 FR 13964, Mar.24, 1997; 65 FR 45713 July 25, 2000; 68 FR 37410, June 24, 2003]excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 2 of 2RM 4.11 Fed Law Regarding Faxing of CII Prescriptions

POLICY:Prescriptions for Infants and ChildrenREVISION DATES:August 1, 2006;September 21, 2009April 30, 2010POLICY NUMBER:RM 4.12DEPARTMENT:MMSCPOLICY:The dosage of each medication prescribed for infants and children (i.e., patientswho are less than 18 years, or who weigh less than 40 kg) will be checkedagainst standard pediatric references to ensure appropriateness for the child’sweight and/or body surface area.PROCEDURES:1. The healthcare professional will provide the pharmacist with weight, age(date of birth) and height if necessary. The current weight (and height) shouldbe documented in the encounter notes and the internal notes.2. For any patient under the age of 18, a notification will automatically appear inthe patient’s profile to alert the pharmacy staff.3. The dosage of a prescribed medication shall be calculated as appropriate tothe patient and the medication being prescribed (i.e., mg/kg/day, mg/kg/dose,mg/m 2 /day).4. When the pediatric dose significantly deviates (+/- 10%) from therecommended dose, or, in the pharmacist’s professional judgment, needsclarification, the prescriber shall be contacted. In the event the prescriber hasbased the medication dosage on current literature, the pharmacist will attemptto obtain the source of the information and document it in the progress notes.5. Doses that exceed the maximum adult dosage for any medication should beclearly documented as to why the dose is so excessive.6. A pediatric measuring device is dispensed as necessary. Theparent/caregiver should be counseled by the hospice nurse on 1) the effectsand use of the prescribed medication, and 2) the appropriate use andcleaning of the measuring device.7. It will be necessary to obtain current weight for the child over time as the childgains or loses weight. With each follow-up nursing encounter, the pharmacistwill verbally confirm patient height and weight and document the updates inSecure Client Access (formerly Xeris ® ) .excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 1RM 4.12 Prescriptions for Infants and Children

POLICY:Medication Labeling and Sample LabelPOLICY NUMBER:RM 4.13DEPARTMENT:CRxPREVISION DATES:August 1, 2006;December 22, 2008;May 18, 2009;July 20, 2010; April 20,2011POLICY:All medications shall be labeled in observance with current federal laws and statelaws where the dispensing pharmacy is located.PROCEDURES:1. All products dispensed by the pharmacy shall bear a label including thefollowing variables:a. Pharmacy name;b. Pharmacy address;c. Pharmacy telephone number;d. Date dispensed;e. Patient's full name;f. Pharmacy's identifying serial number of the prescription;g. Name of the medication or product;h. Strength of the medication or product;i. Medication description: color, shape, form and imprint codej. Amount dispensed;k. Medication or product's expiration date;l. Directions for use;m. Indication;n. Prescriber's name; ando. Any other pertinent information or accessory cautionary labels.2. Infusions shall bear a label visible when hanging which identifies, in additionto the variables listed above:a. The scheduled date of administration;b. The scheduled time of administration; andc. The rate of administration (where rate is clinically important).3. Compounded Medications:a. All compounded medications containing two or more active medicationingredients require a label stating that the name and quantity of eachingredient.b. The ingredient label shall be affixed to the final packaging and verified byan HP checking pharmacist.4. Special arrangements may be made for patients who require foreignlanguage labels. HP may print prescription labels in Spanish. Additionalassistance for other languages is available upon request.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 1RM 4.13 Medication Labeling and Sample Label b

HP Sample LabelsSample Compound Ingredient LabelIngredients: lidocaine2%viscous/diphenhydramine12.5mg/5ml/alamag 1:1:1excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 2 of 2RM 4.13 Medication Labeling and Sample Label b

POLICY:Medication Delivery & Cancelling a MedicationRequestPOLICY NUMBER:RM 4.14DEPARTMENT:CRxP and MMSCREVISION DATES:August 1, 2006;September 1, 2009April 30, 2010POLICY:HP shall use a national contracted courier for standard shipping of medications topatients.PROCEDURES:1. The HP pharmacist or technician works with the nurse to assess the patientto determine the most appropriate method for medication access anddelivery. This may include same day access through a community pharmacyor by HP’s dispensing pharmacy and delivered by a national courier.2. The delivery assessment includes a review of the patient environment(potential for diversion; potential for public health concerns; potential forproduct access by minors, etc.). For more information, please see policy RM4.8 – Safe Medication Dispensing Practices.3. Patient mailing information, including street address and telephone numbers,is placed in the courier labeling system by pharmacy staff and verifiedverbally with the nurse. Post office boxes are not considered a deliveryaddress by national couriers.4. Approved shipping materials are used. All medications are secured andprotected against breakage.5. Exterior packaging will not contain visible signs of HP or the packagecontents. This is done to protect patient confidentiality and meet regulatoryrequirements.6. If a patient or member of the patient’s family refuses a package, HP willaccept the unopened returned package.Delivery Schedule7. Packages are scheduled for Standard or Second Day delivery. This mayinclude ground or air transport. Standard packages can be expected toarrive on the next business day before 8 pm in most areas. Second daypackages can be expected to arrive on the second business day, but mayarrive on the next business day.8. Standard delivery is Monday through Friday. Special service delivery isavailable on Saturdays in certain areas.9. Temperature sensitive products are shipped for standard delivery with coldpacks, and therefore are not available for shipments on Fridays orSaturdays. Infusions are shipped standard delivery.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 1RM 4.14 Medication Delivery

Canceling a Shipment10. A hospice staff member or prescriber may call and request that HP void orcancel a medication shipment under the following circumstances, providedthat the shipment has not yet been delivered to the patients home:a. A patient has been discharged from the hospice’s services or has expiredb. To prevent a QA incident related to the selection of an incorrectmedication or its directions for use11. The cancellation request must occur within the same business day that themedication request was placed.12. The partnering hospice nurse or an administrator should contact theMedication Management Support Center (MMSC) immediately to cancel apackage.13. If the package has not been shipped an HP representative will attempt tovoid and cancel the shipment.14. If the package has already been shipped from the HP dispensing facility,cancelling delivery of the package is not guaranteed. An HP representativewill call the courier and attempt to void the shipment so the package isreturned to HP.15. A healthcare provider, patient, or caregiver can refuse or return the packageto the sender if there is concern with the patient receiving it. Note: Anycharges associated with the package are the responsibility of the hospice.HP will not credit the charges for medications outside the per diem or anyother associated charges for refused or returned packages. For moreinformation, see Policy RM 4.6.Delivery Quality Assurance16. Missing or damaged packages should be reported to HP as soon aspossible. This can be done by submitting a QA in the patient’s profile inSecure Client Access (formerly Xeris ® ) or by calling the HP MMSC andreporting the QA. The QA report should include the patient’s name,expected package contents and date.17. If medication is damaged and unusable, discard according to hospice policy.18. Request that Hospice Pharmacia re-dispense the medication or obtain itlocally if immediate need.19. The HP QA Department will investigate.20. All missing or damaged packages are reported to the courier fordocumentation and follow-up. The hospice will also receive a written reportregarding the outcome of the missing or damaged package.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 2 of 2RM 4.14 Medication Delivery

POLICY:POLICY NUMBER:RM 4.15Hospice PaksDEPARTMENT:MMSC and CRxPREVISION DATES:January 1, 2007;April 1, 2008;July 30, 2010; March 1,2012POLICY:HP facilitates timely access to medications needed for urgent symptommanagement.PROCEDURES:1. Upon admission, the nurse, prescriber and pharmacist collaborate to assesseach patient’s risk for specific symptoms related to the terminal illness, suchsymptoms may include, agitation, anxiety, pain, secretions, nausea/vomiting,fever, seizure, edema and chest pain, among others. The patient’s residenceand caregiver situation should be assessed to ensure that placement of themedications is safe and the drugs can be appropriately used/administered. Itis recommended for the hospice to document the assessment in the patient’smedical record (see policy RM 4.15.1).2. When appropriate, a prescriber requests a Pak containing limited quantities ofmedication addressing specific symptoms, see #1, to be placed in thepatient’s home. A signed prescription for each scheduled agent is maintainedin the pharmacy records according to the C-II Prescription policy (see policyRM 4.10).3. A pharmacist dispenses the Pak with medications labeled for the patient andpackaged in a sealed box. The Pak is also labeled with an expiration date onthe outside of the sealed box. The expiration date of the Pak corresponds tothe medication with the earliest expiration date contained within the Pak. Thedirections on the Pak instruct the patient/caregiver to place it in therefrigerator (except for the CardiacPak) and to only open when instructed bythe hospice nurse or prescriber.4. With the exception of the CardiacPak, storing the Hospice Paks in therefrigerator insures both a consistent and convenient location for the Pak andproduct stability. If the patient’s residence can assuredly be maintainedbetween 59 and 89 °F (15-30°C) the Hospice Paks do not requirerefrigeration, although HP recommends it. The hospice should develop theirown policy on storage location and discuss it with the patient and caregiver.5. Not all medications in the Pak have to be dispensed for each patient. If apatient is allergic to a medication, has a co-morbid disease that precludes theuse of a medication, or if there is a safety risk of having it in the residence ora Pak medication is a duplicate of another medication already in the home,ask the HP pharmacist to not dispense the particular medication(s) in the Pak.6. Contents of the Paks may not be substituted. If an additional medication isrequested, it will be dispensed along with the Pak but will not replace thestandard contents.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 3RM 4.15 Hospice Paks

7. The hospice should consider a policy to assess the patient’s residence uponeach patient visit, check the status of the Pak, and document the use of anyagent and the corresponding symptom, and reviewing the purpose andprocedure for accessing medication use with the patient and primarycaregiver.8. Access and administration of a medication contained within a Pak should bedone under the supervision of a registered health care professional.i. When an urgent symptom is reported by a patient or primary caregiver,the nurse should complete an assessment.ii. When a medication from the Pak is needed to manage the patient’ssymptom, it is recommended that the health care professional(generally a nurse) counsel the patient or caregiver about themedication(s) and its administration according to the directions on theprescription label.iii. When a telephone consultation is the method of supervision to managean emergent symptom, the health care professional should direct thepatient or the caregiver to remove the medication from the Pak andread back to the healthcare professional the information on the labeland describe the contents. When the medication is confirmed by bothlabeling and physical description, the patient and caregiver should beinstructed about medication administration and monitoring of expectedhealth outcome and potential consequences. After administration ofthe medication, the caregiver or patient should be instructed to closethe Pak using the reseal label that accompanies the Pak and placetheir initials on the label. The health care professional shoulddocument the telephone consultation in the patient chart, including anyinstructions provided, noting, when and for what reason the medicationwas administered, the date, instructions, and time of administrationrelayed to the patient or caregiver (see policy RM 4.15.2).iv. Injectable supplies are not included in the Cardiac ComfortPak due topatient safety concerns. It is the hospice’s responsibility to provide anyneeded supplies for administration of injectable medications.9. During normal business hours, it is suggested that the nurse notify the HPpharmacist that the Pak has been accessed and communicate theprescription request for continuation of therapy when necessary.10. At the time of death or at discharge, the Pak items should be disposed of anddocumented according to the hospice’s policy.11. Paks may be dispensed to facilities who accept medications from HP. It is thehospice’s responsibility to verify that the facility in which the patient resideswill accept medications from HP.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 2 of 3RM 4.15 Hospice Paks

The following Paks are available:ComfortPak TMPediatric ComfortPak TMCardiac ComfortPak TMSeizure ComfortPak TMDetails on the contents of each Pak can be found in the Medication UseGuidelines (MUGs ® ).excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 3 of 3RM 4.15 Hospice Paks

POLICY:Hospice Pharmacia Seizure ComfortPak UtilizationPOLICY NUMBER:RM 4.15.1DEPARTMENT:EducationREVISION DATES:January 1, 2007;April 1, 2008March 15, 2011December 17, 2013September 15, 2014POLICY:HP facilitates timely access to medications needed for urgent symptom controland assists healthcare providers in appropriately utilizing medications in a time ofneed. Following is the procedure on the recommended administration of thecontents of the Seizure ComfortPak TM .In the event of acute seizure activity, the medications within the SeizureComfortPak TM should be initiated to help halt seizure activity and preventsubsequent seizures from occurring. The Seizure ComfortPak TM is not intendedfor the following situations:• non-emergent situations (i.e. forgetting to refill medications);• for use in the event that the patient experiences a change in swallowingstatus.Swallowing difficulties should be anticipated as much as possible. Alternative oraldosage forms (e.g., liquids) are readily available for patients with a poorprognosis. This allows the Seizure ComfortPak TM to be available for acutesymptom management.PROCEDURE:HP recognizes three potential clinical scenarios for which medications within theSeizure ComfortPak TM may need to be initiated. Note: additional situations maybe identified by your organization. Contact an HP pharmacist for assistance.1. Acute management of new onset seizure activity:a. Insert one lorazepam suppository per rectum every 10 minutes untilseizure activity stops - up to a maximum of 2 doses (= 4 mg).* If seizure activity does not subside after 2 doses, the prescriber should becontacted immediately for further instruction.*Once acute seizure activity has stopped, initiation of an anticonvulsantshould be considered to prevent further seizures (i.e. secondary prophylaxis).It is recommended to initially administer a loading dose to help achievetherapeutic levels quickly, then to administer a maintenance dose forsecondary prophylaxis. The preferred route for the loading dose is a shortactingoral formulation.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2011 excelleRx, Inc – Page 1 of 2RM 4 15 1 HP Seizure ComfortPak Utilization

2. Breakthrough seizures occurring in patients previously stabilized on ananticonvulsant and currently unable to swallow oral dosage forms:a. Refer to instructions for lorazepam suppository use in section 1a.b. Contact the prescriber and/or HP pharmacist to discuss an alternativeanticonvulsant regimen.3. Patient is stable on oral anticonvulsant(s) therapy and develops swallowingdifficulty:a. Contact the prescriber to discuss the necessity of rotating patient to analternative anticonvulsant therapy (if appropriate) OR to an alternateanticonvulsant regimen.b. Lorazepam suppositories should be reserved for if the patient experiencesbreakthrough seizures. Refer to section 1a if this occurs.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2011 excelleRx, Inc – Page 2 of 2RM 4 15 1 HP Seizure ComfortPak Utilization

POLICY:Medication Expiration and Discard DateREVISION DATES:August 1, 2006;September 1, 2009POLICY NUMBER:RM 4.16DEPARTMENT:CRxPPOLICY:Medications will carry prescription labels with appropriate expiration or “discardafter” dating.PROCEDURE:1. All commercially available products dispensed directly to a patient will containa prescription label with the standard one (1) year discard-after date or thedate on the manufacturer's container if sooner.2. All compounded medications dispensed directly to a patient will contain alabel with a six (6) month discard-after date or the date of any ingredient ifsooner.3. The same dating principles will be applied when products are repackaged fordistribution pursuant to invoice or DEA 222 form.4. HP will dispense and repackage according to normal USP standards andgood pharmacy practice.5. The HP Paks and any other packaging that contains multiple medications(delivery packaging not included) will contain on the outer packaging adiscard-after date that represents the earliest expiration date of all products inthe package.6. Expiration dating of compounded medications is checked by a pharmacistprior to dispensing.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 1RM 4.16 Medication Expiration and Discard Date

POLICY:POLICY NUMBER:RM 4.17On-call ServicesDEPARTMENT:MMSCREVISION DATES:August 1, 2006;October 7, 2009April 30, 2010;August 31, 2010September 16, 2013POLICY:A pharmacist is available 24 hours a day, seven days a week to assist withpatient needs. The pharmacist will assist the nurse in procuring medicationslocally through the HPRxCard upon request (see policy RM 4.19). In order toensure that a pharmacist is available for pressing clinical needs, issues such asrefill requests, general admissions without medication needs, OTC medicationneeds, discharges, medication profiling, and clinical marker documentation areprocessed during normal business hours or through Secure Client Access(formerly Xeris ® ).PROCEDURES:1. A pharmacist can be reached after business hours (including weekends andholidays) by calling the pharmacy’s toll-free after hours phone number: 877-882-7820.2. After hours, follow the telephone prompts to contact the HP answeringservice.3. The answering service will relay your message to the on-call pharmacist, anda pharmacist will return your call within 15 minutes.4. A pharmacy administrator is available 24 hours, seven days a week. Thepharmacy administrator is available by dialing 800-395-2371.5. The on-call pharmacist is able to perform the following services:a. Provide clinical consultation and general drug informationb. Access patient pharmacy records on-line and track medicationdeliveryc. Enroll a patient for pharmacy services and activate the HPRxCardd. Prior-authorize a medication for dispensing through the communitypharmacye. Communicate with a community pharmacy provider to assuremedication dispensingf. Provide patient counseling6. On-call pharmacy team members are required to handle PHI in compliancewith HIPAA regulations.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2013 excelleRx, Inc – Page 1 of 1RM 4.17 On-call Services Updated.doc

POLICY:Hours, Operation and Responsibilitiesof On-call PharmacistPOLICY NUMBER:RM 4.18DEPARTMENT:MMSCREVISION DATES:August 1, 2006September 16, 2013POLICY:HP will provide a trained, knowledgeable, licensed pharmacist 24 hours a day, 7days per week. Such staffing will include an on-call service.PROCEDURES:1. Pharmacists are available in the Medication Management Support CenterMonday through Friday, 8:30am Eastern to 11:00pm Eastern; Saturday andSunday, 9:00am Eastern to 8pm Eastern.2. The on-call pharmacist and technician are accessible at all times whenscheduled for on-call duty beginning after business hours.3. When called, the on-call pharmacist will respond to the call within 15 minutes.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2013 excelleRx, Inc – Page 1 of 1RM 4.18 Hours Operation and Responsibilities of On-call Pharmacist Updated.doc

POLICY:Use of HPRxCard for Local Medication AccessPOLICY NUMBER:RM 4.19DEPARTMENT:Community Pharmacy SupportServiceREVISION DATES:August 1, 2006;March 1, 2008;October 6, 2009;January 30, 2010April 30, 2010August 31, 2010September 16, 2013POLICY:HP recognizes its need to provide timely access to medication for each patient.Local access to emergent medications is achieved through use of the HPRxCard.This enables access to medications at a community pharmacy as outlined in thepartnering agreement. HP provides the hospice with a supply of cards duringimplementation, if needed; additional supplies may be ordered by completing theMaterial Request Form located under the Communication Tools icon in HP’ssecure client access (formerly Xeris ® ).PROCEDURE:1. When a patient is admitted to HP’s services, an HPRxCard is activated toallow for procurement of medications from a community pharmacy whenneeded. If medications are needed right away, call HP and request immediateactivation.2. The HPRxCard enables a patient to receive up to a 15-day supply of hospicerelatedformulary (authorized) medications from a community pharmacy.3. The nurse and patient identify the preferred community pharmacy by usinginformation provided by HP during implementation, Secure Client Access(formerly Xeris ® ), or by calling HP.4. To obtain the medications urgently,a. The nurse contacts HP to update the patient’s medication profile andensure authorizations to dispense are activated where necessary.b. The nurse or prescriber contacts the selected pharmacy. The nurse orprescriber relays the following information to the pharmacy:i. Patient’s name, address, phone number, date of birth, socialsecurity numberii. Name of medication, dose, frequency, directions, indication, andquantityiii. HPRxCard information (group code, group name, and patient’ssocial security number)iv. Prescriber information (full name, phone number, address andDEA number)v. Time medication will be picked upc. For CII prescriptions, the prescriber contacts the pharmacy with theemergency request and faxes the prescription, which serves as a hardcopy (all states except NY).excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2013 excelleRx, Inc – Page 1 of 2RM 4.19 Use of HPRxCard for Local Medication Acess Updated.doc

d. If the nurse or patient is asked payment questions or has communitypharmacy issues, they should call HP.5. Instances when a community pharmacy may not dispense a requestedmedication:a. a medication outside per diem is requested without prior authorizationb. the quantity requested exceeds the quantity authorizedc. a pharmacy outside of the pharmacy network is being usedd. a brand name product is requested when a generic is available andappropriatee. a non-hospice related medication is requestedf. the patient has not yet been enrolled in HPg. MD is unavailable for prescription authenticationh. the prescription is not provided for CIIi. the pharmacy does not have the medication in inventoryj. the prescriber has outstanding CII prescriptions that have not beensigned at the community pharmacy6. If prescription processing is denied (i.e., the pharmacy receives a “rejection”),HP should be contacted.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2013 excelleRx, Inc – Page 2 of 2RM 4.19 Use of HPRxCard for Local Medication Acess Updated.doc

POLICY:Medication Recall & ShortagesPOLICY NUMBER:RM 4.20DEPARTMENT:CRxP, QA, MMSC, Clinical Support& MarketingREVISION DATES:November 11, 2008;December 22, 2008August 27, 2009July 18, 2011POLICY:The number of medication recalls and shortages is increasing. When amedication recall occurs, a systematic process is used to identify, locate, andremove and/or replace dispensed medications that pose a potential healthhazard to patients. Medication shortages occur due to a number of reasons, suchas non-compliance with FDA regulatory standards, raw material shortages,packaging shortages, business decisions, limited manufacturing capability,recalled medications, unexpected demand, or natural disasters. When amedication is in short supply, HP develops a plan to make alternativemedications available.PROCEDURES:Hospice Pharmacia (HP) will communicate with our hospice partners through afacsimile (fax) or email notification concerning an interruption in the ability toacquire medications that are included in the HP per diem. When appropriate, analternative medication included in the HP per diem will be provided. HP will alsoalert our hospice partners when a medication recall that potentially affects thehospice community is reported. Each hospice should also develop, implementand monitor their own policy to guide the hospice’s response to medicationrecalls and shortages.DEVELOPING A HOSPICE POLICY FOR MEDICATION RECALLS ANDSHORTAGES:1. Creating and Implementing: When creating and implementing a MedicationRecall & Shortage Policy, the hospice should consider the following:dissemination of HP medication recall and shortage notifications to staff andother personnel, a process to identify potentially affected patients, and a planto provide an alternative medication when available and/or indicated.2. Informing: When a medication recall is initiated by a manufacturer, allpharmacies, including community, inpatient and long-term care pharmacies,follow their own policy and procedure for handling medication recalls. Patientswho have received medications from a pharmacy other than HP shouldcontact that pharmacy for further instruction.a. Staff:i. Hospice should provide all prescribers, nurses, and appointedpersonnel with the medication recall/shortage notification.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 3RM 4.20 Medication Recall and Shortages

ii. Hospice should engage prescribers, nurses, and identifiedpersonnel to order alternative medication(s) if available orappropriate.b. Patients and Families:i. Hospice should engage the patient and/or their family to helpidentify those who may be affected by the medicationrecall/shortage.ii. Hospice should evaluate whether monitoring side effects and/oradverse drug reactions for the patient should be altered basedon the safety profile of the new medication and subsequentlyadjust the plan of care as necessary.RECALLS:1. Hospice Pharmacia (HP) monitors medication recall alert services to receivetimely information from manufacturers, wholesalers, and the FDA.2. All medication recall alerts are forwarded immediately to HP’s product recalldistribution list, which includes appointed personnel. This team collaboratesto determine a course of action.3. A communication (fax or email) will be sent to all hospice partners by theMarketing department to notify them of the medication recall and subsequentaction taken by HP. The communication will explain the necessity of therecall, define any potential dangers associated with the recall and necessaryhealth actions (should any be necessary), and outline the plan for removing(and replacing) the medication from the home when indicated.4. Depending on the nature of the recall, patients who received the medicationfrom HP may need a replacement of medication. Those requiring areplacement will either receive the medication from HP or it will be madeobtainable through another pharmacy.5. HP’s Director of Purchasing will quarantine the identified medication(s)affected by the recall.6. Levels of Recalls:a. Class I or Patient Level is considered the most serious and dangerousbecause there is a reasonable probability that the use of or exposureto the recalled medication will cause serious adverse healthconsequences or death. With a Class I recall, immediate action isrequired to remove the affected medication from distribution. To notifypatients who may have received the affected medication, both thepharmaceutical company and FDA will issue a press release. On adiscretionary basis, the FDA may also issue a public health notice.b. Class II or Retail Level is considered potentially dangerous becauseuse of or exposure to the recalled medication may cause temporary ormedically reversible adverse health consequences, but the probabilityof serious adverse health consequence is remote. Some, but probablynot all, of the affected medication may have been distributed topatients. Therefore, with a Class II recall, notification is not sent directlyto patients; rather it is sent to distributors of the affected medication,excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 2 of 3RM 4.20 Medication Recall and Shortages

such as retail or mail-order pharmacies. In most cases of Class IImedication recalls, the FDA will not issue a press release.c. Class III or Wholesale Level is considered the least dangerousbecause the use of or exposure to the recalled medication is not likelyto cause adverse health consequences, specifically because it has notbeen distributed to patients. With a Class III recall, the pharmaceuticalcompany notifies its consumers (i.e., drug wholesalers) that themanufacturing of their medication has violated FDA regulations andthat the recalled medication must not be distributed. In the case of aClass III recall, the FDA may not issue a press release.7. If a recalled medication needs to be removed from the patient’s residence,HP will provide the hospice with a list of patients who were prescribed themedication. The hospice is responsible for contacting individual patients asneeded and removing the medication as indicated.8. The disposal of medications remaining in the patient’s residence after deathare not subject to this medication recall process and should be completed inaccordance with applicable hospice policies/procedures.SHORTAGES:1. Hospice Pharmacia (HP) monitors medication shortage alert services toreceive timely information from manufacturers, wholesalers, and the FDA.2. All medication shortage alerts are forwarded immediately to HP’s productrecall distribution list, which includes appointed personnel. This teamcollaborates to determine a course of action.3. Depending on the nature of the medication shortage (i.e., temporary vs.long-term), an alternative medication will be provided, if available. Thealternative medication will be dispensed as soon as it is procured by HP.4. A communication (fax or email) will be sent to all hospice partners by theMarketing department to notify them of the medication shortage andsubsequent action take by HP. The communication will explain the reasonfor the shortage (when available), and will outline a plan for selection of analternative medication.5. Medication availability updates will be provided to HP hospice partners andall internal personnel as they become available.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 3 of 3RM 4.20 Medication Recall and Shortages

POLICY:Adverse Drug Reactions (ADR)REVISION DATES:August 1, 2006;March 1, 2008POLICY NUMBER:RM 4.21DEPARTMENT:MMSCPOLICY:For this policy, an adverse drug reaction will be defined as “any response to adrug which is noxious, undesired, or unintended and which occurs within adosage range and route typically used for prophylaxis, diagnosis, or therapy andrecognized as medically acceptable.” Adverse drug reactions are: (1) predictable,usually dose-dependent, and related to the pharmacological actions of the drug,or (2) unpredictable, often dose-independent, and related to the individual’simmunologic response or to genetic differences in susceptible patients. HPpharmacists will not dispense an agent that has documented cross-reactivitywithout prior conversation with the patient’s physician or hospice nurse andappropriate documentation on the patient profile.HP pharmacists track and document all reports of adverse drug reactions on thepatient’s permanent record. Upon report of an ADR, the pharmacist will check allexisting profiled medications and new medication requests for cross-reactivity toavoid further adverse reactions.PROCEDURE:1. A nurse, patient, physician, or caregiver reports the occurrence of an adversereaction to a medication to the pharmacist.2. The pharmacist will discontinue the offending agent or, when necessary,continue the offending agent and recommend adjunct therapy to manage theadverse reaction. The occurrence is documented on the patient’s permanentrecord.3. Documentation will include the date of the adverse reaction report, suspectedmedication that caused the adverse reaction, and symptoms reported as aresult of the adverse reaction.4. All existing profiled medications (including “prn” medications) and subsequentmedication requests will be checked to ensure no similar reaction can existwith the offending agents.5. If a medication request is placed for an agent that has a documented chanceof emulating a reaction similar to the offending agent is requested, thepharmacist will notify the nurse and either the nurse or the pharmacist willcontact the physician prior to HP dispensing the medication.6. In the event the requesting physician cannot be reached, the hospice nurse orthe pharmacist will contact the hospice’s medical director to discuss themedication requests prior to HP dispensing the medication.7. In the event of a severe reaction, the pharmacist will report the adverse eventto the HP QA department, who, in turn, will report it to the FDA using FormexcelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 1RM 4.21 Adverse Drug Reactions

3500. The FDA’s definition of a reportable adverse drug reactions are, “thosecases associated with a serious outcome” such as:a. Initial or prolonged hospitalizationb. Life threatening conditionc. Disabilityd. Congenital abnormalitye. Deathf. Required surgical or medical intervention to prevent impairment orsequelae.8. HP faxes the completed FDA Form 3500 (MedWatch) to 1-800-FDA-0178, orcompletes it on-line. The original copy is kept on file in the pharmacy.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 2 of 2RM 4.21 Adverse Drug Reactions

POLICY:Drug Utilization Review (DUR)POLICY NUMBER:RM 4.22DEPARTMENT:MMSCREVISION DATES:August 1, 2006;December 22, 2008;September 1, 2009;January 30, 2010September 18, 2013POLICY:HP Pharmacists complete drug utilization reviews (DUR) for all new dispensedmedication requests to identify potential and actual mediation related problems.Prospective and/or retrospective DURs are provided for profiled medications per theterms within the individual hospice contract.PROCEDURES:1. HP Pharmacists complete a DUR to identify the presence of actual or potentialmedication-related problems , including but not limited to, the following:a. Patient allergies or potential sensitivitiesb. Existing or potential interactions between the medication ordered and themedications the patient is currently takingc. The appropriateness of the medication, dose, frequency and route ofadministrationd. Effectiveness of the drug therapy for the given indicatione. Adverse reactions related to the patient’s medication. Additionalinformation can be found in policy RM 4.21: Adverse Drug Reactions.f. Current or potential impact of therapy as indicated by laboratory values,when providedg. Therapeutic duplicationh. Other contraindications2. HP Pharmacists perform a DUR for each patient upon receipt of a newmedication dispense request.3. The pharmacist will discuss significant medication-related problems identifiedduring the DUR with the nurse or prescriber and, when applicable, will documentin HP’s clinical record.4. The patient’s active medication report (AMR) is stamped with the date, time andinitials of the pharmacist completing the DUR. The AMR may be accessed byselecting Report Options after logging onto the Secure Client Access site.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2013 excelleRx, Inc – Page 1 of 1RM 4.22 Drug Utilization Review Updated.doc

POLICY:POLICY NUMBER:RM 4.23Dangerous AbbreviationsDEPARTMENT:Performance Improvement/MMSCREVISION DATES:August 1, 2006;August 1, 2008;October 13, 2009April 30, 2010POLICY:HP encourages use of standardized abbreviations. Abbreviations found on our“Do Not Use” list are not used by HP pharmacy team members in any patientspecificcommunication documents.PROCEDURE:1. HP pharmacy team members will refrain from using unapproved abbreviationsand will comply with the attached “Do Not Use” list.2. “Do Not Use” abbreviations must not appear in any free text field in Secure ClientAccess (formerly Xeris ® ) or other HP pharmacy technology systems. The list of“Do Not Use” abbreviations and Secure Client Access (formerly Xeris ® ) free textfields follows in the attached table.3. It is currently acceptable for HP to receive patient-specific communicationdocuments from prescribers, partnering hospice facilities, or other health careproviders that use or contain the following abbreviations in medication requestsor other patient records. HP team members will attempt to educate healthcareproviders about the danger of using unsafe abbreviations. These opportunities toinform other healthcare providers highlight HP and its partnering hospices’performance improvement efforts to reduce medication errors.4. If HP receives a patient-specific communication document from a prescriber,partnering hospice facility or other health care provider that is unclear, an HPteam member will attempt to clarify the document by contacting the sender or thehospice.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 1RM 4.23 Dangerous Abbreviations

"Do Not Use" List forDangerous Sig Codes and AbbreviationsThe following abbreviations must not appear in any free text field in Secure Client Access (formerlyXeris ® ) or other pharmacy systems. Free text fields include, but may not be limited to:• Medication requests in Secure Client Access (formerly Xeris ® ) encounter• Internal, external or Secure Client Access (formerly Xeris ® ) encounter comment fields• MDS or clinical assessments• Prescription labels• QA system documentation• Any other hand-written or printed documents used for patient-specific communicationAbbreviation Intended Meaning Misinterpreted Meaning Safety Strategy**Trailing zeros after thedecimal point(ex: coumadin 1.0 mg)**No leading zero beforea decimal point(ex: morphine .5 mg)1 mg Can be misread as 10 mg, if the decimal pointis missed.0.5 mg Can be misread as 5 mg if decimal point ismissed.**U or u unit Can be mistaken as the number 0 or 4,resulting in a 10 fold overdose(ex: 4U mistaken as 40).Express doses in whole numbers.(ex: Coumadin 1 mg)Use a zero before the decimal pointwhen the dose is less than a whole unit.“Unit” has no acceptable abbreviation.Write out “unit”.**IU or I.U. international unit Mistaken as IV or 10. “Unit” has no acceptable abbreviation.Write out “unit”.**Q.D., QD, Q/D or q.d. daily Mistaken as “qid” for “four times daily”. Use “qday” or write out “daily”.**Q.O.D., QOD, q.o.d., qod every other day**MS, MSO4, MgSO4MS and MSO4 = morphinesulfate; MgSO4 =magnesium sulfateMistaken as “qd” (daily) or “qid” (four timesdaily).MS and MSO4 mistaken for magnesium sulfateand MgSO4 mistaken for morphine sulfate.Use "qotherd" or write out "every otherday".Write out "morphine sulfate" or"magnesium sulfate".cc cubic centimeters Can be mistaken as u. Use "mL".hs, qhs Nightly at bedtime Mistaken as “qhr” or every hour Use “nightly” or “at bedtime”SC, SQ or sub q subcutaneous Can be mistaken as SL or SQ for "every five(ex: "heparin sub q 2 hours before surgery" isread erroneously as "give heparin every twohours before surgery").SS or SSRIsliding scale or slidingscale regular insulinMistaken as Strong Solution (of Iodine) orselective serotonin reuptake inhibitor.µg microgram Mistaken as "mg". Use "mcg".Write "subcut" or "subcutaneous".Write out "sliding scale".TIW 3 times a week Mistaken for "3 times a day" or "twice a week". Use "three times weekly".AU, AS, AD or OU, OS, OD A = ear; O = eye A is mistaken for eye, O is mistaken for ear.OD mistaken for once dailyWrite out "left/right/both" AND"ear/eye".HCT hydrocortisone Mistaken for hydochlorthiazide or hematocrit. Write out "hydrocortisone".@ At Mistaken as “2” Use “at”& And Mistaken as “2” Use “and”+ Plus or And Mistaken as “4” Use “and”º Hour Mistaken as a zero (e.g., q2 º seen as q20) Use “hr” “h” or “hour”> or < “greater than” or“less than”Unfamiliarity with these symbols can result inconfusing one for the other.Write out “greater than” or “less than”.** Joint Commission required “Do Not Use” abbreviationsDisclaimer: This document is intended for informational purposes only. It is not intended as legal or clinical advice and does notreplace medical advice or care.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 2 of 2RM 4.23 Dangerous Abbreviations

POLICY:List of Look-Alike/Sound-Alike DrugsPOLICY NUMBER:RM 4.24DEPARTMENT:MMSC, CRxP and PIREVISION DATES:August 1, 2006;August 1, 2008;October 12, 2009April 30, 2010;September 15, 2014POLICY:Medications that have the potential for confusion due to look-alike or sound-alike drugnames or packaging are identified and treated with extra precautions to prevent error.HP uses safe medication practices to reduce medication errors.PROCEDURE:1. MMSC and CRxP observe multiple safety precautions that prevent the confusion oflook-alike/sound-alike medications. For instance:a. Where possible, medication names are presented as both trade and genericnames.b. When a medication is selected, the available dosage forms and strengths arepresented.c. Patient information is readily available to those involved in the medicationmanagement process including an indication for each medication ordered.2. Verbal/telephone requests require the recipient of the verbal/telephone request towrite down or enter the order into the computer and read it back to the healthcareprovider.3. Specific safety strategies are followed for a specified list of potential lookalike/sound-alikemedication combinations. These strategies include:a. Store in separated locations within the pharmacy area.b. Purchase a different brand of one product to avoid name confusion or lookalikeproducts.c. Limit stock areas within the pharmacy.d. Limit supply to set strengths or concentrations which will avoid confusion.4. A specific list of potentially problematic look-alike/sound-alike medications isdistributed and is reviewed and updated annually.5. Medication errors and potential errors are routinely reviewed for potential additions tothe look-alike/sound-alike medication list.a. In addition, national publications are routinely reviewed for potential additionsto this list. Changes are submitted to the Medication Use Guidelines (MUGs ® )Committee for review and approval.b. The MUGs Committee considerational review of medications for inclusion intothe MUGs accounts for a review of look-alike/sound-alike error potential.c. If a medication has the potential for a look-alike/sound-alike error it will beconsidered for inclusion on the Look-Alike/Sound-Alike Medications list.6. HP team members are educated regarding the specific safety strategies required foreach look-alike/sound-alike medication combination.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 2RM 4.24 List of Look-Alike Sound-Alike Drugs

2014 Look-Alike/Sound-Alike MedicationsGeneral Guidelines:1. Clearly specify the dosage form, drug strength, and complete directions on the patient’s medication profile.2. Include the indication in the patient’s medication profile and prescription label.3. Read back the entire request(s) at the end of the call.Confusing Medication NamesBRAND names listed in UPPER case, generics are listed in lower caseACE InhibitorsFosinopril (MONOPRIL®)Lisinopril (PRINIVIL®, ZESTRIL®)Enalapril (VASOTEC®)ACCUPRIL® (quinapril)ACIPHEX® (rabeprazole)ARICEPT® (donepezil)AZILECT® (rasagiline)ADDERALL® (amphetamine salts)INDERAL® (propranolol)amitriptyline (ELAVIL®)nortriptyline (PAMELOR®)AVINZA® (morphine)EVISTA® (raloxifene)AVINZA® (morphine)EVISTA® (raloxifene)BENADRYL® (diphenhydramine)Benazepril (LOTENSIN®)bupropion (WELLBUTRIN®, ZYBAN®)buspirone (BUSPAR®)Calcium Channel BlockersDiltiazem productsCARDIZEM®CARDIZEM CD®TIAZAC®Nifedipine productsPROCARDIA®PROCARDIA XL®ADALAT CC®Nicardipine (CARDENE®)Carbamazepine (TEGRETOL®)Oxcarbazepine (TRILEPTAL®)CARDURA®(doxazosin)COUMADIN® (warfarin)CEFTIN® (cefuroxime)CEFZIL® (cefprozil)HTN (hypertension)Most Common Reason for UseDyspepsiaAlzheimer’s diseaseParkinson’s diseaseCNS stimulantHTN (hypertension)Depression/ Nerve painDepression/ Nerve painAnalgesicOsteoporosis agentAnalgesicOsteoporosis agentAntihistamineHTN (hypertension)Depression, Smoking CessationAnxietyHTN (hypertension)Seizure DisorderSeizure DisorderHTN (hypertension); Benign Prostatic HypertrophyAnticoagulantCephalosporin antibiotic/InfectionsCephalosporin antibiotic/InfectionsexcelleRx®, Inc. d.b.a. Hospice PharmaciaCopyright © June, 2014 excelleRx, Inc.1

2014 Look-Alike/Sound-Alike MedicationsConfusing Medication NamesBRAND names listed in UPPER case, generics are listed in lower caseCELEBREX® (celecoxib)CELEXA® (citalopram hydrobromide)ZYPREXA® (olanzapine)Divalproex productsDEPAKOTE ER®DEPAKOTE DR®DEPAKOTE SPRINKLE®DEPAKENE®Duloxetine (CYMBALTA®)Fluoxetine (PROZAC®)Fentanyl (DURAGESIC®)Phenytoin (DILANTIN®)glipizide (GLUCOTROL®)glyburide (DIABETA®, MICRONASE®)HALDOL® (haloperidol)nadolol (CORGARD®)hydrocodone (with Acetaminophen)---LORTAB®, VICODIN®, Norco)oxycodone (with Acetaminophen)---PERCOCET®, ENDOCET®)oxycodone (OXYCONTIN®)hydromorphone various forms (DILAUDID®)morphine sulfate various forms (MS CONTIN®, ROXANOL®, MSIR®,ASTRAMORPH®, DURAMORPH®, INFUMORPH®)hydroxyzine (ATARAX®, VISTARIL®)hydralazine (APRESOLINE®)IMDUR® (isosorbide mononitrate)IMURAN® (azathioprine)insulin products (LANTUS®, HUMULIN®, HUMALOG®, NOVOLIN®,NOVOLOG®, NOVOLIN 70/30®, NOVOLOG MIX®, regular insulin 500units)KEPPRA® (levetiracetam)KEFLEX® (cephalexin)ketoprofen Gelketamine Gellabetalol (TRANDATE®, NORMODYNE®)lamotrigine (LAMICTAL®)levofloxacin (LEVAQUIN®)levetiracetam (KEPPRA®, KEPPRA XR®)levothyroxine (SYNTHROID®)liothyronine (CYTOMEL®)Most Common Reason for UsePain/ AnalgesicDepression/ AnxietyAntipsychoticSeizure Disorder/ AgitationSeizure Disorder/ AgitationSeizure Disorder/ AgitationSeizure Disorder/ AgitationDepression/ Nerve PainDepressionPain/ AnalgesicSeizure DisorderDiabetesDiabetesPsychotic DisordersHTN (hypertension), TachycardiaPain/ AnalgesicPain/ AnalgesicPain/ AnalgesicPain/ AnalgesicPain/ AnalgesicAnxiety/ ItchingHTN (hypertension)Angina/ Chest PainImmunosuppressantDiabetes Mellitus / Multiple Products and StrengthsSeizure DisorderAntibioticNSAID, analgesicAnesthetic adjunctHTN (hypertension)Seizure DisorderAntibioticSeizure DisorderThyroid replacementThyroid replacementexcelleRx®, Inc. d.b.a. Hospice PharmaciaCopyright © June, 2014 excelleRx, Inc.2

2014 Look-Alike/Sound-Alike MedicationsConfusing Medication NamesBRAND names listed in UPPER case, generics are listed in lower caseLEXAPRO® (escitalopram oxalate)ZYPREXA® (olanzapine)lorazepam (ATIVAN®)alprazolam (XANAX®)lovastatin (MEVACOR®)LOTENSIN® (benazepril)methadone (DOLOPHINE®, METHADOSE®)methylphenidate (RITALIN®)MIRAPEX® (pramipexole)MIRALAX® (PEG-3350)MS CONTIN® (morphine sulfate)OXYCONTIN® (oxycodone)olanzapine (ZYPREXA®)clozapine (CLOZARIL®)omeprazole (Prilosec/Prilosec OTC®)olanzapine (Zyprexa®)opium Tincturecamphorated opium tincture (PAREGORIC®)Pancreatic Replacement ProductsCreon®, Pancrease®, Pangestyme®, Ultrase®, Zenpep®penicillinpenicillaminePLAVIX® (clopidogrel)PRADAXA® (dabigatran)prednisoloneprednisonePROSCAR® (finasteride)PROZAC® (fluoxetine)PRILOSEC® (omeprazole)quinidine (QUINAGLUTE®, QUINIDEX®)quinineRESTORIL® (temazepam)RISPERDAL® (risperidone)rifaximin (XIFAXAN®)rifampin (RIFADIN®)risperidone (RISPERDAL®)ropinirole (REQUIP®)Most Common Reason for UseDepression, Generalized Anxiety DisorderPsychotic DisordersAnxietyAnxietyCholesterol-loweringHTN (hypertension)Pain/ Analgesic, DetoxificationCNS StimulantParkinson’sConstipationPain/ AnalgesicPain/ AnalgesicAntipsychoticAntipsychoticGERD/HeartburnPsychotic DisordersPain/ AnalgesicPain/ Analgesic/ Anti-diarrhealVerify brand name, component strengthsAntibioticChelating agentAntiplateletAnticoagulantGlucocorticoidGlucocorticoidBPH (benign prostatic hyperplasia)DepressionDyspepsiaAtrial FibrillationMalaria/ Leg CrampsAnxiety/ InsomniaAgitation/ Delirium/ Psychotic DisorderInfections/ Antibiotic/ Hepatic encephalopathyInfections/ AntibioticPsychotic DisordersRestless Leg Syndrome, Parkinson’sexcelleRx®, Inc. d.b.a. Hospice PharmaciaCopyright © June, 2014 excelleRx, Inc.3

2014 Look-Alike/Sound-Alike MedicationsConfusing Medication NamesBRAND names listed in UPPER case, generics are listed in lower caseROXICET® (oxycodone/acetaminophen)ROXANOL® (morphine)ROXICODONE® (oxycodone)SALAGEN® (pilocarpine)selegiline (ELDEPRYL®, ZELAPAR®)SANDOSTATIN® (octreotide)simvastatin (ZOCOR®)SEROQUEL® (quetiapine)sertraline (ZOLOFT®)SERZONE® (nefazodone)SINEMET® (levodopa-carbidopa)SINEQUAN® (doxepin)SEROQUEL® (quetiapine)SINGULAIR® (montelukast)SUDAFED® (pseudoephedrine)sotalol (BETAPACE®)tizanidine (ZANAFLEX®)tiagabine (GABITRIL®)tramadol (ULTRAM®)trazodone (DESYREL®)TOPAMAX® (topiramate)TOPROL XL® (metoprolol succinate)Topical corticosteroidshydrocortisone, betamethasone, fluocinolone, flucocinonide, andtriamcinolone creams, ointments, gels, lotions, shampoosValacyclovir (VALTREX®)valganciclovir (VALCYTE®)ZAROXOLYN® (metolazone)ZYPREXA®(olanzapine)ZYRTEC® (cetirizine)ZANTAC (ranitidine)ZESTRIL® (lisinopril)ZETIA® (ezetimibe)ZEBETA® (bisoprolol)ZOSTRIX® (capsaicin)ZOVIRAX® (acyclovir)ZOCOR® (simvastatin)ZYRTEC® (cetirizine)Pain/ AnalgesicPain/ AnalgesicPain/ AnalgesicMost Common Reason for UseDry Mouth (salivary gland hypofunction)Parkinson’sSomatostain analogueCholesterol-loweringPsychotic DisorderDepressionDepressionParkinson’sDepressionPsychotic DisorderAsthma/ Dyspnea / Seasonal allergyNasal decongestantAntiarrhythmicMuscle spasms/ CrampsSeizure DisorderPain/ AnalgesicDepression, (Insomnia – off label)Seizure DisorderHTN (hypertension)Itching/ Skin rashAntiviralAntiviralDiureticPsychotic DisorderAntihistamineDyspepsiaHTN (hypertension)Cholesterol LoweringHTN (hypertension)Pain/ AnalgesicAntiviralCholesterol LoweringAntihistamineexcelleRx®, Inc. d.b.a. Hospice PharmaciaCopyright © June, 2014 excelleRx, Inc.4

2014 Look-Alike/Sound-Alike MedicationsConfusing Medication NamesSPECIAL CONSIDERATION CATEGORIESConcentrated liquid morphine and oxycodone products (e.g. 20mg/mlROXANOL®) vs.Conventional concentrations of liquid morphine and oxycodoneproducts (e.g. 10mg/5ml)Morphine prefilled syringes5mg = Morphine 20mg/ml syringe filled to 0.25ml10mg = Morphine 20mg/ml syringe filled to 0.5ml20mg = Morphine 20mg/ml syringe filled to 1mlConcentrated liquid methadone products (e.g. 10mg/mlMETHADOSE®) vs.Conventional concentrations of liquid methadoneproducts (e.g. 1mg/1ml, 10mg/5ml)Different Salt FormsHydroxyzine Pamoate (VISTARIL®)vs. Hydrochloride (ATARAX®)Metoprolol Tartrate (LOPRESSOR®) (twice daily dosing)vs. Succinate (TOPROL XL®) (once daily dosing)Isosorbide MononitrateIMDUR® (once daily dosing)ISMO®, MONOKET® (twice daily dosing)Isosorbide DinitrateDILATRATE® (isosorbide dinitrate IR) (once daily dosing)ISORDIL® (isosorbide dinitrate ER) (2-3 times daily dosing)Pain/ AnalgesicMost Common Reason for Use• Always include the concentration and dose on theprescription label.• Always include the mL to mg conversion on theprescription label.• Verify that patients and caregivers understand howto measure the proper dose• Verify that the dose for pre-filled syringe products iscorrect, product chosen corresponds exactly to thepatient dose and does not require using a partialsyringe, and dispense quantity is stated in mLs vs.syringesAnxiety/ ItchingAnxiety/ ItchingHTN (hypertension)HTN (hypertension)AnginaAnginaAnginaAnginaSimilar PackagingAlbuterol nebulizer solution (PROVENTIL®)Ipratropium nebulizer solution (ATROVENT®)DyspneaDyspneaexcelleRx®, Inc. d.b.a. Hospice PharmaciaCopyright © June, 2014 excelleRx, Inc.5

2014 Look-Alike/Sound-Alike MedicationsConfusing Medication NamesSPECIAL CONSIDERATION CATEGORIESImmediate Release vs Extended Release Productsoxycodone extended release (OXYCONTIN SR®)oxycodone immediate release tablets (MY-OXY®, ROXICODONE®)morphine immediate release (MSIR®, ROXANOL®)morphine long-acting (KADIAN®, AVINZA®)morphine extended release (MS CONTIN®)WELLBUTRIN SR® (bupropion: twice daily dosing)WELLBUTRIN XL® (bupropion: once daily dosing)WELLBUTRIN® (bupropion: 2-3 times daily dosing)TEGRETOL® (carbamazepine: 2-4 times daily dosing)TEGRETOL XL® (carbamazepine: twice daily dosing)EFFEXOR XR® (venlafaxine: once daily dosing)EFFEXOR® (venlafaxine: 2-3 times daily dosing)KEPPRA® (levetiracetam: twice daily dosing)KEPPRA XR® (levetiracetam: once daily dosing)CARDIZEM SR® (diltiazem: twice daily dosing)CARDIZEM CD® (diltiazem: once daily dosing)methylphenidate LA capsule (RITALIN LA®, METADATE CD®)methylphenidate ER tablet (RITALIN SR®, CONCERTA®, METADATE ER®)methylphenidate (RITALIN®, METHYLIN®)Pain/ AnalgesicPain/ AnalgesicPain/ AnalgesicPain/ AnalgesicPain/ AnalgesicMost Common Reason for UseAnxiety/ Smoking cessationAnxiety/ Smoking cessationAnxiety/ Smoking cessationSeizure disorderSeizure disorderAnxiety/ DepressionAnxiety/ DepressionSeizure disordersSeizure disordersHTN (hypertension)HTN (hypertension)CNS stimulantCNS stimulantCNS stimulantexcelleRx®, Inc. d.b.a. Hospice PharmaciaCopyright © June, 2014 excelleRx, Inc.6

POLICY:POLICY NUMBER:RM 4.25High Risk MedicationsDEPARTMENT:MMSC, CRxP and PIREVISION DATES:June 1, 2006; August 1,2008; October 12,2009, April 30, 2010;September 15, 2014POLICY:HP takes precautionary measures to ensure high risk/high alert medications areprocessed and handled safely and dispensed accurately.PROCEDURES:1. The management teams of the MMSC, CRxP and PI Departments annuallyreview the high risk/high alert medications from Joint Commission and ISMPand make updates to the HP internal high risk/high alert medication list.2. The list is developed based on commonly dispensed high risk/high alertmedications and the medications listed in the MUGs ® .3. The following procedures are in place for the identified high risk/high alertmedications:a. Warfarin (Coumadin ® ), Methadone, and Infusion/Injectables: Thehealthcare provider must verbally relay the medication directionsdirectly to the pharmacist (via telephone). That pharmacist must thentranscribe and verify the request.b. Paregoric and Opium Tincture: Opium Tincture is not stocked ordispensed by HP.c. Opioid concentrated liquids: When transcribing and verifyingconcentrated liquid requests, the dose including mg and mL shall beincluded on the prescription label.d. Methotrexate: The clinical pharmacist must transcribe and verify hisown work. If the purpose of the medication is not made apparent, theweekly dose is greater than 15mg, or the dose frequency other than aweekly schedule is requested, the pharmacist must call the prescriberto verify the use, dose, and frequency prior to the medication beingprofiled or dispensed. Furthermore the outcome of the call to theprescriber must be documented in the encounter comments and in theinternal comments.4. Abbreviations can cause problems with high-risk medications. Partneringhospices are encouraged to avoid the use of inappropriate abbreviations.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2014 excelleRx, Inc – Page 1 of 2RM 4 25 High Risk Medications

HIGH RISK MEDICATIONSConcentrated LiquidsHydromorphone injection andmorphine injectionInfusions and InjectablesLANTUS (insulin glargine)LENTE (insulin zinc suspension)HUMULIN (human insulin products)HUMALOG (insulin lispro)NOVOLIN (human insulin products)NOVOLOG (human insulin aspart)NOVOLIN 70/30 (70% isophane insulin[NPH] and 30% insulin injection [regular])NOVOLOG MIX 70/30 (70% insulin aspartprotamine suspension and 30% insulin aspart)MethadoneParegoric and Opium TinctureWarfarin SodiumHypoglycemics, oralModerate sedation agents, IV (e.g.midazolam)Moderate sedation agents, oral, forchildren (e.g. chloral hydrate)Methotrexate, oral, non-oncologicusePromethazine, IVHigh Alert and High Risk MedicationsSAFETY STRATEGIES• Always include the concentration and dose on the prescription label when profilingor dispensing.• Always include the mL to mg conversion on the prescription label, such as:Roxanol 20mg/mL: Take 0.5 mL (=10mg) by mouth every6 hours as needed for pain• Verify that patients and caregivers understand how to measure the proper dose.Healthcare providers have mistakenly believed that hydromorphone is the generic namefor morphine, however these products are not interchangeable. Read back and confirmthe product with the healthcare provider.The clinical pharmacist for the encounter must transcribe and verify his or her ownwork.• Similar names, strengths and concentration ratios of some products (70/30) cancontribute to medication errors.• Emphasize the word “mixture” or “mix” along with the name of the insulin products.• Always write out “units” when transcribing these requests.Only specifically trained pharmacists may provide clinical recommendations formethadone according to the HP dosing and monitoring algorithm and take methadoneverbal requests. The methadone-trained pharmacist must verify and transcribe his orher own work.excelleRx does not stock or dispense Opium Tincture.The clinical pharmacist for the encounter must transcribe and verify his or her ownwork. Hospice nurses are required to report monthly INR values, which aredocumented in the patient’s clinical pharmacy record.Pharmacists are to assess for adequate patient nutritional intake when an oralhypoglycemic medication is profiled for any patient.The clinical pharmacist for the encounter must transcribe and verify his or her ownwork.When the patient is a child, his or her weight must always be documented in theSecure Client Access (formerly Xeris®) encounter and in the internal comments fields.The clinical pharmacist for the encounter must also transcribe his or her own work.The clinical pharmacist for the encounter must transcribe and verify his own work. Ifthe purpose of the medication is not made apparent, the weekly dose is greater than15mg, or the dose frequency other than a weekly schedule is requested, thepharmacist must call the prescriber to verify the use, dose, and frequency prior to themedication being profiled or dispensed. The outcome of the call to the prescriber mustbe documented in the encounter comments and in the internal comments.• The clinical pharmacist for the encounter must transcribe and verify his or her ownwork.• Pharmacists will receive education regarding appropriate routes of administration forparenteral promethazine.Disclaimer: This document is intended for information purposes only. It is not intended as legal or clinical advice and does notreplace medical advice or care.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2014 excelleRx, Inc – Page 2 of 2RM 4 25 High Risk Medications

POLICY:Unit Dosed Prefilled Oral SyringesREVISION DATES:October 30, 2014POLICY NUMBER:RM 4.26DEPARTMENT:Call Center and FulfillmentPOLICY:Unit dosed prefilled oral syringes are available for specific medications and doses, uponrequest.PROCEDURES:1. If deemed appropriate, the Clinical Pharmacist will review available options for unitdose oral liquid medications.2. All dispenses requested for unit dose will need to be dispensed in the exact sizewhich equals the dose to be administered.3. Due to patient safety reasons, doses where pre-filled syringes are not available inthe requested dose will not be honored. The Clinical Pharmacist will discussalternative options available with the nurse and prescriber.4. Unit dose prefilled oral syringes will have a packaging cost per syringe associatedwith each dispense.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2014 excelleRx, Inc – Page 1 of 1RM 4.26 Oral UD Prefilled Syringes V2 edited

POLICY:Fall Assessment and PreventionREVISION DATES:August 1, 2006;August 1, 2008POLICY NUMBER:RM 4.27DEPARTMENT:MMSCPOLICY:Although it is often difficult to assess whether the risk of falls is directlyassociated with drug effects or with indications for drug use (insomnia, mentalstatus changes, etc.), especially in the elderly and/or hospice population, HPpharmacists will provide their input and expertise about medications and apatient’s risk for falls when requested.HP takes the necessary steps to ensure that high fall risk medications areproperly evaluated by identifying medications that have an increased potential toinduce falls, especially in the elderly population (see table attached). Upon arecommendation or consideration for the use of one or more of the medicationsdeemed as high risk for falls, a risk versus benefit analysis will be completed by aclinical pharmacist prior to the dispensing and administration of such agents.PROCEDURE:1. HP clinical pharmacists will analyze risks versus benefits upon arecommendation or consideration for the use of one or more medications ifthe medication is considered to potentially increase the patient’s risk for falls.2. HP recommends that hospice patients with a high risk for falls receivingmedications that may increase that risk should be continually assessed bytheir hospice nurse for side effects including falls as well as other risk factorsthat may contribute to falls (i.e., environmental, functional impairments). HPpharmacists should advise and remind nurses to be aware of the potential fora fall when a patient takes a medication that increases that risk.3. HP may also provide education programs focused on medication related fallrisk factors and preventative measures that can be taken to reduce the riskfor falls in the elderly. The partnering hospice is responsible for providingeducation to patients and caregivers about common environmental factorsthat can increase the risk for falls in the home care setting.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2014 excelleRx, Inc – Page 1 of 2RM 4.27 Fall Assessment and Prevention

***THIS DOCUMENT IS FOR HP INTERNAL USE ONLY.***HIGH FALL RISKMEDICATION CLASSESAnalgesicsAnxiolyticsAntidepressantsAnticholingericsAntihypertensivesCardiac medicationsSedative-hypnoticsHigh Fall Risk MedicationsMAY INCREASE RISK OF FALLS DUE TO:Sedation, dizziness, cognitive impairmentSedation, dizziness, cognitive impairmentDizziness, cognitive impairment, postural hypotensionSedation, postural hypotension, blurred visionHypotensionHypotensionSedation, dizziness, cognitive impairmentHypoglycemicsDizziness, cognitive impairment, blurred vision, alteredbalance (from acute hypoglycemia)NeurolepticsSedation, dizziness, cognitive impairment, EPS, posturalhypotensionAny of the above medication classes or any other medication class that can cause sedation, dizziness,cognitive impairment, hypotension, visual changes, and altered balance should be evaluated forappropriateness for the patient.Adapted from: Fuller G. Falls in the Elderly. American Family Physician 2000;61(7)Sample Safety Strategies• Analyze risks versus benefits upon a recommendation or consideration for theuse of one or more medications if the medication is considered to potentiallyincrease the patient’s risk for falls.• As appropriate, advise and remind nurses and/or caregivers to be aware of thepotential for a fall when a patient takes a medication that increases that risk.• Additional risk factors that increase risk of fall include but are not limited to:o A previous fall in the last 6 monthso Difficulty walking or getting out of bed or chairso Difficulty maintaining balance while walkingo Feeling weak or dizzyo Forgetting limitations or cognitive impairments such as Alzheimer’sAdapted from: US Department of Veterans Affairs, National Center for Patient Safety 2004 Falls ToolkitexcelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2014 excelleRx, Inc – Page 2 of 2RM 4.27 Fall Assessment and Prevention

POLICY:Patient Information Leaflets (PILs)POLICY NUMBER:RM 4.28DEPARTMENT:Performance ImprovementREVISION DATES:August 1, 2006September 1, 2009April 30, 2010August 31, 2010October 3, 2013POLICY:HP is committed to fostering safe and informed use of medications. PatientInformation Leaflets (PILs) are an important part of effective patient counselingpractices. Patient information is provided with each new prescription dispensedconsistent with the intended use of the medication.The patient information distributed by HP includes both commercially availableand customized information.PROCEDURE:1. Patient Information Leaflet Review: Patient information leaflets arereviewed to ensure that the language and content is current and accurate.Patient information leaflets chosen for review are selected based uponfrequency of use, FDA notifications and product labeling updates.2. Patient Information Leaflet Customization: Customized PILs may becreated for medications compounded by HP and for medications specificallyintended for use in hospice patients. The PILs are developed to meet therecommended criteria set forth in the Action Plan for the Provision of UsefulPrescription Medicine Information (Keystone Guidelines).3. Distribution of Patient Information Leaflets: PILs are distributed andpackaged with the first dispense of the corresponding medication.Additionally, a copy of the PIL can be viewed and printed from HP Online,under “Patient’s Orders”. However, only the PIL associated with the firstdispense of a medication may be viewed, not refilled medications. Patientinformation leaflets may also be distributed when requested by the patient,caregiver, nurse or physician. Requests for PIL distribution should bedirected to the PILs development group at PILS@excelleRx.com.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright ©2014 excelleRx, Inc – Page 1 of 1RM 4.28 Patient Information Leaflets

POLICY:Infection Control GuidelinesREVISION DATES:August 1, 2006October 1, 2009POLICY NUMBER:RM 4.29DEPARTMENT:MMSC, CRxP and HRPOLICY:HP team members will promote practices and techniques that monitor andreduce risks of infection and ensure safeguards that will prevent thecontamination of pharmacy products.PROCEDURE:Hand Washing1. Wash hands with a bactericidal product before handling drug products.2. Wash hands with a bactericidal product after contamination or spillage.3. Properly scrub hands with a bactericidal product and don sterile gloves priorto preparing sterile products. Follow aseptic techniques and clean roomprocedures.4. Wash hands with a bactericidal product after use of the lavatory or afterhandling food products.5. Wash hands with a bactericidal product as needed for routine cleanliness.Cleaning of Work Surfaces and Equipment:1. Spray all work surfaces with alcohol and wipe down with a clean paper towelat the end of each working day when spillage occurs, and as needed.2. Clean counting trays and spatulas with alcohol daily and as needed, or washin dishwasher as needed and at the end of each day.3. Clean compounding equipment in hot soapy water and rinse thoroughly aftereach mixture. Wash in dishwasher at the end of each working day.4. Use aseptic techniques when preparing sterile compounds and intravenousproducts. Please refer to policies regarding procedures for clean roomcompounding technique.Employee Health Guidelines:1. Employees with a cough, fever, flu, or contagious cold symptoms may notprepare unpackaged medications.2. Report open cuts, rashes or scores on your hands or other body parts toSupervisor prior to reporting to work and wear gloves. Any open or drainingwounds may be subject to a physician’s note to return to work.3. Communicable diseases must be reported to HR prior to reporting to work. Aphysician’s note may be required.4. No food products or eating will be permitted in the lab work areas.5. The workspace counters will be limited to medication preparation and clear ofall non-related items.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2014 excelleRx, Inc – Page 1 of 1RM 4.29 Infection Control Guidelines

POLICY:Clinical and Administrative ReportsREVISION DATES:April 30, 2010DOCUMENT NUMBER:RM 4.30DEPARTMENT:Client Relations, PerformanceImprovement, IT/DevelopmentHospice Pharmacia provides online access to clinical and administrative reports.These reports provide current and historical information helpful in managingmedication utilization across the organization, within a specific team/group or foran individual patient.For information about billing reports, please refer to RM 3.2 – Understanding andPrinting Your Hospice Pharmacia Billing Report.The following tables summarize the most commonly used clinical andadministrative reports available on Secure Client Access (formerly Xeris ® ). For afull list of available reports, please see the online listing under “Report Options.”Clinical ReportsReport Name Description Potential Use(s)Active MedicationReport (AMR)Shows the active medication profile forall patients within a specific group(s) fora selected day. Display of inactiveand/or discontinued medications is anoption. Lists the date of the most recentmedication profile review completed bya pharmacist.Review and reconcile patientmedication profiles.Refill ReminderReportMedicationAdministrationRecord Report(MAR)Shows the most current record ofmedications that have been dispensedby Hospice Pharmacy as of today’sdate.Provides a form that may be used as arecord of the medications administeredto a patient at a facility by a nurse orother healthcare professional. Pleasenote this is only available for patientsadmitted to an inpatient unit.Review with patient or caregiver toidentify medication needs. Plan forvacations or holidays.Record administration of routineand PRN medications.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2014 excelleRx, Inc – Page 1 of 3RM 4.30 Clinical and Administrative Reports

Administrative ReportsReport Name Description Potential Use(s)Billable DaysReportList of all patients that were active withHospice Pharmacia, the number of billabledays, and charge for those days for aselected time period.Census management.ComfortPakExpiration ReportLists all patients to whom HospicePharmacia has dispensed aComfortPak TM . Included within the reportare the dispense date of the ComfortPak,the expiration date, number of days untilthe ComfortPak expires, and the type ofComfortPak.Use during IDT meetings to identifypatients who require a replacementComfortPak.Hospice CIIPrescriptionsRequiring SignatureLists prescriptions for controlledsubstance schedule 2 (CII) medicationsthat require a prescriber signature fordispense by Hospice Pharmacia.Use daily to identify prescriptionsthat require a prescriber signature.Medication OutsidePer DiemDispensed ReportList of all medications dispensed outsideof the per diem by patient for a selectedperiod of time.Identify patients for whom amedication outside the per diem wasdispensed, the drug, total price, andauthorizing nurse and/or hospiceadministrator.Medication OutsidePer Diem UtilizationBy MedicationReportList of all medications dispensed outsideof the per diem (including quantitydispensed and total cost) for a selectedperiod of time.Identify the common medicationsoutside per diem used by yourorganization or group/team.Medication OutsidePer Diem Utilizationby PrescriberReportLocal PharmacyReportLTC PatientMedication StatusSummaryList of medications dispensed outside ofthe per diem and the physician whoprescribed the medication for a selectedtime period.Lists all medications dispensed by localpharmacies and the patient for whom themedication was dispensed for a selectedperiod of time.Indicates whether or not a profiledmedication profile was authorized and ifthe medication was ultimately billed toHospice Pharmacia. Please note thisreport is only available for patientsresiding in a LTC facility.Identify medication outside per diemprescribing trends according tophysician.Identify medications being filled atlocal pharmacies.Monitor the status of LTC patients’medications.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2014 excelleRx, Inc – Page 2 of 3RM 4.30 Clinical and Administrative Reports

PROCEDURE:To access an organization or group/team report:1. Go to www.hospicepharmacia.com2. Type in the Username and password given to you by your Secure ClientAccess (formerly Xeris ® ) Hospice Administrator.3. Select “Report Options” ( ) on the left side of the screen.4. Select the desired report.5. Enter the requested information (i.e., date range, group/team, reportdisplay options, etc.). To generate a report for the entire organization,select “All Groups.” To generate a report for a specific group or team,select the name of the desired group.6. Select “Run Report” at the bottom of the screen.7. The report will be generated as a PDF file. You may print, save or exportthe file as a Microsoft Excel ® spreadsheet.To access a report on an individual patient:1. Go to www.hospicepharmacia.com2. Type in the Username and password given to you by your Secure ClientAccess (formerly Xeris ® ) Hospice Administrator.3. Select “Find Patients” ( ) on the left side of the screen.4. Enter the name of the patient in the provided box (i.e., [LastName,FirstName] or [FirstName LastName]).5. Select the desired patient by clicking on the arrow next to the patient’sname ( ). This is only necessary if there multiple patients with the samename.6. Select “Patient Reports” ( ) on the left side of the screen.7. Select the desired report. Please note that only clinical reports areavailable for individual patients.8. If necessary, enter the requested information (i.e., date range, reportdisplay options.9. The report will be generated as a PDF file. You may print, save or exportthe file as a Microsoft Excel ® spreadsheet.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2014 excelleRx, Inc – Page 3 of 3RM 4.30 Clinical and Administrative Reports

Hospice PharmaciaResource ManualCopyright © 2012 excelleRx, IncSection V: Quality ImprovementRM 5.1 Performance ImprovementRM 5.2 Quality Control Process and ReportingRM 5.3 Performance Improvement PathwayRM 5.4 Medication Waste and DisposalexcelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 1Section 5 - Quality Improvement

POLICY:POLICY NUMBER:RM 5.1Performance ImprovementDEPARTMENT:Performance ImprovementREVISION DATES:August 1, 2006February 15, 2009March 10, 2009September 1, 2009POLICY:HP conducts a number of ongoing performance initiatives. HP tracks andmonitors performance and allocates resources to study and document corporateperformance.PROCEDURE:1. The Performance Improvement department is charged with the responsibilityto manage performance improvement initiatives across the company.2. The Performance Improvement department establishes, reviews, andevaluates performance improvement initiatives and specific performanceimprovement plans as part of leadership meetings and ad hoc project groups.3. Performance and QA reports are presented to leadership teams as well asclients.4. Performance Improvement processes includes documentation of issue/event,root cause analysis, improvement plan implementation, outcome evaluation,and follow-up.5. The need for Performance Improvement initiatives is assessed throughreported events, departmental reviews, internal/external satisfaction surveys,customer expectation monitoring/feedback, and general system reviews.6. QA data is reviewed for trends on a Quarterly basis and PI projects areinitiated when trends are identified. Quarterly updates are distributed to allpartnering Hospices, addressed to the QA contact.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2012 excelleRx, Inc – Page 1 of 1RM 5.1 Performance Improvement

POLICY:Quality Control Process and ReportingPOLICY NUMBER:RM 5.2DEPARTMENT:Customer Service/ QualityAssuranceREVISION DATES:February 15, 2009March 9, 2009September 1,2009April 30, 2010October 11, 2011September 19, 2013POLICY:HP maintains ongoing performance improvement programs. The CustomerService department and Clinical Support Team determine the need for QualityImprovement initiatives and programs through tracking, documentation, andreview of Customer Service reports. Performance-related issues concerningpersonnel, goods, or services provided by HP reported through Secure ClientAccess by phone or other written means will be documented, tracked, andevaluated in accordance with a systematic procedure.PROCEDURE:1. Each unexpected event, occurring as a result of the personnel, goods and/orsystems used by HP to provide medication management services andmedications to patients, is documented in the CS/QA reporting System.2. An event may be reported by HP team members or submitted to HP from thepartnering hospice or health care provider. QA events may be reported usingthe CS form in Secure Client Access, verbally over the phone to an HP teammember or submitted in writing. All reported QA events will be documented inThe HP database upon submission through Secure Client Access. Directionsfor how to submit a CS/QA event in Secure Client Access are found below.3. When a CS/QA event is entered into the system, an event report is opened;this report is assigned to a CS coordinator for review, investigation, rootcause analysis, and resolution plan documentation.4. The CS Coordinator collects and tracks outstanding issues and maintainsevents in the database. The CS Coordinator will determine the process routefor each report including level determination (see priority grid found below),root cause analysis, and processing as necessary.Procedure for Reporting EventsAs soon as a performance-related issue is identified by any HP personnel, aQuality Assurance report is initiated in the HP database.CS/QA report document includes the following:1. The current date and person filling out the form;2. The date of the incident and patient/family involved (if applicable);3. A full explanation:a. Who was involved, what occurred, where the incident took place, whenit occurredb. The action that was taken, by whom, and whenc. When available, the outcome of the incident and the resultant actionexcelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2013 excelleRx, Inc – Page 1 of 3RM 5.2 Quality Control Process and Reporting.doc

d. If any follow-up is to occur (or has occurred), what it is, who should doit, and when it should be donee. Additional dialogue or information is placed in the comments section;All Sentinel Events or Priority One incidents are reported to the administratoron-call at 1-800-395-2371 or the Director, Clinical Support (ext. 1738).Procedure for Tracking and Communication of Events1. The HP team members involved are identified; the person responsible forthe root-cause analysis is identified.2. Nurse(s) and hospice are listed.3. The incident is prioritized and communicated according to the guidelinesprovided in the QA Event Priority Stratification table found below.4. Sentinel and Priority One Events are communicated by the CustomerService Supervisor, or Client Services Account Manager. Seniormanagement is immediately notified. Immediate response and dailyupdates are required until resolution is satisfactory.5. QCRs are processed by the CS Coordinator every weekday and resolvedwithin the time outlined by the level of the event.6. Completed reports are routed automatically by the system to theSupervisor of Customer Service7. The CS Supervisor reviews QA reports and trends daily to providefeedback to partnering hospices, team members, and seniormanagement.8. Upon resolution of the event, a formal QA summary or report can beprovided to the Hospice client. Secure transmission is required so Hospicewill need to provide current contact information and preference forcommunication (Phone, Fax, or Email).9. Aggregate reports regarding QA categories are available to partneringhospice administrators for use in performance improvement initiatives.10. HP’s Customer Service team members are available for routine and adhocQA conferences with partnering hospices.11. QA reports are graphed and trended. Negative trends are identified on aquarterly basis and a Quality initiative is discussed, to begin the process.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2013 excelleRx, Inc – Page 2 of 3RM 5.2 Quality Control Process and Reporting.doc

QA Event Priority StratificationPriority Hospice Communication Internal CommunicationSentinel Event:The patient is at risk for harm.Priority One:• The incident needs immediatecorrection.• The patient, family or hospice teammember have requested animmediate response.• This type of event has occurredmore than five times and requirespriority investigation.Priority Two:• The patient is not at risk for harm,but the incident needs furtherinvestigation.• The incident has been resolved, butit needs further follow-up.• The incident has occurred at leastonce during the last 30 days.Priority Three:• Medication access or otherpharmacy service was not availableas expected; the patient did havemedication.• The incident does not needimmediate correction.• The reported incident is old; there isno immediate patient concern; rootcause analysis is necessary.• The incident has been resolved, butneeds further follow-up.Assure hospice contact immediateaction will take place and QCRreport will be filed. If received byfax/other, call the hospiceimmediately; confirm receipt andoutline corrective action plan.Assure hospice contact immediateaction will take place and QCRreport will be filed. If received byfax/other, call the hospiceimmediately, confirm receipt, andoutline corrective action plan.Assure caller/hospice contact that aQCR will be filed, and aninvestigation of events may take upto 1 week to perform. HP willcontinue to follow-up with thehospice contact to assure that theevent has been resolved.Assure caller/hospice contact that aQCR report will be filed and aninvestigation of events will takeplace.Fix the problem or get help to fix theproblem. Page the Administrator oncallto inform him/her of the eventand, communicate your resolutionplan or get further direction.File the QCR report. The CScoordinator will document the full rootcause analysisFix the problem or get help to fix theproblem. Page the Administrator oncallto inform him/her of the event,and communicate your resolutionplan or get further direction.File the QCR report. The CScoordinator will document the full rootcause analysisFile a QCR in the database for QA.The CS coordinator will investigatethe report and perform a full rootcause analysis where warranted.File QCR report. The CS coordinatorwill document the case.How to Enter a QA Event in Secure Client Access:Step 1: Go to www.hospicepharmacia.com.Step 2: Type in the Username and Password given to you by your Secure ClientAccess Hospice Administrator (XHA).Step 3: Search for the patient for whom the QA is being submitted.Step 4: Click the CS iconand fill out the QA Event Reporting form.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2013 excelleRx, Inc – Page 3 of 3RM 5.2 Quality Control Process and Reporting.doc

POLICY:Performance Improvement PathwayPOLICY NUMBER:RM 5.3DEPARTMENT:Performance ImprovementREVISION DATES:August 1, 2006February 15, 2009March 10, 2009September 1, 2009April 30, 2010September 19, 2013Event reported by hospicepersonnel to HP staff; HPstaff acknowledges receiptand enters issues in theQA system.Hospice personnel enters aQuality Assurance event inthe QA system.QA report is sent (phone,fax, e-mail) directly to theCustomer Service Team.QA system assigns a case numberand CS Coordinator. The CSCoordinator assigns a priority level andinitiates an investigation. Level 1 reportsare confirmed and HP Clinical Supportteam is notified.For Sentinel or Level 1events, HP oncal staff, orCS Supervisor isimmediately notified , andthe hospice is contacted.Confirm priority levelReport case assignmentand follow-upexpectations.Internal Communicationsbased on priority level.Root Cause Analysisperformed by CRxP, MMSC,CS Coordinator or designee.Research is tracked by the CSCoordinator.Findings and resolutionsare documented in the QAdatabase, therebycompleting the QA Report.Client ContactQA report is provided tohospice when requested,via secure fax or emaildocument.Staff NotificationHP staff involved is notified ofevent and improvement planexpectations are set by thesupervisor.ReportingCS Supervisor reviews dailyreported events, trends andmakes performanceimprovement recommendations.Vendor NotificationVendors involved are notifiedof the event and improvementor resolution plans.Trends are reviewed on a quarterlybasis and Quality Initiative projectsare assigned based on identifiedtrends. Quarterly updates arecommunicated to all partneringHospices.Outcome of performanceimprovement or qualityinitiatives are tracked andreported to seniormanagement.excelleRx ® , Inc. d.b.a. Hospice PharmaciaCopyright © 2013 excelleRx, Inc – Page 1 of 1RM 5.3 Performance Improvement Pathway.doc

POLICY:Medication Waste and DisposalPOLICY NUMBER:RM 5.4DEPARTMENT:Corporate ComplianceREVISION DATES:March 1, 2008;April 1, 2008;May 5, 2009;October 15, 2014POLICY:Enclara Pharmacia (“EP”) is committed to providing hospices with “best practice”recommendations to assist our partners in the development of their ownmedication waste and disposal policy. EP is at the forefront of researching andparticipating in programs to address the problem of medication waste. Inaccordance with Federal, State, and local regulations and the MedicareConditions of Participation (COPs), the hospice shall develop its own internalpolicy for the destruction of controlled substances after a drug regimen isdiscontinued or the patient expires.PROCEDURE:Medications, once dispensed to the patient, are the patient’s personal property.It is the hospice’s responsibility to implement and monitor its policies; thehospice administrator, medical director and legal counsel should review thehospice’s medication waste and disposal policy. The followingrecommendations may be used by our partnering hospices whendeveloping their own policies.I. Medication Waste Policy Components: The Drug EnforcementAdministration’s (DEA’s) final rule for the Disposal of Controlled Substances(“The Disposal Act”) became effective October 9, 2014. The Disposal Actexpands the available options to collect and dispose of unused, unwanted, orexpired controlled substances in a secure and safe manner. Most states mayalready have regulations on destruction of unused medications for patients inlong term care or inpatient unit settings; some may also have regulations onmedication destruction in the homecare setting. In view of the Disposal Act,Hospices should update policies and procedures for medication destruction inaccordance with any changes in regulations at the Federal, state, and locallevels. A policy for medication collection and destruction for homecaresettings should include the following components:1. Creating and Implementing: Hospice should consider several factorswhen creating and implementing a Medication Waste Disposal Policy,including but not limited to relevant laws, regulations, and guidelines,commitment to environmentally-friendly or “green” policies, staffing issues,and the risk of diversion of certain medications. The final policy should befollowed and enforced. Revisit the policy from time to time to ensure itremains viable and up to date with current laws and disposal practices.2. Informing:Enclara PharmaciaCopyright © 2014Page 1 of 9RM 5.4 Medication Waste Disposal.doc

a. Staff: Hospice shall provide all nurses with training on his/her role intracking, collecting and disposing of unused controlled substancesafter a patient expires.b. Patients and Families: Upon admission, present the patient and/orcaregiver with information about the hospice’s policies regarding thedisposal of medications. These policies can be included in theadmission packet. Information should be re-presented at time ofmedication discontinuation or patient’s death.3. Collecting:a. Based upon the DEA Disposal Act, medications are the property of thepatient and/or the patient’s dependents upon his/her death. Hospiceemployees may educate or supervise the family in disposal, but theycannot take possession of the medications during the act of disposal;doing so is considered “distribution”.b. After a patient expires, and dependent upon hospice’s policy, thehospice nurse may assist the family or family caregiver with thecollection and disposal of any unused controlled and non-controlledsubstance medications. The hospice may provide kitty litter or othersubstances for the family to use to safely dispose of medications, orprovide containers for collection centers or other.c. The DEA Office of Diversion Control’s Registration Call Center can becontacted at 1-800-882-9539 for a list of local authorized collectors andcollection and disposal information related to any unused controlledand non-controlled substance medications.d. In the case of a refusal by a patient’s caregiver to destroy or dispose ofmedication, the hospice nurse should contact their supervisor anddocument the refusal in the patient’s chart.e. Hospice nurses should never transport medications for destruction ordisposal. Several options exist for families related to disposal: onsitedisposal or deliverance to authorized collectors.4. Tracking:a. A complete list of the medications that are disposed of by the patient orcaregiver at time of medication discontinuation or patient’s deathshould be provided on a form supplied by the hospice designed todocument medication disposal/destruction.b. The disposal/destruction medication list should include themedication’s name, strength, and quantity. The list should identify thedate, location and method of destruction and names and signatures ofwitnesses, as required by law.c. A copy of the disposal/destruction medication list should be provided tothe patient’s caregiver and the original shall be kept in the patient’schart.d. A sample form is attached.5. Disposing:a. Hospice policy should identify standardized methods of destruction anddisposal, including mail-back programs, take-back events, or collectionEnclara PharmaciaCopyright © 2014Page 2 of 9RM 5.4 Medication Waste Disposal.doc

eceptacles. For example, retail pharmacies and hospitals/clinics withan on-site pharmacy may operate collection receptacles at long-termcare facilities.b. Hospice should periodically review Federal, state, and local regulationsfor any changes in disposal procedures.c. For a list of suggested best practices, please see attached.d. Medications should be disposed of by the patient/family or caregiver insuch a manner that does not allow for the controlled substance to beeasily retrieved. In situations where patient has expired, the hospicestaff may supervise and educate a caregiver on the proper disposal ofany unused controlled substance medications.II. Medication Disposal – Suggested Best Practices1. Office of National Drug Control Policy: Hospices should review theguidelines published by Federal government for best practices (attached).2. Community Drug Collection and Disposal: Some states and countiesmay have organized local household prescription drug take-back eventswhere they will collect unused medications for safe destruction, incompliance with Federal, state, and local laws. Due to the Disposal Act,the DEA has no plans to sponsor nationwide additional Drug Take- BackDays. Furthermore, such take-back programs may be utilized by familycaregivers but not hospice nurses or other staff when acting in theirprofessional capacity.3. Destruction in the Homecare Setting:a. Document all destruction of Controlled Substances. It isconsidered best practice that destruction should be facilitated andwitnessed by a licensed healthcare practitioner and witnessed by atleast one other individual.i. If the patient expires while lawfully in possession of a controlledsubstance for personal use, any person lawfully entitled to disposeof the deceased’s property may deliver the controlled substance toauthorized collectors for disposal (e.g. reverse distributors,pharmacy mail-back programs, take-back events, or collectionreceptacles). Therefore, a member of the hospice patient’shousehold may dispose of the patient’s controlled substances, butthe hospice nurse or staff cannot do so unless otherwise authorizedby state law. The hospice nurse may educate and supervise thefamily in proper disposal and/or witness the disposal.1) Certain Controlled Substances can be flushed down the toilet(attached list).b. Non-Controlled Substances.i. Remove medication from original containers. To discard thecontainer, eliminate all Protected Health Information [PHI] includingpatient’s name. This can be done with black permanent marker orby scratching out.ii. Modify the Contents.Enclara PharmaciaCopyright © 2014Page 3 of 9RM 5.4 Medication Waste Disposal.doc

1) Solid Medications: add a small amount of water to pills orcapsule in order to partially dissolve them into a slurry. Mix theslurry with any of the materials recommended in section below.2) Liquid Medications: add enough kitty litter, flour, cornmeal,table salt, charcoal or non-toxic powder or spice to create adistasteful, pungent mixture in order to discourage consumption.Never mix medications with toxic chemicals or otherproducts that may be harmful to humans if swallowed ordigested. Do not flush medications in toilets containingClorox ® or other bleach tablets.3) Blister packs: wrap packages in multiple layers of opaque ducttape.iii. Seal and Conceal. Once the unused medications have beenmodified, seal them in the container to be disposed of. Make surethe container can be sealed or closed. Tape the container withpacking or duct tape. Ensure that the container cannot be seen byplacing the sealed container inside a non-transparent bag orcontainer [e.g. cardboard box, coffee can, opaque disposal bag].Do not conceal the contents in food, as this may inadvertently leadto consumption by local wildlife.iv. Discard the Container. Place the sealed and concealed containerinto the household garbage can for municipal pickup. Do not placeinto the household-recycling bin.Reference:DEA Disposal of Controlled Substances; Final Rule, 21 C.F.R. Parts 1300, 1301, 1304, et al. (2014).Available at: http://www.deadiversion.usdoj.gov/fed_regs/rules/2014/2014-20926.pdf. Accessed October15, 2014.Enclara PharmaciaCopyright © 2014Page 4 of 9RM 5.4 Medication Waste Disposal.doc

Medicines Recommended for Disposal by FlushingListed by Brand Name and Generic NameThere is a small number of medicines that may be especially harmful and, in some cases, fatal with just one dose ifthey are used by someone other than the person for whom the medicine was prescribed. This list from FDA tellsyou what expired, unwanted, or unused medicines you should flush down the sink or toilet to help prevent dangerto people and pets in the home.Brand Name (dose form)Generic NameAbstral (sublingual tablets)FentanylActiq* (oral transmucosal lozenge) Fentanyl citrateAvinza (extended- release capsules) Morphine sulfateBuprenorphine hydrochloride*Buprenorphine hydrochloride(sublingual tablets)Butrans (extended- release patch) BuprenorphineDaytrana ( transdermal patch system) MethylphenidateDemerol* (tablets)Meperidine hydrochlorideDemerol* (oral solution)Meperidine hydrochlorideDiastat/Diastat AcuDial (rectal gel) DiazepamDilaudid* (tablets)Hydromorphone hydrochlorideDilaudid (oral liquid)Hydromorphone hydrochlorideDolophine hydrochloride* (tablets) Methadone hydrochlorideDuragesic* (extended- release patch) FentanylEmbeda (extended- release capsules) Morphine sulfate, NaltrexonehydrochlorideExalgo (extended- release tablets) Hydromorphone hydrochlorideFentora (buccal tablets)Fentanyl citrateKadian (extended- release capsules) Morphine sulfateMethadone hydrochloride* (oral solution) Methadone hydrochlorideMethadose* (tablets)Methadone hydrochlorideMorphine sulfate* (immediate-release Morphine sulfatetablets)Morphine sulfate* (oral solution) Morphine sulfateMS Contin* (extended-release tablets) Morphine sulfateNucynta ER (extended-release tablets) TapentadolOnsolis (buccal soluble film)Fentanyl citrateOpana (immediate-release tablets) Oxymorphone hydrochlorideOpana ER (extended-release tablets) Oxymorphone hydrochlorideOxecta (immediate-release tablets) Oxycodone hydrochlorideOxycodone hydrochloride* (capsules) Oxycodone hydrochlorideOxycodone hydrochloride* (oral Oxycodone hydrochloridesolution)Oxycontin* (extended-release tablets) Oxycodone hydrochloridePercocet* (tablets)Acetaminophen, Oxycodone hydrochloridePercodan* (tablets)Aspirin, Oxycodone hydrochlorideSuboxone (sublingual film)Buprenorphine hydrochloride, NaloxonehydrochlorideXyrem (oral solution)Zubsolv (sublingual tablets)Sodium oxybateBuprenorphine hydrochloride, Naloxonehydrochloride*These medicines have generic versions available OR are only available in generic formulations. FDA continually evaluates medicines for safety risksand will update the list as needed. Please visit the Disposal of Unused Medicines: What You Should Know page at www.fda.gov for moreinformation. November 2013

Medicines Recommended for Disposal by FlushingListed by Generic Name and Brand NameThere is a small number of medicines that may be especially harmful and, in some cases, fatal with just one dose ifthey are used by someone other than the person for whom the medicine was prescribed. This list from FDA tellsyou what expired, unwanted, or unused medicines you should flush down the sink or toilet to help prevent dangerto people and pets in the home.Generic NameBrand Name (dose form)Acetaminophen, Oxycodone hydrochloride Percocet* (tablets)Aspirin, Oxycodone hydrochloride Percodan* (tablets)BuprenorphineButrans (extended- release patch)Buprenorphine hydrochlorideBuprenorphine hydrochloride*Buprenorphine hydrochloride, NaloxonehydrochlorideDiazepamFentanylFentanyl citrateHydromorphone hydrochlorideMeperidine hydrochlorideMethadone hydrochlorideMethylphenidateMorphine sulfateMorphine sulfate, NaltrexonehydrochlorideOxycodone hydrochlorideOxymorphone hydrochlorideSodium oxybateTapentadol(sublingual tablets)Buprenorphine hydrochloride,Naloxone hydrochlorideSuboxone (sublingual film)Zubsolv (sublingual tablets)Diastat/Diastat AcuDial (rectal gel)Abstral (sublingual tablets)Duragesic* (extended- release patch)Actiq* (oral transmucosal lozenge)Fentora (buccal tablets)Onsolis (buccal soluble film)Dilaudid* (tablets)Dilaudid (oral liquid)Exalgo (extended- release tablets)Demerol* (tablets)Demerol* (oral solution)Dolophine hydrochloride* (tablets)Methadone hydrochloride* (oral solution)Methadose* (tablets)Daytrana ( transdermal patch system)Avinza (extended- release capsules)Kadian (extended- release capsules)Morphine sulfate* (immediate-releasetablets)Morphine sulfate* (oral solution)MS Contin* (extended-release tablets)Embeda (extended- release capsules)Oxecta (immediate-release tablets)Oxycodone hydrochloride* (capsules)Oxycodone hydrochloride* (oralsolution)Oxycontin* (extended-release tablets)Opana (immediate-release tablets)Opana ER (extended-release tablets)Xyrem (oral solution)Nucynta ER (extended-release tablets)*These medicines have generic versions available OR are only available in generic formulations. FDA continually evaluates medicines for safety risksand will update the list as needed. Please visit the Disposal of Unused Medicines: What You Should Know page at www.fda.gov for moreinformation. November 2013

Medication Waste and Disposal/Destruction LogSample Hospice Name and AddressPatient Name:Date of Birth:Patient Address:Nurse:Phone:Date of Inventory and Disposal/Destruction: Time: am / pmInstructions: Unused medication should be disposed and destroyed in accordance with hospice policy. Use blank spaces providedbelow to indicate all unused medications belonging to this patient. Original form should be placed in patient’s chart and copyprovided to family upon request.Drug Strength Dosage FormUnused Qty forDisposal/DestructionDisposal/DestructionMethodInitials ofWitnessSAMPLEFor example purposes only.Comments:Signature of Nurse:Signature of Caregiver:This document contains protected health information (PHI) and is subject to all privacy regulations set forth under HIPAA.