Transitions Hospice, LLC

“It is required that each patient’s individualized written plan of care reflect patient and family goals and include measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 23 (13%) clinical records reviewed it was revealed that the agency did not ensure patient-specific measurable goals for treatment were included in the patient’s plan of care (POC). CLINICAL RECORD 15: The patient resided in an assisted living facility and elected the hospice benefit on 10/02/2025 with a terminal diagnosis of senile degeneration of the brain. During the admission visit on 10/02/2025, the patient was observed to be alert and oriented to person only and was noted to be forgetful, confused, and disoriented. At the Interdisciplinary Group (IDG) meeting on 02/11/2026, the nurse summarized the prior two weeks of care and reported that the patient exhibited acting out behaviors when care was attempted. The nurse further indicated that the primary plan of care implemented during the previous two weeks focused on “safety.” On 03/12/2026, nursing visit documentation included that the patient was agitated and continued to experience hallucinations. The patient’s medication regimen included Hydroxyzine HCL 25 mg three times daily as needed (PRN) for anxiety; Lorazepam Intensol 2 mg/mL, 0.5 mg every four hours PRN for agitation and restlessness; Seroquel 100 mg every evening; and Seroquel 25 mg every morning for anxiety. Additionally, a physician’s order dated 03/02/2026 documented the use of ABH Cream (Ativan 1 mg/Benadryl 25 mg/Haldol 1 mg) applied topically on a scheduled twice daily basis for agitation and restlessness. A review of the patient’s plans of care covering the benefit periods from 10/02/2025 to 12/30/2025 and 12/31/2025 to 03/30/2-26 identified anxiety and altered neurological status as patient problems. However, the plans of care lacked patient specific, measurable goals addressing the management of the patient’s aggressive, acting out behaviors. CLINICA RECORD 18: The patient resided in a nursing facility and elected the hospice benefit on 01/31/2025 with the terminal diagnosis of acute and chronic congestive heart failure, with comorbid pulmonary embolism without acute cor pulmonale. On 01/17/2026, nursing documentation reflected that the patient’s oxygen saturation was 95% on 1.5 liters per minute (LPM) of oxygen, with continued symptoms of cough and dyspnea on exertion. During the Interdisciplinary Group (IDG) meeting on 02/04/2026, the nurse summarized the preceding two weeks of care and reported that the patient was alert and oriented to person, place, and time, was receiving oxygen at 3 LPM via nasal cannula, and was experiencing increased SOB, increased fatigue, and difficulty eating due to dyspnea. Despite these ongoing and progressive symptoms, no changes to the patient’s plan of care (POC) were identified for the prior two weeks. Similar findings were again documented by the nurse during the IDG meeting held on 02/18/2026, with continued reports of SOB, fatigue, and activity intolerance, without corresponding updates to the POC. A review of the patient’s plans of care for the benefit periods from 11/27/2025 to 01/25/2026 and 01/26/2026 to 03/26/2026 identified altered cardiopulmonary status and activity intolerance as patient problems. However, the plans of care did not include patient-specific, measurable goals addressing the management and treatment of the patient’s ongoing shortness of breath, air hunger, and declining functional tolerance. CLINICAL RECORD 23: The patient resided at home and elected the hospice benefit on 01/01/2026 with the terminal diagnosis of malignant neoplasm of the colon, with secondary malignancies to the liver and intrahepatic bile duct. During the admission visit on 01/01/2026, the RN documented that the patient was alert and oriented to person and place and initially denied pain. However, the assessment identified ongoing generalized pain localized to the right hip, described by the patient as sore, dull, and aching. The pain occurred intermittently throughout the day, was more pronounced at night, and negatively affected the patient’s emotional status, sleep and rest, mobility, and overall functional status. During the Interdisciplinary Group (IDG) meeting on 01/07/2026, the nurse documented that the patient continued to experience generalized pain and right hip pain and noted that the Fentanyl dosage had been increased to 50 mcg/hr. at the time of hospice admission. A review of the patient’s plan of care for the benefit period from 01/01/2026 to 03/31/2026 identified pain and the need for pain education as clinical problems. The documented goals included managing pain at an acceptable level for the patient, ensuring that the patient and caregiver verbalized understanding of pain management strategies, and reporting changes in pain to hospice. However, the patient’s stated pain goal was not incorporated into the plan of care, and the documented goals were neither patient-specific, measurable, nor time-limited. Anxiety and terminal agitation were also identified as problems within the plan of care; however, the associated goals were generalized and unmeasurable, focusing on the patient and caregiver verbalizing understanding of the cause of anxiety and terminal agitation and appropriate measures to minimize or control symptoms. The patient’s self-identified acceptable anxiety score was not included in the plan of care. The plan of care did not reflect patient-specific, measurable goals related to the management and evaluation of the patient’s anxiety and terminal agitation. After a clinical record review, discussion, and an interview with the Administrator/RN (Personnel Record 2) on 03/28/2026, she confirmed that the goals identified for each patient were neither specific to the patient nor measurable. She additionally offered that the agency is working with a new feature of the electronic medical record (EMR) and educating staff with a focus on patient-centered care plans, hoping to improve documentation for more patient-directed and patient-centered problems, interventions, and measurable goals.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. Review of the agency Volunteer Program Data revealed that the agency did not ensure that volunteer hours were equal to five percent (5%) of the total patient care hours of all paid hospice employees and contract staff for 2023, 2024, and 2025. During the review of Volunteer Program documentation and interviews with the Volunteer Coordinator (Personnel Record 7) on 03/26/2026, it was determined that the average volunteer percentage of the total patient care hours of all paid hospice employees and contract staff were 0.34% in 2023, 0.5% in 2024, and 0.7% in 2025. As a result of continued noncompliance, a Performance Improvement Project (PIP) was initiated on 01/31/2024 and remained active at the time of the site visit. During the review of Volunteer Program documentation and interviews with the Volunteer Coordinator (Personnel Record 7) on 03/26/2026, it was determined that the average volunteer percentage of the total patient care hours of all paid hospice employees and contract staff were 0.34% in 2023, 0.5% in 2024, 0.7% in 2025, and 0.67% year-to-date in 2026. These rates remain significantly below the targeted 5% volunteer requirement. As a result of continued noncompliance, a Performance Improvement Project (PIP) was initiated on 01/31/2024 and remained active at the time of the site visit. A Volunteer Coordinator has been assigned to each area - parent location and each alternate delivery site (ADS), with one coordinator hired in 2019 and two additional coordinators hired in 2023. Administrative oversight of volunteer hours has been implemented, along with enhanced efforts to recruit and retain volunteers. Education has been provided to the Interdisciplinary Team regarding the role of volunteer services and the process for requesting volunteer support. Documented recruitment strategies include posting opportunities on the Volunteer Match and Idealist websites, utilizing social media platforms, distributing flyers, outreach to local colleges, and participation in career fairs. Documented retention efforts include individualized phone calls and text messages to volunteers, inclusion of volunteers in staff gatherings, provision of small appreciation gifts, and one-on-one meetings to promote engagement through face-to-face interaction.”

“Based on the clinical record review and Staff interview, it was determined in 9 of 19 (Pts. # 3, 5, 8, 12, 15, 16, 17, 18 and 19) clinical records reviewed, the IDG failed to ensure a completed comprehensive assessment within 5 days after the Hospice election. Findings include: 1. Pt. #3 was admitted to the Hospice services on 05/23/23 with diagnosis of Senile Degeneration of the Brain. The clinical record was reviewed on 02/04/25. The clinical record included a Hospice election form dated 05/23/24. The Hospice team did not meet for completing the comprehensive assessment until 05/29/24 (more than 5 days of the election 05/23/24). 2. Pt. #5 was admitted to the Hospice services on 09/24/24 with diagnosis of Senile Degeneration of the Brain, not elsewhere Classified. The clinical record was reviewed on 02/04/25. The clinical record included a Hospice election form dated 09/24/24. The Hospice team did not meet for completing the comprehensive assessment until 10/02/24. (more than 5 days of the election 09/24/24). 3. Pt. #8 was admitted to the Hospice services on 05/19/23 with diagnosis of Cerebrovascular Disease, Unspecified. The clinical record was reviewed on 02/04/25. The clinical record included a Hospice election form dated 05/19/23. The Hospice team did not meet for completing the comprehensive assessment until 05/25/23 (more than 5 days of the election 05/19/23). 4. Pt. #12 was admitted to Hospice services on 11/30/24 with the diagnosis of Cerebrovascular Disease. The clinical record was reviewed on 02/05/24. The clinical record included a Hospice election form dated 11/29/24. The Hospice team did not complete a comprehensive assessment within 5 days after the election. 5. Pt. #15 was admitted to Hospice services on 08/08/24 with the diagnosis of Malignant Neoplasm of Lower Lobe Left Bronchus of Lung. The clinical record was reviewed on 02/05/24. The clinical record included a Hospice election form dated 08/08/24. The psychosocial and spiritual comprehensive assessments were not completed until 08/15/24, which was more than 5 days after the election. 6. Pt. #16 was admitted to Hospice services on 02/09/24 with the diagnosis of Malignant Neoplasm of Bone and Articular Cartilage. The closed clinical record was reviewed on 02/05/25. The clinical record included the “;Client Coordination Note Report” completed by the Chaplain and dated 02/13/24. This report contained; “;Chaplain called, spoke to patients... (family member) ... This week is not good for patient as far as a visit goes, but... (family member) requested a visit next Friday 2/23 between 1/1:30 PM.” The record lacked documentation that a Chaplain conducted an initial assessment visit on or after 02/23/24, or that the Pt./family refused the visit. 7. Pt. #17 was admitted to Hospice services on 09/19/23 with the diagnosis of Alzheimers Disease with Late Onset. The closed clinical record was reviewed on 02/05/25. The clinical record included the Election of Hospice Benefits form dated 09/19/23. The record lacked documentation the Chaplain and Social Worker completed their initial assessments within 5 days after Hospice services was elected, or the Pt./POA/family refused the Chaplain and Social Worker services during this time. 8. Pt. #18 was admitted to Hospice services on 10/20/23 with the diagnosis of Non-Small Cell Lung Cancer with Metastasis to Lung. The closed clinical record was reviewed on 02/05/25. The clinical record included the Election of Hospice Benefits form dated 10/23/23. The “;Client Coordination Note Report” completed by the RN and dated 10/21/23 contained “;... Social Worker... To Follow Up On Funeral Home...” The record lacked documentation that the Pt/POA/family refused an initial assessment visit by the Social Worker, until 11/02/23 (13 days after the Election of Hospice Benefits form was signed by the POA), a “;Client Coordination Note Report” contained “;Reason For The Missed Visit: SW Visit Not Needed At This Time.”. The record lacked documentation that the Pt./POA/family refused an initial Social Worker assessment within 5 days after Hospice was elected. 9. Pt. #19 was admitted to Hospice services on 05/08/24 with diagnosis of Senile Degenerations of the Brain. The closed clinical record was reviewed on 02/05/25. The clinical record included the Election of Hospice Benefits form dated 05/08/24. The “;Client Coordination Note Report” completed by the RN and dated 05/08/24 contained, “;Social Worker: Accepted”. As of 02/05/25, the record lacked documentation the Social Worker assessed the Pt./family. 10. During staff interviews on 2/5/25 at 12:15 PM with the Alternate Administrator; 2/5/25 at 1:30 PM with the Administrator, Regional Vice President, CEO, and the Compliance Officer; 2/6/25 at 8:45 AM with the Administrator, Alternate Administrator, Vice President of Operations, and the Compliance Officer, it was confirmed that the IDG failed to ensure the initial comprehensive assessment was completed within 5 days of the Hospice election.”

“Based on a review of Hospice personnel files and staff interviews, it was determined in 2 of 8 (E #18 and 20) Hospice Aides, the Hospice failed to ensure the Hospice Aides receive 12 annual hours of training in 2024. Findings include: 1. The Hospice Aide personnel files were reviewed on 02/05/25. The following files lacked documentation that in 2024 the Hospice Aides received 12 hours of annual training: E #18. Date of hire 07/17/22. Lacked 9 hours. E #20. Date of hire 01/31/22. Lacked 12 hours. 2. During staff interviews on 2/5/25 at 11:00 AM with the Alternate Administrator, and Human Resource Director; and 2/6/25 at 12:06 PM with the Administrator, Alternate Administrator, and the Vice President of Operations, the above findings were confirmed.”

“Based on clinical record review, policy review and staff interview, it was determined that for 2 of 14 (Pts. #12 and #13) Pts. reviewed with Aide services, the Hospice failed to ensure that Hospice Aide notified the RN of patient changes in condition. Findings include: 1.Pt. #12 was admitted to Hospice services on 11/30/24 with the diagnosis of Cerebrovascular Disease. The clinical record was reviewed on 02/05/25. The record included the Aide Care Plan Report effective 02/04/25 which required, “;Alert Nurse of New Onset/Worsening changes to skin integrity.” The record included the following: Client Coordination Note Report date 12/11/24 which included the documentation “;...Son is worried about a UTI Patient Urine is really dark”; the Hospice Aide note dated 01/03/25 which included the documentation, “;...No BM since 12/24...”; Client Coordination Note Report dated 01/15/25 which included the documentation, “;...Patient has 3 sores on her bottom...” The clinical record lacked documentation the Hospice Aide reported the above-mentioned changes in Pt. status to the RN. 2.Pt. #13 was admitted to Hospice services on 06/06/24 with the diagnosis of Parkinsonism, unspecified. The clinical record was reviewed on 02/05/25. The record included the Aide Care Plan Report effective 02/04/25 which required, “;Alert nurse of new onset/worsening bruising, redness or areas of concern.” The clinical record included the Aide Hospice Visit Note Report dated 01/21/25 which included the documentation “;...small pressure sore on right heel and pressure sore on right butt cheek...”; the Aide Hospice Visit Note Report dated 01/26/25 which included the documentation, “;patient has a pressure sore on his left leg new from Friday...” The clinical record lacked documentation the Hospice Aide reported the above mentioned changed in Pt. status to the RN. 3. The Policy titled, “;Interdisciplinary Group Coordination of Care” revised on 12/2018 was reviewed on 02/04/25 and required, “;(Agency) personnel will communicate changes in a timely manner via telephone, one-to one meetings, interdisciplinary group meetings, and home visits. Documentation of all communication note, interdisciplinary group meeting form, and clinical note. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication.” 4. During an interview with the Administrator and Alternate Administrator on 02/06/25 at 11:50 AM, the above findings were confirmed.”

“Based on document review, and staff interview, it was determined the Hospice failed to ensure that the minimum of 5% cost saving requirement of total Pt. care hours of all Hospice paid employees achieved by using volunteers were met for the years 2023 and 2024. This has the potential to affect all Pts. receiving Hospice services. Findings include: 1. The Hospice Volunteer Requirement Report for the years 2023 and 2024 was reviewed. The reports reflect the requirement was not met, for 2023 the savings were 0.34% and for 2024 were 0.53%. 2. On 02/04/25, during an interview with the Volunteer Coordinator, it was stated the requirement was not met. The findings were confirmed during staff interviews on 02/06/25 between 8:45 AM and 10:00 AM with the Administrator, Alternate Administrator, Vice President of Operations, and Chief Compliance Officer.”

“Based on clinical record review, hospice policy and staff interviews, it was determined that for 2 of 3 (Pts. #12 and #13) Pts. reviewed who were receiving wound care, the Hospice failed to ensure that the clinical documentation entered into the clinical record was complete and/or entered in a timely manner. Findings include: 1.Pt. #12 was admitted to Hospice services on 11/30/24 with the diagnosis of Cerebrovascular Disease. The clinical record was reviewed on 02/05/25. The clinical record included the document “;Wound Record Report” which lacked documentation of the wound measurements and assessments for the pressure ulcer on the right buttocks for the weeks of 12/15/24 to 12/21/24 and 01/19/25 to 01/25/25. 2. Pt. #13 was admitted to Hospice services on 06/06/24 with the diagnosis of Parkinsonism, unspecified. The clinical record was reviewed on 02/05/25. The clinical record included the document “;Wound Record Report” which lacked the following documentation: for the week of 01/12/25 to 01/18/25 – lacked wound measurement and assessments for pressure ulcer on the right heel; for the week of 01/26/25 to 02/01/25 – lacked measurement and assessments of the pressure ulcer on the left calf. 3. The Policy titled, “;Wound Care Policy” revised on 4/2022 was reviewed on 02/05/24. The Policy required, “;2... At each visit the patients skin will be assessed. At each dressing change, the wound will be assessed, and documentation will include a description of the wound bed, drainage, signs and symptoms of infection, healing, and peri wound skin condition... 3. At least every week, the wound assessment and documentation will include measurement of length, width and undermining and tunneling if present.” 4. During an interview with the Administrator and Alternate Administrator on 02/06/25 at 11:50 AM, the above findings were confirmed.”

“Based on staff interviews, review of the Hospice complaint log, clinical records review, review of a licensed home services agency Medication Count Sheets, and Hospice policy review, it was determined the Hospice failed to ensure the Pt. received medications from qualified caregivers; medications were labeled correctly; and failed to investigate controlled medication discrepancies. Findings include: 1. In 1 of 3 active clinical records reviewed, the Hospice failed to ensure the Pt. received medication from qualified caregivers (L692). 2. In 1 of 3 clinical records reviewed, the Hospice failed to ensure medications were labeled correctly (L693). 3. In 1 of 3 active clinical records reviewed, the Hospice failed to investigate controlled medication discrepancies (L700). The cumulative effect of these systemic practices resulted in Hospices inability to ensure the Pt. received appropriate medications for medical and symptom management.”

“Based on document review and staff interview, it was determined for 2 of 4 (Pts. #3 and 4) clinical records reviewed, the Hospice failed to coordinate all aspects of the Pt.’s care in accordance with professional standards and practice. Findings include: 1. Pt. #3 was admitted to Hospice services on 08/24/24 with the diagnosis of End Stage Congestive Heart Failure. The clinical record was reviewed on 12/30/24. The clinical record included the IDG Summary Report dated 12/18/24 that included the “Medication List” requiring the Pt. to receive Acetaminophen in multiple forms which included; “Acetaminophen 650 MG rectal suppository every 6 hours as needed for mild pain or fever, Hydrocodone 5 MG Acetaminophen 325 MG tablet 1 tab every 6 hours as needed for pain, Tylenol (Acetaminophen) 325 MG tablet take 2 tabs by mouth every 6 hours as needed for mild pain or fever, and Tylenol Extra Strength 500 MG tablet give 1 tablet po daily”. The record lacked documentation that the Hospice RN provided instruction to the caregiver(s) on the maximum recommended dose of Acetaminophen to ensure Pt. #3 was not given more than the maximum daily allowance of Acetaminophen. 2. On 12/30/24 the Administrator presented several “;Medication Count Sheets” for December 2024, with the symbol and name of the paid caregivers agency on the Medication Count Sheets. There were separate sheets for drugs Lorazepam, Hydrocodone and Tylenol. The sheets contained signatures of the people that completed the medication count. During an interview with the Administrator and Director of Nursing #3, it was confirmed that only one name was identified as a Hospice employee. The Administrator stated, “I don’t know who those others are...” The record lacked documentation of coordination of medication usage and narcotic count with the patient’s care team. 3. The medication count sheet for Tylenol documented Pt. #3 received 2 pills “once daily on 12/13/24, 12/14/24, 12/15/24, 12/20/24, 12/23/24, 12/26/24, 12/28/24, 12/29/24; and 2 pills twice a day on 12/17/24, and 12/24/24. The IDG meeting note dated 12/18/24 included documentation Pt. #3 received Hospice SN services 2 times a week with documentation that the SN conducted medication reconciliation weekly. The record lacked coordination with the Hospice SN and the IDG and/or the home services agency that Pt. #3 received incorrect doses of Acetaminophen. 4. The Hospice policy titled, “Medication Profile” was reviewed on 12/30/24. The policy required, “...Procedure...12. Deviations from taking medications as ordered will be documented in clinical notes and the physician (or other authorized independent practitioner) will be notified.” 5. Pt. #4 was admitted to Hospice services on 08/24/24 with the diagnosis of Cerebrovascular Disease, unspecified. The closed clinical record was reviewed on 12/30/24. The clinical record lacked the Hospice form, “Medication Count Sheet”. During an interview with the Administrator and Director of Nursing #3/Clinical Director on 12/30/24 at 11:50 AM, it was stated the form was used to document the medication the pt. takes. The forms are maintained in the home and then put in the pt.’s clinical record upon discharge from Hospice. Pt. #4 was discharged on 11/10/2024. The Director of Nursing #3/Clinical Director could not locate the “Medication Count Sheets” in the clinical record. The policy titled “Medication Management and Control” was reviewed on 12/26/24. 6. The policy included, “...A medication administration record is to be used by the patient/caregiver to document all doses and times that controlled substances are administered.” As of 12/30/24 it cannot be determined if the Hospice was able to assess and coordinate the patient’s pain management with IDG team. 7. The above findings were confirmed during interviews with the Administrator and Director of Nursing #3/Clinical Director on 12/30/24 from 9:00 AM to 4:13 PM. During the interview the Administrator stated the hospice nurses were aware that the unqualified caregivers were giving Pt. #3 medications.”

“Based on a review of the clinical records and staff interviews, it was determined that in 1 of 3 (Pt. #3) active clinical records, the Hospice IDG failed to review the plan of care and determine if the patient, or family, can safely self-administer drugs and biologicals to the patient in their home. 1. Pt. #3 was admitted to Hospice services on 8/24/23 with the diagnosis of End Stage Congestive Heart Failure. The clinical record was reviewed on 12/30/24. The clinical record included the SN initial comprehensive assessment dated 8/24/23 and the IDG Summary Report dated 12/18/24 with documentation that the Pt. lived alone, alert but confused, totally dependent on others for completing activities of daily living and received 24-hour paid caregiver services through a licensed home services agency. Family members were not available for providing care or pain management, only communication between hospice and family/POA was through telephone calls. During an interview with the Administrator on 12/30/24 at 1:34 PM and 4:13 PM, the Administrator stated the Hospice nurses were aware that the unqualified caregivers were giving Pt. #3 medications. During the same interview, Pt. #3s mental status was confirmed as described above, and that Pt. #3 could not understand the medications she was taking from the home services caregivers. 2. The above findings were confirmed with the Administrator during the interview on 12/30/24 at 4:13 PM.”

“Based on clinical records review and staff interview it was determined for 1 of 3 (Pt. #3) active patients, the hospice failed to ensure medication was labeled correctly. Findings include: 1.Pt. #3 was admitted to Hospice services on 08/24/23 with a diagnosis of End Stage Congestive Heart Failure. The clinical record for Pt. #3 was reviewed on 12/30/24. The record included a SN visit note dated 07/04/24. The note included an assessment by SN stating, “...Narcotic count was completed and the hydrocodone count sheet stated there should have been 53 pills but upon examining the pills they did not appear to be hydrocodone...The unknown pills were disposed and ADON...was notified...POA was also updated on...the discrepancy in the medication. The record also included a SN visit note dated 07/31/24 that stated, “...The RN completed a narc count and found the hydrocodone bottle was missing. Upon asking the caregiver she stated over the weekend or “sometime during the week my boss...took the bottle because the narc count did not match up and there were Tylenol in the bottle again” This RN notified hospice administration of this occurrence...POA also notified...” The clinical record lacked further documentation of corrective actions in reference to the mislabeled and missing controlled medication. 2. During interviews with the Administrator and Director of Nursing #3/Clinical Director on 12/30/2024 between 9:00 AM to 4:13 PM the findings were confirmed.”

“Based on clinical records review, document review and staff interview, it was determined for 1 of 3 (Pt. #3) active clinical records reviewed the hospice failed to conduct an investigation into discrepancies of dispensing and storing controlled drugs. Findings include: 1. Pt. #3 was admitted to Hospice services on 08/24/23 with a diagnosis of End Stage Congestive Heart Failure. The clinical record for Pt. #3 was reviewed on 12/30/24. The record included a SN visit note dated 07/04/24. The note included an assessment by SN stating, “...Narcotic count was completed and the hydrocodone count sheet stated there should have been 53 pills but upon examining the pills they did not appear to be hydrocodone...The unknown pills were disposed and ADON...was notified...POA was also updated on...the discrepancy in the medication. The record also included a SN visit note dated 07/31/24 that stated, “...The RN completed a narc count and found the hydrocodone bottle was missing. Upon asking the caregiver she stated over the weekend or “sometime during the week my boss...took the bottle because the narc count did not match up and there were tylenol in the bottle again” This RN notified hospice administration of this occurrence...POA also notified...This RN is unable to complete narc count or state when pt has had her pain medication...” The clinical record lacked further documentation of any further investigation of the above noted discrepancies in controlled drugs. 2. On 12/30/24 a request was made to see the the Narcotic count sheets for Pt. #3 from 07/2024 to present. The Hospice was unable to provide the hospice narcotic count sheets. 3. The complaint log for 2024 was reviewed on 12/30/24 at 9:20 AM. The log lacked documentation of controlled substance discrepancies. During an interview with the Administrator and Director of Nursing #3/Clinical Manager on 12/30/24 at 10:35 AM, the Administrator stated there had been issues regarding “diversion” with Pt. #3. At 11:00 AM the Administrator presented three separate complaints involving Pt. #3, none of the complaints were regarding “diversion” or the discrepancy with controlled medication. No investigation documentation was provided in reference to the controlled medication discrepancy. 4. During an interview with the Administrator and Director of Nursing #3/Clinical Director on 12/30/24 between 9:00 AM and 4:13 PM the above findings were confirmed.”