Hospice of Acadiana Inc.

“Upon patient record review, 4 of 31 (Patient #2, 4, 7, 21) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 02: The medication profile includes Miralax 17G powder orally one time a day for bowel regimen, it does not include a diluent. The medication profile includes Voltaren gel, no dose indicated, apply topically 2 times a day as needed for pain, it does not include an application site. (Order corrected on site.) Patient 04: Upon review of the medications in the home, the primary caregiver reports that the patient does not take tamsulosin 0.4mg which remains on the medication profile. Patient 07: The medication profile includes polyethylene glycol 17G powder orally one time a day for bowel regimen, it does not include a diluent. (Order corrected on site.) Patient 21: The medication profile includes polyethylene glycol 17G powder packet, take orally 1 time a day, it does not include a diluent. (Order corrected on site.)”

“Upon patient record review, 4 of 31 (Patient #4, 6, 7, 9) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 04: The patient was admitted on 11/5/24 with a primary diagnosis of sarcopenia, he has a secondary diagnosis of epilepsy determined as related to his hospice services, he takes phenobarbital and levetiracetam for epilepsy/seizure management. The plan of care does not include a problem statement with interventions and goals for the management of the epilepsy/seizures or seizure precautions. Patient 06: The patient was admitted on 4/24/25 to General Inpatient level of care with a primary diagnosis of Neurocognitive disorder with Lewy bodies, he is admitted with signs and symptoms of agitation and combativeness and was transferred from the hospital where he exhibited the same behaviors. The plan of care does not include a problem statement with interventions and goals for the management of the agitation. Patient 09: The patient record includes documentation of dysphagia with changes in patients ability to feed herself with noted symptoms of possible aspiration. The patient consumed 3 meals per day one month prior to admission and now eats 1 small meal a day, requires assisted feeding and medications must be crushed and added into pudding. The plan of care does not include a problem statement for nutrition with interventions and goals to include aspiration precautions.”

“Upon patient record review, 1 of 31 (Patient #3) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 03: The plan of care includes hospice aide services with frequency orders of a range of 1-2 times per week, effective 1/2/25 and continuing into benefit 2 effective 4/2/25. (Updated and corrected order on site.)”

“Upon patient record review, 3 of 31 (Patient #2, 7, 21) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 02: Medication orders on 9/21/24 includes Miralax 17G powder orally one time a day for bowel regimen, it does not include a diluent. Orders on 4/22/24 includes Voltaren gel, no dose indicated, apply topically 2 times a day as needed for pain, it does not include an application site. (Orders updated and corrected on site.) Patient 07: Medication orders on 4/10/25 includes polyethylene glycol 17G powder orally one time a day for bowel regimen, it does not include a diluent. (Orders updated and corrected on site.) Patient 21: The medication orders on 5/23/24 for polyethylene glycol 17G powder packet, take orally 1 time a day, does not include a diluent. (Orders updated and corrected on site.)”

“Upon patient record review, 4 of 31 (Patient #2, 3, 7, 10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 02: The patient documentation on 4/25/25 indicates the patient utilizes a rollator (rolling walker) for ambulatory assistance, this is not included in the plan of care. (Corrected on site.) Patient 03: The patient record indicates that the patient utilizes a rollator (rolling walker) for ambulatory assistance, this is not included in the plan of care. (Corrected on site.) Patient 07: The patient record indicates the patient is non-ambulatory and utilizes a wheelchair to self propel himself for mobility. The plan of care does not include a wheelchair. (Corrected on site.) Patient 10: The patient record upon admission (7/19/24) and onward indicates that the patient is weak and utilizes a wheelchair for ambulation, this is not included in the plan of care. Documentation on 3/5/25 performed by LPN indicates that the patient ambulates with a walker, this is not included in the plan of care. (Corrected on site.)”

“Upon patient record review, 4 of 31 (Patient #2, 8, 12, 18) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient 02: The patient has declined spiritual care and social work services and visits and denies needs or interventions, the plan of care has not been updated to discharge previous interventions and goals. (Corrected on site.) Patient 08: The patient record includes evidence of significant wounds including stage IV coccyx wound, left hip wound, unstageable right heel wound with eschar and right heel wound with eschar. The plan of care does not include patient specific interventions for the wounds. (Updated on site.) Patient 12: The plan of care includes orders for monthly SW visits, the plan of care does not include problem statements with interventions and goals for SW services. (Updated plan of care on site.) Patient 18: The plan of care includes order for volunteer visits 1-4 times per month starting 2/4/25, the plan of care is not updated to include volunteer services with interventions and goals. The patient/primary caregiver have initiated requests for assistance with nursing home placement with SW visits, interventions and goals that have not been included in the plan of care. (Updated and corrected on site.)”

“Upon patient record review, 4 of 31 (Patient #26, 27, 28, 29) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 26: The patient record does not include a plan of care for bereavement services reflective of the needs of the bereaved following the patient death. Patient 27: The patient record does not include a plan of care for bereavement services reflective of the needs of the bereaved following the patient death. Patient 28: The patient record does not include a plan of care for bereavement services reflective of the needs of the bereaved following the patient death. Patient 29:The patient record does not include a plan of care for bereavement services reflective of the needs of the bereaved following the patient death.”

“Upon patient record review, 2 of 31 (Patient #5, 6) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 05: The patient was admitted on 4/22/25 to General Inpatient level of care, the aide task assignment does not specify frequencies for performing oral care, hair care, or bathing. (Updated and corrected on site.) Patient 06: The patient was admitted on 4/24/25 to General Inpatient level of care, the aide task assignment does not specify a frequency of tasks for bathing, hair care/shampooing, and oral care. The assistance level for patient needs is not specified and ranges from fully independent to full assistance, the aide is allowed to determine level of task and the care is not assigned as patient specific. (Updated and corrected on site.)”

“Upon patient record review 3 of 31 (Patient #13, 15, 16) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training. Patient 13: The patient record includes orders for Hospice Aide services for 6 times per week. The patient received 7 visits the week of 3/23/25 - 3/29/25 Patient 15: The patient record includes orders for Hospice Aide services 2 times per week. The patient received 1 visit the week of 3/2/25 - 3/8/25, and 1 visit the week of 4/13/25 - 4/19/25 Patient 16: The patient record includes order for Hospice Aide services 6 times per week. The patient received 5 visits the week of 4/14/25 - 4/19/25 and 5 visits the week of 3/30/25 - 4/5/25.”

“Upon patient record review, 2 of 31 (Patient #7, 30) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 07: The patient was admitted on 4/10/25 with a secondary related diagnosis of Type II diabetes mellitus without complications, the patient is prescribed Humalog twice daily, dose dependent on finger stick blood glucose results. The plan of care does not include a problem statement with interventions and goals for the management of the diabetes. The patient record indicates that he has a history of aggression and anxiety with a diagnosis of Paranoid Schizophrenia, indicated as a related diagnosis. The patient takes sertraline, trazadone, Zyprexa, buproprion, risperidone to control his mood and behavior, the plan of care dose not include a problem statement with interventions and goals for the management of the aggression and anxiety. The patient record includes volunteer services to be provided weekly effective 4/16/25, there is no evidence of volunteer visits being made. Patient 30: The medication profile in the hospice plan of care includes haloperidol 1mg every 4 hours as needed, the patient resides at a skilled nursing facility, this medication is not included in the plan of care at the skilled nursing facility. (Order corrected.)”

“Upon inspection throughout the facility, it was observed that the penetrations through the ceiling to the attic/roof space were not properly sealed to provide a fire barrier or fire stop. These openings were found in the electrical room, riser room, garage, storage rooms, oxygen storage room and boiler room. In healthcare facilities, unsealed penetrations and gaps in life safety ceilings can compromise fire protection measures, potentially delaying sprinkler or smoke detector activation and increasing the risk of fire spread. CODE REFERENCE: NFPA 101-2012, 8.3.5.1 “Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communication systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. Gaps and holes from unsealed penetrations allow easy access for both fire and smoke to spread quickly throughout the building.”