The Hospice of Baton Rouge

“Based on interviews and record reviews, the Hospice agency failed to protect a patient and/or their legal representative’s right to voice their grievance/complaint and have it investigated for 1 (#1) of 3 patients reviewed. This deficient practice had the potential to affect a current census of 404 patients. Cross Reference: L648. Findings: Review of the Hospice agency’s Patient Rights and Responsibilities Policy and Procedure, reviewed 03/2025, revealed, in part, the following: Procedure: A. The agency ensures the patient or his/her legal representative has the right to: 11. Voice grievances concerning patient care, treatment, ... and have any such complaints investigated by the agency. Review of the Hospice agency’s Complaint Resolution Policy and Procedure, revised 03/2025, revealed, in part, the following: Procedure: 2. Hospice patients/caregivers are informed of their right to lodge complaints about whatever concerns they may have, including but not limited to … violation of any patient rights. 6. Complaints/concerns brought to the direct attention of any Hospice employee or volunteer are addressed immediately whenever possible and brought to the attention of the appropriate manager and S1CEO. 7. All complaints are documented in a complaint log maintained by S1CEO. 8. All documented inquiry is conducted by appropriate personnel of all written or verbal complaints received by the agency. 9. To resolve complaints, attempts to contact the person filing the complaint are documented including date and time. Information shared with the complainant may include corrective actions general to the organization. If telephone contact is unsuccessful, an electronic or mailed letter can be sent. Each contact, attempted contact, or action taken to resolve the issue is documented with the original complaint. 10. The avenues for resolution of concerns and/or problems will be as follows: a. S1CEO will address all concerns and/or problems brought to their attention. b. Medical concerns may be handled by the Medical Director, and if needed by consulting with the QAPI team. c. Overall concerns affecting the programs will be taken by S1CEO to the QAPI Team and/or Executive Committee of the Board. When necessary, legal counsel can be sought. 11. Corrective action is implemented, as appropriate, in response to substantiated complaints. 12. Complaints are tracked and regularly reviewed to identify patterns or trends and performance improvement opportunities. Review of the Hospice agency’s Grievance/Complaint Log, dated 06/22/2026 through 08/31/2026, revealed, in part, no entries regarding Patient #1. Review of Patient #1’s Clinical Record revealed she was admitted to the Hospice agency on 06/22/2026 with an Initial Certification Period of 06/22/2026 through 09/19/2026. An interview was conducted on 09/02/2026 at 2:44 p.m. with Patient #1’s daughter. She confirmed on 06/29/2026, she was very upset and called the Hospice agency to make them aware of her complaint regarding her mother’s admission and communication process. She stated she voiced her complaint to someone in medical records because they were the only person she could get on the phone. She stated she informed them she was her mother’s HCPOA, not the person who signed her admission consents, so she did not feel her admission was valid. She confirmed the Hospice agency informed her they did not have a copy of Patient #1’s HCPOA on file. She stated she also informed them they had been communicating with the wrong family members regarding her mother’s care. She stated the Hospice agency only communicated with Patient #1’s sister and one of her sons, but not with her, as her HCPOA. She stated she informed them she wanted to know how this occurred and wanted to re-do all her admission packet to include her signature, instead of Patient #1’s sister. She stated after she hung up, she received a blank admission packet from the Hospice agency electronically which she completed and returned electronically, along with a copy of her mother’s HCPOA. She stated the only person from the agency who spoke to her after she called in her complaint was S4MSW when she made a home visit the afternoon of 06/29/2026. She stated during the home visit, S4MSW did not ask questions pertaining to the information she reported and only asked questions which appeared to be making sure she was happy with the agency again. An interview was conducted on 09/02/2026 at 12:00 p.m. with S4MSW. S4MSW confirmed she was familiar with Patient #1. S4MSW stated on 06/29/2026 she received a report from the office indicating Patient #1’s daughter was upset and had called the office earlier in the day with some concerns, so she needed to make a home visit to smooth things over. An interview was conducted on 09/02/2026 at 11:58 a.m. with S2DOC. S2DOC confirmed she was responsible for the Hospice agency’s compliance and quality, which included the QAPI program and she also helped with the grievance/complaint program. S2DOC confirmed patient rights included the right to file a grievance/complaint and have it investigated by the Hospice agency. S2DOC confirmed she was aware of the aforementioned issue communicated by Patient #1’s daughter. S2DOC confirmed the Hospice agency did not create a grievance/complaint following the aforementioned information reported by Patient #1’s daughter. S2DOC confirmed the Hospice agency did not investigate or make an attempt to determine if Patient #1’s admission was valid and/or why her HCPOA was not obtained during admission. S2DOC stated after Patient #1’s daughter called upset, they provided her with a blank admission packet to fill out and provided her with the medical records she requested so there was no need to activate their grievance/complaint procedure. An interview was conducted on 09/03/2026 at 11:54 a.m. with S1CEO. S1CEO confirmed she was responsible for the Hospice agency’s complaint/grievance program. S1CEO confirmed she was aware of the aforementioned issue communicated by Patient #1’s daughter. S1CEO confirmed the Hospice agency did not create a grievance/complaint following the aforementioned information reported by Patient #1’s daughter nor did they perform an investigation into the matter. S1CEO stated she did not feel this was a grievance/complaint so there was no need to activate their grievance/complaint procedure.”

“Based on interviews and record review, the Hospice agency failed to protect a patient’s right to refuse care or treatment during end of life. This deficient practice was evidenced by the Hospice agency’s failure to have a system in place which ensured a patient’s declared code status of DNR was honored once incapacitated during end of life for 1 (#1) of 3 patients reviewed. This deficient practice had the potential to affect a current census of 404 patients. Cross Reference: L648. Findings: Review of the NIH’s Legal Considerations in End-of-Life Decision-making in Louisiana, dated 2011, revealed, in part, the following: Once physicians establish the patient’s condition is terminal and irreversible, the treating physician must determine if the patient has made his or her wishes known through an Advance Directive. If a valid Advance Directive exists, it should be followed. Sometimes, despite a valid Advance Directive, family members disagree and want the healthcare team to act contrary to the Advance Directive. In such cases, it is appropriate to request an ethics consult from the Bioethics Committee. Review of the state’s LaPOST Handbook for Healthcare Professionals, dated 01/2024, revealed, in part, the following: **Introduction: LaPOST should only be completed after a thorough discussion with the patient or his/her HCPOA regarding the patient’s understanding of the illness, treatment preferences, values and goals of care. Completion of a LaPOST document encourages communication between doctors and patients, enables patients to make informed decisions and clearly documents these decisions to other physicians and health care professionals. As a result, LaPOST can help ensure that a patient’s wishes are honored and prevent unwanted or non-beneficial treatments. **Discussing LaPOST with the Patient: The completion of the LaPOST document involves a thorough discussion between patients and physicians with physicians responsible for the completion of the document. **Voiding the Document:If the patient no longer has decision-making capacity, their HCPOA may only revoke the LaPOST document if there is new knowledge of a change in the patient’s wishes or medical condition. Review of the state’s LaPOST Implementation Guide, dated 01/2024, revealed, in part, the following: **Chapter I: Overview of LaPOSTLaPOST should be completed only after a thorough discussion with the patient or his/her HCPOA regarding the patient’s understanding of the illness, treatment preferences, values and goals of care. **Chapter III: LaPOST Procedures3. The physician or medical director will document his/her review of the patient’s LaPOST in the patient’s medical record.4. The attending physician or medical director may issue new orders consistent with the most current information available about the patient’s treatment preferences and goals of care. The reasons for any deviation from the LaPOST will be documented in the medical record.**Reviewing/Revising A Patient’s LaPOST: Discussions about revising and/or revoking the patient’s LaPOST should be documented, dated and timed in the patient’s medical record. This documentation must include a description of the conversation and the parties involved in the discussion. The attending physician and the patient, or the patient’s HCPOA, may review or revise the LaPOST consistent with the patient’s most recently expressed wishes. In the case of a patient who lacks decision-making capacity, the attending physician and the patient’s HCPOA may revise the LaPOST, as long as it is consistent with the known desires of, and in the best interest of, the patient.**Conflict Resolution:If the patient’s LaPOST document conflicts with the patient’s previously expressed health care instructions or Advance Directive, then, to the extent of the conflict, the most recent expression of the patient’s wishes are honored. Review of the state’s BME’s Decision regarding a Physician’s Role in Assessing Capacity for Code Status, as of 09/03/2026, revealed, in part, the following: A physician must assess and document a patient’s decision-making capacity before authorizing a code status order, such as LaPOST. Assessing a patient’s decision-making capacity, specifically for determining code status, such as LaPOST, is a strictly non-delegable medical act that must be performed by a licensed physician. Documentation: When a physician establishes or changes a patient’s code status based on a capacity assessment, the BME and state’s R.S.s require clear documentation in the patient’s Clinical Record to be valid:1. The specific facts establishing the patient’s capacity or lack thereof.2. The specific medical necessity for the code status modification if the patient is unable to speak for themselves.3. The names and relationships of any surrogates involved in the discussion.4. The signed verification from the secondary confirming physicianThe LaPOST must be written, dated, and signed by a physician, with clear documentation of the capacity assessment and the rationale for the decision. This ensures compliance with both state law and the state’s BME standards. Review of the Hospice agency’s Advance Directive – LaPOST Policy and Procedure, last revised 03/2025, revealed, in part, the following: Procedure: 1. Patients and their family/caregiver are counseled and educated, upon admission and as needed, regarding Hospice philosophy on the provision of resuscitation. 2. The agency will accept an LaPOST as an Advance Directive. 4. State law requires LaPOST be followed by a healthcare provider. Using LaPOST14. A patient or healthcare representative (if patient is incapacitated) can evoke the LaPOST at any time and request treatment based on the known desires of the patient. Review of Patient #1’s Clinical Record revealed she was admitted to the Hospice agency on 06/22/2026 with an Initial Certification Period of 06/22/2026 through 09/19/2026 and expired on 07/05/2026. Further review revealed she was referred for admission while inpatient at a local hospital and she signed an HCPOA in 04/2026 naming her daughter HCPOA. Review of Patient #1’s LaPOST, dated 06/19/2026, revealed, in part, the following: A. DNR selected. B. Comfort focused treatment selected. C. No artificial nutrition by tube selected. Signatures: Patient’s Signature: Patient #1’s sister signed by proxy per patient request on 06/19/2026.Physician’s Signature: S3MD on 06/23/2026. An interview was conducted on 09/02/2026 at 11:18 a.m. with S5CRM. S5CRM confirmed she worked in the Hospice agency’s marketing department and attended meetings with patients/family members to complete their pre-admission packets, which included their LaPOST. S5CRM confirmed she met with Patient #1, Patient #1’s sister and Patient #1’s referring physician on 06/19/2026. S5CRM stated both of Patient #1 sons were involved in the conversation via telephone when Patient#1 made it clear she wished to be a DNR. S5CRM confirmed Patient #1’s daughter was not a part of the conversation when Patient #1 made her wishes known and completed the legal document to become a DNR. S5CRM confirmed Patient #1’s daughter had been invited to attend the meeting. S5CRM confirmed Patient #1’s referring physician confirmed Patient #1 was at full capacity for medical decision making when she made her wishes known to be DNR and completed her LaPOST with her sister signing the form by proxy with witnesses present. S5CRM confirmed no one from the Hospice agency reached out to her to ask questions or discuss Patient #1’s pre-admission meeting. An interview was conducted on 09/01/2026 at 5:45 p.m. with Patient #1’s sister. She confirmed she had multiple conversations with Patient #1 about her wishes for her care prior to and after her Hospice admission. She confirmed Patient #1’s referring physician was present and participated in many of those conversations leading up to her Hospice admission. She confirmed her sister was at full decision making capacity when these conversations were held and she consistently voiced her desire to be admitted to Hospice with DNR status. She confirmed Patient #1 voiced her wishes to her, her referring physician, and both of her sons. She confirmed her sons were involved in the meeting for Hospice admission when she completed the paperwork to become a DNR. She confirmed she signed Patient #1’s LaPOST by proxy per her sister’s request due to weakness in her dominant hand and her signature did not mean the change to DNR status was her wishes for Patient #1. She confirmed Patient #1’s daughter was not involved in her care or present at the hospital during these conversations but she and Patient #1’s sons made her daughter aware of her mother’s wishes. An interview was conducted on 09/01/2026 at 6:13 p.m. with Patient #1’s son. He confirmed he was involved in Patient #1’s admission to Hospice when her code status was changed to DNR. He confirmed Patient #1 made him aware she wanted to have DNR status. An interview was conducted on 09/01/2026 at 6:19 p.m. with Patient #1’s other son. He confirmed he was involved in Patient #1’s admission to Hospice when her code status was changed to DNR. He confirmed Patient #1 made him aware she wanted to have DNR status. Review of Patient #1’s LaPOST, dated 06/29/2026, revealed, in part, the following: A. CPR selected. B. Full treatment selected. C. Trial period of artificial nutrition by tube selected. Signatures: Patient’s Signature: Patient #1’s HCPOA on 06/29/2026.Physician’s Signature: S3MD on 07/01/2026. Further review revealed no documented evidence to indicate prior to S3MD signing this document, S3MD assessed Patient #1’s decision making capacity, reviewed any of her Advance Directives, or held the required discussion with Patient #1/her HCPOA. Review of Patient #1’s Clinical Record, as of 09/03/2026, revealed no documented evidence to indicate S3MD assessed Patient #1’s decision making capacity, reviewed her Advance Directives, or held the required discussion with Patient #1/her HCPOA regarding the requested Code Status change prior to S3MD signing Patient #1’s LaPOST dated 06/29/2026. Further review revealed no indication any Hospice agency employees held a discussion with Patient #1 or her HCPOA regarding Patient #1’s Code Status changing back to Full Code. Review of Patient #1’s EMS Run Report, dated 07/05/2026, revealed, in part, the following: CPR Initiated: Manually on 07/05/2026 at 7:17 a.m.Patient expired in ED: 07/05/2026 at 8:38 a.m.Narrative: Upon arrival to Patient #1’s home, they were informed she was on Hospice and there was no DNR order in place. Family reported patient had been down for 8 minutes prior to EMS arrival. Patient was unresponsive and found to be in cardiac arrest with no shockable rhythm. Manual CPR was initiated while team member obtained LUCAS and ventilator. Patient #1 was intubated and hooked up to the ventilator and LUCAS. ROSC achieved 3 times during the call with persistent hypotension present each time to spite initiation of pressors and re-arrest occurring. Patient #1 was transported to the local ED. Patient #1 was coded a total of 3 times before her death was called in the local ED by the physician onsite. An interview was conducted on 09/02/2026 at 2:44 p.m. with Patient #1’s daughter. She confirmed Patient #1 completed an HCPOA in 04/2026 indicating she was her HCPOA. She stated she contacted the Hospice agency on 06/29/2026 and informed them she was Patient #1’s HCPOA, not the person who signed her admission documents and she wanted to re-sign them. She stated she informed them Patient #1 should not have been made a DNR because she wanted her to be a full code, so the LaPOST needed to be re-signed. She stated after she hung up, the Hospice agency emailed her blank admission documents for Patient #1, including a LaPOST. She confirmed she completed the blank LaPOST changing Patient #1’s code status from DNR to Full Code then emailed it back to the Medical Records person on 06/29/2026. She stated she did not feel Patient #1 would have wanted to be a DNR. She confirmed she was not present at the hospital when her referring physician had discussions with Patient #1 about her wishes for being a DNR, nor was she present for the meeting involving S5CRM when the legal documents were completed. She confirmed Patient #1’s sister and Patient #1’s sons were involved in the meeting and they did not follow her wishes for Patient #1’s care, as the HCPOA. She confirmed she wanted Patient #1 to be a Full Code from the start and if her aunt and brothers would have honored her HCPOA status, she would have never allowed Patient #1 to become a DNR. She confirmed she was not contacted or visited by S3MD or anyone from the Hospice agency to discuss the change in Patient #1’s code status. She confirmed when Patient #1 was found unresponsive on 07/05/2026, she received CPR by hand then by a machine and had a tube placed down her throat which was hooked to a machine to make her breathe. An interview was conducted on 09/02/2026 at 11:35 a.m. with S7PRA. S7PRA confirmed she was not a nurse. S7PRA confirmed she reviewed patient admission paperwork, which typically included LaPOST, and entered the information received into the patient’s chart then gave the paperwork to Medical Records. S7PRA stated Medical Records would then email the LaPOST to S3MD to sign off then upload the completed document into the patient’s Clinical Record. She confirmed she was familiar with Patient #1. S7PRA confirmed on 06/29/2026, she received the LaPOST from Patient #1’s daughter/HCPOA changing her from a DNR to a Full Code. S7PRA stated when she received it, she updated her facesheet then forwarded it to Medical Records to get S3MD’s signature. S7PRA confirmed she did not speak with Patient #1 or her HCPOA after she received the documents. An interview was conducted on 09/02/2026 at 7:32 a.m. with Patient #1’s referring physician at the time she completed the LaPOST on 06/19/2026 for DNR status. He confirmed he was very familiar with Patient #1 and confirmed towards the end of Patient #1’s inpatient stay, he had a very in-depth conversation with her where she told him she was “tired of all of it and ready”. He confirmed Patient #1 then refused any further lab draws and invasive treatments during her inpatient stay and stated she wanted to be discharged to home on Hospice as a DNR, so he made the referral and attended her Hospice admission meeting. He stated he attended the Hospice admission meeting to advocate for his patient’s wishes but was not the physician who signed her LaPOST, her Hospice physician did. He confirmed during Patient #1’s Hospice admission meeting on 06/19/2026, she made the official decision to change to DNR status and carried full decision-making capacity to do so. He stated Patient #1 told he and S5CRM her sister could sign any paperwork necessary as her proxy due to her physical decline limiting signing capability. He stated Patient #1’s two sons were involved in some of the conversation, and she made them aware of her wishes, as well. He stated while Patient #1 was cognitive and at full capacity for medical decision making her HCPOA would not be in effect and her sister’s signature by proxy was valid, legal and no different than Patient #1 signing the document herself. He stated if Patient #1’s HCPOA were present during the meeting on 06/19/2026 and did not want DNR status, it would not have mattered. He confirmed Patient #1’s HCPOA could not override the patient’s wishes for DNR status since she was at full decision-making capacity when she completed the LaPOST. He confirmed a HCPOA was a surrogate decision maker, not a sole decision maker, meaning the HCPOA was responsible for carrying out the patient’s known wishes, not their own wishes. He confirmed a HCPOA would only come into effect if/when a patient became incapacitated, and if/when it occurred, the HCPOA must follow the patients previously stated and/or written wishes. He confirmed if/when Patient #1 was no longer at capacity, her HCPOA could not legally or ethically be allowed to impose their own wishes on the patient because the patient made her wishes clear while at full decision-making capacity. He confirmed in the event Patient #1’s HCPOA wished to change the patient’s code status based on the HCPOA’s own personal wishes and not Patient #1’s, her HCPOA should have been educated on Patient #1’s wishes, along with the legal responsibilities and limits a HCPOA was legally and ethically allowed in determining Patient #1’s level of care/treatment moving forward. He stated the only time a HCPOA was able to determine a patient’s code status was if the patient never verbalized or put their wishes for their code status in writing, which did not apply to Patient #1. He confirmed, in a court of law and per the state’s Medical Board, Patient #1’s LaPOST, dated 06/29/2026, indicating Full Code was not valid and she should not have received CPR or been intubated and placed on a ventilator because a patient’s code status could not be changed under the circumstances in which it was changed for Patient #1. An interview was conducted on 09/02/2026 at 12:43 p.m. with S3MD. S3MD confirmed she was familiar with Patient #1. S3MD confirmed she signed Patient #1’s LaPOST, dated 06/19/2026, making her a DNR and also signed her LaPOST, dated 06/29/2026, making her a Full Code again. S3MD confirmed she had never assessed Patient #1 nor had a conversation with her or her family. S3MD stated she received an email with Patient #1’s LaPOST from Medical Records on 06/29/2026, signed it on 07/01/2026, then emailed it back to Medical Records to go in her Clinical Record. S3MD confirmed when she received Patient #1’s LaPOST on 06/29/2026, changing her from DNR to Full Code, she was aware Patient #1 was at full decision-making capacity on 06/19/2026 when she made the decision to become a DNR independently with her sister signing for her by proxy. S3MD confirmed the signature by proxy was the same as Patient #1 signing herself. S3MD stated on 06/29/2026 when she received the LaPOST to change Patient #1’s code status from DNR to Full Code, she did not recall if she spoke with anyone at the Hospice agency to determine why and could have made an assumption the patient no longer wished to be a DNR. S3MD confirmed she did not speak to Patient #1 or her HCPOA prior to signing the LaPOST changing her from DNR to Full Code on 06/29/2026 and this was not part of the agency’s process to require her to do so. S3MD confirmed if a patient were at full capacity and their HCPOA did not agree with the patient’s decision for treatment, the HCPOA’s wishes could and would be honored over the patient’s. S3MD confirmed if an incapacitated patient made their code status wishes known in writing while at full decision-making capacity, it was the HCPOA’s responsibility to honor the patient’s code status wishes, not the responsibility of the agency to ensure they did so. S3MD confirmed if the HCPOA said the patient changed their mind, she would trust the HCPOA because it was not her responsibility to question a decision made by a HCPOA. An interview was conducted on 09/03/2026 at 11:58 a.m. with S2DOC. S2DOC confirmed all patients have the right to dictate the treatment they do and do not receive and to have their wishes honored. S2DOC confirmed this included a patient at full capacity’s wishes for DNR status as indicated on their LaPOST. S2DOC confirmed she was not aware a HCPOA could not change a patient’s previously declared DNR status because they wanted different treatment than the patient. S2DOC confirmed she was not aware Patient #1 was cognitive and at full decision-making capacity when she completed her LaPOST on 06/19/2026 to become a DNR. S2DOC confirmed she was not aware Patient #1’s admission documents were signed by her sister as the patient’s proxy, not as the patient’s decision maker. S2DOC confirmed by proxy was no different than the patient signing the paperwork herself which meant Patient #1’s LaPOST was valid and her own declared wishes. S2DOC confirmed prior to allowing Patient #1’s HCPOA to change her Code status on 06/29/2026, no one at the Hospice agency reached out to Patient #1’s referring physician to determine the level of her decision-making capacity when she indicated DNR on her LaPOST on 06/19/2026. S2DOC confirmed when Patient #1 was found unresponsive, she received CPR and advanced life support. An interview was conducted on 09/03/2026 at 11:54 a.m. with S1CEO. S1CEO stated all Hospice agencies deal with family members changing their mind about a patient’s code status all the time and if the person changing their mind was the legal decision maker, the Hospice agency could not stop them.”

“Based on interviews and record reviews, the Hospice agency’s Governing Body failed to be responsible for the management of a continuous QAPI Program as evidenced by failure to identify, create, implement, and monitor a PIP regarding Advance Directives following an allegation of Patient #1’s Advance Directive (HCPOA) not being verified prior to admission. The provider also failed to identify Patient #2 and #3’s Advance Directives were missing from their medical records resulting in Advance Directives issues for 3 of 3 (#1, #2, #3) patients reviewed. This deficient practice had the potential to affect a current census of 404 patients. Cross Reference: L514, L648, L505, L669, and L677. Findings: Review of the undated publication by the state’s Governor’s Office of Elderly Affairs titled Planning for Incapacity - Advance Directive Forms for Louisiana, revealed, in part, the following: A competent adult can communicate preferences about future medical treatment through a legal document called an Advance Directive. What are three types of Advance Directives? In Louisiana, there are three types of advance care planning documents available. These include the HCPOA, the Living Will, and the LaPOST document. Review of the agency’s QAPI Program Policy and Procedure, revised 11/2025, revealed, in part, the following: II. Program OrganizationA. The agency’s Governing Body is responsible for ensuring:1. An ongoing program for quality improvement and patient safety is defined, implemented, and maintained, and is evaluated annually. 2. The Hospice-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness. 6. Patient care practices are reviewed and evaluated to assess, preserve, and improve the overall quality, safety, and efficiency of patient care and services.B. The agency’s QAPI program will be directed by the Director of Quality who will report QAPI activities and effectiveness to the CEO and Governing Body. VII. PIPs B. The agency utilizes the following procedures for PIPs: 1. Identify problem area. Patient #1Review of Patient #1’s Clinical Record revealed she was admitted to the Hospice agency on 06/22/2026 with an Initial Certification Period of 06/22/2026 through 09/19/2026. Further review revealed her Admission Packet and Consents were signed by her sister. Review of Patient #1’s Clinical Records obtained from the local hospital she was in at the time of her admission to the Hospice agency revealed she had a HCPOA in place which indicated her daughter was her legal decision maker in the event she became incapacitated. Review of Patient #1’s Admission Packet and Initial Assessments for the Hospice agency revealed no documented evidence of the aforementioned HCPOA prior to 06/29/2026. Further review revealed no documented evidence of attempts to obtain the legal document prior to 06/29/2026. An interview was conducted on 09/02/2026 at 2:44 p.m. with Patient #1’s daughter. She confirmed Patient #1 had 3 adult children; herself and two brothers. She confirmed Patient #1 named her as HCPOA in 04/2026 and a copy of her legal document was on file at the local hospital where she was inpatient when admitted to the Hospice agency. She confirmed on 06/29/2026, she was very upset and called the Hospice agency to voice a complaint regarding Patient #1’s admission and could only get someone in medical records on the phone. She stated she informed them they were communicating with the wrong family members because she was Patient #1’s HCPOA. She stated she informed them Patient #1’s admission was not valid because she did not sign the admission documents so she needed to re-sign all of them immediately. She stated she also informed them she wanted to know how this was allowed to happen. She confirmed she was informed they had not obtained a copy of Patient #1’s HCPOA during admission, so she provided it via email. She stated after she hung up, she was emailed a blank admission packet, which she completed and emailed back. She stated the only Hospice employee who spoke with her about her complaint was S4MSW during a home visit on the afternoon of 06/29/2026 and she only asked questions which appeared to be making sure she was happy with the agency again. An interview was conducted on 09/02/2026 12:00 p.m. with S4MSW. S4MSW confirmed she was the MSW assigned to Patient #1. S4MDS stated on 06/29/2026, the Hospice agency informed her of these concerns and asked her to make a home visit to smooth things over. S4MSW confirmed she was not told to, nor did she investigate the complaint. An interview was conducted on 09/02/2026 at 11:18 a.m. with S5CRM. S5CRM confirmed she met with Patient #1 on 06/19/2026 to complete her admission documents. S5CRM confirmed Patient #1 was at full decision-making capacity when she requested her sister sign as her proxy. S5CRM confirmed after 06/19/2026, the Hospice agency did not ask her any questions regarding Patient #1’s admission. Patient #2Review of Patient #2’s Clinical Record revealed she was admitted to the Hospice agency on 06/22/2026 with an Initial Certification Period of 06/22/2026 through 09/19/2026. Further review revealed she was referred for admission while inpatient at a local hospital and was incapacitated at the time of her admission to the Hospice agency. Review of Patient #2’s Informed Consent in her Admission Packet revealed she had a HCPOA and a Living Will which indicated her son was her legal decision maker in the event she became incapacitated. Review of Patient #2’s Referral Packet submitted by the local hospital she was in at the time of her admission to the Hospice agency revealed no documented evidence of a HCPOA. Review of Patient #2’s Clinical Record revealed no documented evidence of the aforementioned HCPOA and Living Will. Further review revealed no documented evidence of attempts to obtain the legal documents. An interview was conducted on 08/31/2026 at 3:30 p.m. with Patient #2’s son. He confirmed Patient #2 was incapacitated at the time of her admission to the Hospice agency and had two adult children. He confirmed Patient #2 completed an HCPOA in 03/2026 indicating he was her HCPOA. He confirmed the agency was made aware of the legal document upon admission but did not ask him to provide them with a copy. Patient #3Review of Patient #3’s Clinical Record revealed he was admitted to the Hospice agency on 06/27/2026 with an Initial Certification Period of 06/27/2026 through 07/10/2026. Further review revealed he was referred for admission from his physician’s office and was incapacitated at the time of his admission to the Hospice agency. Review of Patient #3’s Informed Consent in his Admission Packet revealed he had a HCPOA and a Living Will which indicated his spouse was his legal decision maker. Review of Patient #3’s Referral Packet submitted by his physician at the time of his admission to the Hospice agency revealed no documented evidence of a HCPOA. Review of Patient #3’s Clinical Record revealed no documented evidence of the aforementioned HCPOA and Living Will. Further review revealed no documented evidence of attempts to obtain the legal documents. An interview was conducted on 09/01/2026 at 5:04 p.m. with Patient #3’s spouse. She confirmed Patient #3 was incapacitated at the time of his admission to the Hospice agency. She confirmed Patient #3 had a HCPOA and Living Will in place at the time of his admission to the Hospice agency indicating she was his HCPOA. She confirmed the agency was made aware of the legal document upon admission but did not ask her to provide them with a copy. Review of the Hospice agency’s PIP documentation regarding obtaining and maintaining Advance Directives in a patient’s Clinical Record was requested on 08/31/2026, 09/01/2026, 09/02/2026 and again on 09/03/2026 with no documented evidence made available for review. An interview was conducted on 09/02/2026 at 11:58 a.m. with S2DOC. S2DOC confirmed she was responsible for running the Hospice agency’s QAPI program. S2DOC confirmed she was aware of the complaint regarding Patient #1 but did not open a PIP. S2DOC stated Patient #1’s HCPOA was allowed to re-sign the admission packet and was provided with the medical records she requested so the matter was resolved with no need for investigation or a PIP. S2DOC confirmed the validity of Patient #1’s admission was not investigated prior to allowing her admission documents to be re-signed nor did they investigate why her HCPOA was not identified and obtained. S2DOC confirmed she was unaware a patient’s HCPOA was an Advance Directive and should be in their Clinical Record. S2DOC confirmed they were not aware of the scope of patients missing Advance Directives in their Clinical Record and had not identified Patient #2 and #3’s missing Advance Directives. An interview was conducted on 09/03/2026 at 11:54 a.m. with S1CEO. S1CEO confirmed she was ultimately responsible for the Hospice agency’s QAPI program. S1CEO confirmed she was aware of the complaint regarding Patient #1 but did not feel an investigation or PIP were necessary because the situation resolved itself once they allowed her HCPOA to re-sign her admission documents. S1CEO confirmed they did not determine if Patient #1’s admission documents were valid prior to allowing them to be re-signed nor did they investigate why her HCPOA was not identified and obtained. S1CEO confirmed they were not aware of the scope of patients missing Advance Directives in their Clinical Record and had not identified Patient #2 and #3’s missing Advance Directives.”

“Based on interviews and record reviews, the Hospice agency’s Medical Director failed to assume responsibility for the medical component of the hospice’s patient care program. This deficient practice was evidenced by S3MD being unaware of the professional and legal requirements necessary to:1. Create a valid state’s Physician’s Order for Scope of Treatment (LaPOST) for 3 of 3 (#1, #2, #3) patients reviewed in the sample; and 2. Prevent the unauthorized modification of a full capacity patient’s declared code status once incapacitated for 1 (#1) of 3 patients reviewed. This deficient practice had the potential to affect a current census of 404 patients. Cross Reference: L648 and L514. Findings: Review of the state’s BME’s Decision regarding a Physician’s Role in Assessing Capacity for Code Status, as of 09/03/2026, revealed, in part, the following: A physician must assess and document a patient’s decision-making capacity before authorizing a code status order, such as LaPOST. This is a statutory and regulatory requirement under the state’s law and the standards of the state’s BME. The state’s law requires a LaPOST be completed by the physician who evaluates the patient’s ability to understand their medical condition, the implications of CPR, and the alternatives to resuscitation. Assessing a patient’s decision-making capacity, specifically for determining code status, such as LaPOST, is a strictly non-delegable medical act that must be performed by a licensed physician. **Documentation: When a physician establishes or changes a patient’s code status based on a capacity assessment, the BME and state’s R.S.s require clear documentation in the patient’s Clinical Record in order to be valid:1. The specific facts establishing the patient’s capacity or lack thereof.2. The specific medical necessity for the code status modification if the patient is unable to speak for themselves.3. The names and relationships of any surrogates involved in the discussion.4. The signed verification from the secondary confirming physicianThe LaPOST must be written, dated, and signed by a physician, with clear documentation of the capacity assessment and the rationale for the decision. This ensures compliance with both state law and the state’s BME standards. Review of the state’s LaPOST Implementation Guide, dated 01/2024, revealed, in part, the following: **Chapter I: Overview of LaPOSTLaPOST should be completed only after a thorough discussion with the patient or his/her HCPOA regarding the patient’s understanding of the illness, treatment preferences, values and goals of care. **Chapter III: LaPOST Procedures3. The physician or medical director will document his/her review of the patient’s LaPOST in the patient’s medical record.4. The attending physician or medical director may issue new orders consistent with the most current information available about the patient’s treatment preferences and goals of care. The reasons for any deviation from the LaPOST will be documented in the medical record.**Reviewing/Revising A Patient’s LaPOST: Discussions about revising and/or revoking the patient’s LaPOST should be documented, dated and timed in the patient’s medical record. This documentation must include a description of the conversation and the parties involved in the discussion. The attending physician and the patient, or the patient’s HCPOA, may review or revise the LaPOST consistent with the patient’s most recently expressed wishes. In the case of a patient who lacks decision-making capacity, the attending physician and the patient’s HCPOA may revise the LaPOST, as long as it is consistent with the known desires of, and in the best interest of, the patient.**Conflict Resolution:If the patient’s LaPOST document conflicts with the patient’s previously expressed health care instructions or Advance Directive, then, to the extent of the conflict, the most recent expression of the patient’s wishes are honored. Review of the state’s LaPOST Handbook for Healthcare Professionals, dated 01/2024, revealed, in part, the following: LaPOST can help ensure that a patient’s wishes are honored and prevent unwanted or non-beneficial treatments. Discussing LaPOST with the Patient:The completion of the LaPOST involves a thorough discussion between patients and physicians with physicians responsible for the completion of the document. LaPOST should only be completed after a thorough discussion with the patient or his/her legally recognized representative/HCPOA regarding the patient’s understanding of the illness, treatment preferences, values and goals of care. Voiding the Document:If the patient no longer has decision-making capacity, their legally recognized representative/HCPOA may revoke the LaPOST only if there is new knowledge of a change in the patient’s wishes or medical condition. Review of the Hospice agency’s Advance Directive – LaPOST Policy and Procedure, last revised 03/2025, revealed, in part, the following: Procedure: 1. Patients and their family/caregiver are counseled and educated, upon admission and as needed, regarding Hospice philosophy on the provision of resuscitation. 4. State law requires LaPOST be followed by a healthcare provider. Obtaining LaPOST5. Upon pre-admission visit, staff will discuss written information regarding LaPOST with each patient. 7. Admitting RN will confirm patient’s Advance Directive as stated on LaPOST. RN will phone Medical Director at time of admit to discuss patient choices and obtain verbal order for LaPOST. 8. Any staff having had discussions with patients about Advance Directives/LaPOST will document discussion in the medical record. Using LaPOST14. A patient or healthcare representative (if patient is incapacitated) can evoke the LaPOST at any time and request treatment based on the known desires of the patient. Review of the Hospice agency’s Staff Directory indicated S3MD was the Medical Director. Review of the Hospice agency’s Job Description for the Medical Director revealed, in part, a Primary Qualification was to have an Active License through the state’s BME. 1. Unaware of requirements to create a valid state’s Physician’s Order for Scope of Treatment (LaPOST). Review of the state’s R.S. 40:1155 and the resulting Administrative Code 48, I-207-209 revealed for a LaPOST to be a valid Physician’s Order, the form must include the following: The qualified patient’s life-limiting and irreversible condition;Who the physician discussed summary of goals with; The basis for the physician’s orders (Assessment confirming incapacitation if signed by anyone other than the patient; Presence of and review of any Advance Directives; etc.); and When completing a new form, the old form must be properly voided by drawing a line through the “Physician’s Orders” section with “Void” written in large letters. A notation signed and dated by the physician indicating a new form has been executed should be stated on the old form. Patient #1Review of Patient #1’s Clinical Record revealed she was admitted to the Hospice agency on 06/22/2026 with an Initial Certification Period of 06/22/2026 through 09/19/2026 and expired on 07/05/2026. Further review revealed she was referred for admission while inpatient at a local hospital and she signed an HCPOA in 04/2026 naming her daughter HCPOA. Review of Patient #1’s LaPOST, signed by S3MD, dated 06/19/2026, revealed, in part, the following: Patient’s Diagnosis of Life Limiting Disease and Irreversible Condition - Blank; Discussed with: Patient (has capacity) – Blank; andPatient’s Healthcare Representative – Selected.The basis for these orders is: Patient’s declaration – Not selected;Patient’s Healthcare Representative (Patient incapacitated) – Not selected;Advance Directive available – Not selected;Date Advance Directive signed - Blank;Advance Directive reviewed – Not selected;Healthcare agent named in Advance Directive – Not selected; and Name/Contact information for who LaPOST was discussed with - Blank.Signatures: Patient’s Signature: Patient #1’s sister signed by proxy per patient request on 06/19/2026.Physician’s Signature: S3MD on 06/23/2026. Further review revealed no documented evidence of the requirements to properly void this form. Review of Patient #1’s Clinical Record, as of 09/03/2026, revealed no documented evidence to indicate S3MD assessed Patient #1’s decision-making capacity, reviewed her Advance Directives, or held the required discussion with Patient #1/her HCPOA regarding her Code Status wishes prior to S3MD signing Patient #1’s aforementioned LaPOST. An interview was conducted on 09/02/2026 at 11:18 a.m. with S5CRM. S5CRM confirmed she worked in the Hospice agency’s marketing department and was responsible for holding meetings with patients/family members to complete their pre-admission packets, which included the LaPOST to indicate their Code Status wishes. S5CRM confirmed none of the Hospice physicians attended or participated in her pre-admission meetings with patients and/or their families. S5CRM confirmed she met with Patient #1, Patient #1’s sister and Patient #1’s referring physician on 06/19/2026. S5CRM confirmed Patient #1’s referring physician confirmed Patient #1 was at full capacity for decision-making when she made her wishes known to be DNR and completed her LaPOST with her sister signing the form as her proxy with witnesses present. S5CRM confirmed Patient #1’s referring physician did not sign her LaPOST, it was emailed to S3MD to sign after the meeting ended. Review of Patient #1’s LaPOST, signed by S3MD, dated 06/29/2026, revealed, in part, the following: Patient’s Diagnosis of Life Limiting Disease and Irreversible Condition - Blank;Goals of Care - Blank;Discussed with:Patient (has capacity) – Not selected; Patient’s Healthcare Representative – Not selected.The basis for these orders is:Patient’s declaration – Not selected;Patient’s Healthcare Representative (Patient incapacitated) – Not selected; Advance Directive available – Not selected; Date Advance Directive signed - Blank;Advance Directive reviewed – Not selected;Healthcare agent named in Advance Directive – Not selected; and Name/Contact information for who LaPOST was discussed with - Blank.Signatures: Patient’s Signature: Patient #1’s HCPOA on 06/29/2026. HCPOA’s Address/Phone Number – Blank.Physician’s Signature: S3MD on 07/01/2026. Review of Patient #1’s Clinical Record, as of 09/03/2026, revealed no documented evidence to indicate S3MD assessed Patient #1’s decision-making capacity, reviewed her Advance Directives, or held the required discussion with Patient #1/her HCPOA regarding changing the patient’s Code Status wishes prior to S3MD signing Patient #1’s aforementioned LaPOST. An interview was conducted on 09/02/2026 at 2:44 p.m. with Patient #1’s daughter who confirmed she was Patient #1’s HCPOA. She stated she contacted the Hospice agency on 06/29/2026 and informed them she was Patient #1’s HCPOA, not the person who signed her LaPOST on 06/19/2026. She stated she informed them Patient #1 should not have been made a DNR, she wanted her to be a Full Code, so the LaPOST needed to be re-signed. She stated after she hung up, the Hospice agency emailed her blank admission documents for Patient #1, including a LaPOST. She confirmed she completed the LaPOST changing Patient #1’s code status from DNR to Full Code then emailed it back to the Medical Records person on 06/29/2026. She confirmed she was not contacted or visited by S3MD or anyone from the Hospice agency to discuss the change in Patient #1’s code status. Patient #2Review of Patient #2’s Clinical Record revealed she was admitted to the Hospice agency on 06/22/2026 with an Initial Certification Period of 06/22/2026 through 09/19/2026. Further review revealed she was incapacitated with an HCPOA and Living Will in place at the time of her admission to the Hospice agency. Review of Patient #2’s LaPOST, dated 06/22/2026, revealed, in part, the following: Patient’s declaration – Not selected;Advance Directive available – Not selected;Date Advance Directive signed – Blank;Advance Directive reviewed – Not selected;Healthcare agent named in Advance Directive – Blank; and Name/Contact information for who LaPOST was discussed with - Blank.Signatures: Patient’s Signature: Patient #2’s son/HCPOA on 06/22/2026.Physician’s Signature: S3MD on 06/23/2026. Review of Patient #2’s Clinical Record, as of 09/03/2026, revealed no documented evidence to indicate S3MD assessed Patient #2’s decision-making capacity, reviewed her Advance Directives, or held the required discussion with Patient #2/her HCPOA regarding her Code Status wishes prior to S3MD signing Patient #2’s LaPOST dated 06/22/2026. Patient #3Review of Patient #3’s Clinical Record revealed he was admitted to the Hospice agency on 06/27/2026 with an Initial Certification Period of 06/27/2026 through 07/10/2026. Further review revealed he was incapacitated with an HCPOA and Living Will in place at the time of his admission to the Hospice agency. Review of Patient #3’s LaPOST, signed by S3MD, dated 06/27/2026, revealed, in part, the following: Patient’s Diagnosis of Life Limiting Disease and Irreversible Condition - Blank; and Goals of Care – Blank.The basis for these orders is:Patient’s declaration – Not selected;Advance Directive available – Not selected; Date Advance Directive signed - Blank;Advance Directive reviewed – Not selected;Healthcare agent named in Advance Directive – Not selected; and Name/Contact information for who LaPOST was discussed with - Blank. Signatures: Patient’s Signature: Patient #3’s Spouse on 06/27/2026.Spouse’s Address/Phone Number – Blank.Physician’s Signature: S3MD on 06/29/2026. Review of Patient #3’s Clinical Record, as of 09/03/2026, revealed no documented evidence to indicate S3MD assessed Patient #3’s decision-making capacity, reviewed his Advance Directives, or held the required discussion with Patient #3/his HCPOA regarding his Code Status wishes prior to S3MD signing Patient #3’s LaPOST dated 06/27/2026. An interview was conducted on 09/01/2026 at 5:04 p.m. with Patient #3’s spouse/HCPOA. She confirmed she informed the team she was Patient #3’s HCPOA but was not asked to provide the legal document for review prior to allowing her to complete his LaPOST changing him to DNR. She confirmed she completed her husband’s LaPOST with the staff member who brought his admission packet and it was not a physician. She confirmed she did not have a conversation with S3MD or any Hospice physician at any time regarding her husband’s wishes for end-of-life care. She stated she just filled out the paperwork while the admission person was there then gave it back to her to get a physician’s signature once they got back to the office. She confirmed her spouse lived at home with her so if a Hospice physician came to assess him and/or have a discussion with him, they would have to set it up with her because he was not cognitive and this never occurred. An interview was conducted on 09/02/2026 at 11:35 a.m. with S7PRA. S7PRA confirmed she received the agency’s incoming patient referral paperwork and was responsible for contacting the patient/family to set up an appointment for S5CRM or another staff person to meet with them to complete their Admission Packet paperwork, which included a blank LaPOST. S7PRA confirmed when she set up appointment times, it did not include setting up a time for a Hospice physician to assess the patient or talk with the patient/their family. S7PRA confirmed the meeting to complete the paperwork was not always conducted by a RN. S7PRA stated once the Admission Packet was completed, it came back to her to review, create their Clinical Record, and enter their demographics, which included the code status indicated on their newly completed LaPOST. S7PRA stated the patient’s code status was entered into the patient’s face-sheet when S5CRM returned to the office with their admission paperwork prior to obtaining a physician’s order. S7PRA confirmed she did not review the form to ensure required information was present and was not sure what was required to make it valid. S7PRA confirmed once she entered the patient’s information, Medical Records sent the LaPOST to S3MD to sign, then Medical Records uploaded it into the patient’s Clinical Record. An interview was conducted on 09/02/2026 at 1:55 p.m. with S3MD. S3MD confirmed she did not perform an in-person assessment of Patient #1 to confirm her capacity at the time either of her LaPOSTs were completed nor did she discuss her preferences for end-of-life care with the patient or her HCPOA. S3MD confirmed she did not perform an in-person assessment to confirm capacity at the time an LaPOST was completed nor did she discuss the patient’s preferences for end-of-life care with the patient or their HCPOA for Patient #2, #3 or any other Hospice agency’s patients. S3MD confirmed she was familiar with Patient #1. S3MD confirmed she signed Patient #1’s LaPOST, dated 06/19/2026, making her a DNR and also signed her LaPOST, dated 06/29/2026, making her a Full Code again. S3MD confirmed she had never assessed Patient #1, #2 or #3 nor had a conversation with the patients or their family. S3MD stated she receives an email with each patient’s LaPOST from the Hospice agency’s Medical Records person, signs them, then emails them back to Medical Records to go in the patient’s Clinical Record. S3MD confirmed she did not document a patient’s assessment of decision-making capacity on their LaPOST or within their Clinical Record because there was nowhere for her to do this. S3MD stated she couldn’t put a note into a patient’s Clinical Record unless she actually performed an in-person visit because it messed up billing. S3MD stated the Hospice agency staff were the ones in the field collecting the information and documenting it on the patient’s LaPOST so she relied on them to ensure the LaPOST was documented in its entirety prior to sending it to her to obtain her signature validating the order. An interview was conducted on 09/03/2026 at 11:58 a.m. with S2DOC. S2DOC confirmed all patients have the right to dictate the treatment they do and do not receive during their end of life and the Hospice agency utilized the LaPOST to document their wishes. S2DOC confirmed patients had a right to have their wishes honored, which required a valid LaPOST. S2DOC confirmed Patient #1’s sister signing her LaPOST by proxy was the same as Patient #1 signing the document herself and her LaPOST should reflect this information accurately. S2DOC confirmed the Hospice agency did not require S3MD to perform all the requirements necessary to create a valid LaPOST. 2. Unauthorized modification of a full capacity patient’s declared code status once incapacitated. Review of the NIH’s Legal Considerations in End-of-Life Decision-making in Louisiana, dated 2011, revealed, in part, the following: Once physicians establish the patient’s condition is terminal and irreversible, the treating physician must determine if the patient has made his or her wishes known through an Advance Directive. If a valid Advance Directive exists, it should be followed. Sometimes, despite a valid Advance Directive, family members disagree and want the healthcare team to act contrary to the Advance Directive. In such cases, it is appropriate to request an ethics consult from the Bioethics Committee. Review of Patient #1’s initial LaPOST, signed by S3MD, dated 06/19/2026, revealed, in part, the following: A. DNR selected. B. Comfort-focused treatment selected. C. No artificial nutrition by tube selected. Signatures: Patient’s Signature: Patient #1’s sister signed by proxy per patient request on 06/19/2026.Physician’s Signature: S3MD on 06/23/2026. An interview was conducted on 09/01/2026 at 5:45 p.m. with Patient #1’s sister. She confirmed she had multiple conversations with Patient #1 about her wishes for her care prior to and after her Hospice admission. She confirmed Patient #1’s referring physician was present and participated in many of those conversations leading up to her Hospice admission. She confirmed her sister was at full decision-making capacity when these conversations were held and she consistently voiced her desire to be admitted to Hospice with DNR status. She confirmed Patient #1 voiced her wishes to her, her referring physician, and both of her sons. She confirmed her sons were involved in the meeting for Hospice admission when she completed the paperwork to become a DNR. She confirmed she signed Patient #1’s LaPOST by proxy per Patient #1’s request due to weakness and her signature did not mean DNR status was made by her decision for Patient #1. She confirmed Patient #1’s daughter was not involved in her care or present at the hospital during these conversations but she and Patient #1’s sons made her daughter aware of her mother’s wishes. An interview was conducted on 09/01/2026 at 6:13 p.m. with Patient #1’s son. He confirmed he was involved in Patient #1’s admission to Hospice when her code status was changed to DNR. He confirmed Patient #1 made him aware she wanted to have DNR status. An interview was conducted on 09/01/2026 at 6:19 p.m. with Patient #1’s other son. He confirmed he was involved in Patient #1’s admission to Hospice when her code status was changed to DNR. He confirmed Patient #1 made him aware she wanted to have DNR status. An interview was conducted on 09/02/2026 at 11:18 a.m. with S5CRM. S5CRM confirmed she met with Patient #1, Patient #1’s sister and Patient #1’s referring physician on 06/19/2026. S5CRM stated both of Patient #1 sons were involved in the conversation via telephone when Patient#1 made it clear she wished to be a DNR. S5CRM confirmed Patient #1’s daughter was not a part of the conversation when Patient #1 made her wishes known and completed the legal document to become a DNR but had been invited to attend the meeting. S5CRM confirmed Patient #1’s referring physician confirmed Patient #1 was at full capacity for medical decision making when she made her wishes known to be DNR and completed her LaPOST with her sister signing the form by proxy with witnesses present. S5CRM confirmed no one from the Hospice agency reached out to her to ask questions or discuss Patient #1’s pre-admission meeting. Review of Patient #1’s LaPOST, dated 06/29/2026, revealed, in part, the following: A. CPR selected. B. Full treatment selected. C. Trial period of artificial nutrition by tube selected. Signatures: Patient’s Signature: Patient #1’s HCPOA on 06/29/2026.Physician’s Signature: S3MD on 07/01/2026. Review of Patient #1’s Clinical Record, as of 09/03/2026, revealed no documented evidence to indicate S3MD assessed Patient #1’s decision-making capacity, reviewed her Advance Directives, or held the required discussion with Patient #1/her HCPOA regarding changing the patient’s Code Status wishes prior to S3MD signing Patient #1’s LaPOST dated 06/29/2026. Review of Patient #1’s EMS Run Report, dated 07/05/2026, revealed, in part, the following: CPR Initiated: Manually on 07/05/2026 at 7:17 a.m.Patient expired in ED: 07/05/2026 at 8:38 a.m.Narrative: Upon arrival to Patient #1’s home, they were informed she was on Hospice and there was no DNR order in place. Family reported patient had been down for 8 minutes prior to EMS arrival. Patient was unresponsive and found to be in cardiac arrest with no shockable rhythm. Manual CPR was initiated while team member obtained LUCAS and ventilator. Patient #1 was intubated and hooked up to the ventilator and LUCAS. ROSC achieved 3 times during the call with persistent hypotension present each time to spite initiation of pressors and re-arrest occurring. Patient #1 was transported to the local ED. Patient #1 was coded a total of 3 times before her death was called in the local ED by the physician onsite. An interview was conducted on 09/02/2026 at 2:44 p.m. with Patient #1’s daughter. She confirmed Patient #1 completed an HCPOA in 04/2026 indicating she was her HCPOA. She stated she contacted the Hospice agency on 06/29/2026 and could only get someone in Medical Records on the phone. She stated she informed them she was Patient #1’s HCPOA, not the person who signed her LaPOST upon admission, and she wanted to re-do it. She confirmed she was informed they had not obtained a copy of Patient #1’s HCPOA during admission, so she provided it via email. She stated she informed them Patient #1 should not have been made a DNR because she wanted her to be a Full Code, so the LaPOST needed to be re-signed. She stated after she hung up, the Hospice agency emailed her blank admission documents for Patient #1, including a LaPOST. She confirmed she completed the blank LaPOST changing Patient #1’s code status from DNR to Full Code then emailed it back to the Medical Records person on 06/29/2026. She stated she did not feel Patient #1 would have wanted to be a DNR. She confirmed she was not present at the hospital when her referring physician had discussions with Patient #1 about her wishes for being a DNR, nor was she present for the meeting involving S5CRM when the legal documents were completed. She confirmed Patient #1’s sister and Patient #1’s sons were involved in the meeting and they did not follow her wishes for Patient #1’s care, as her HCPOA. She confirmed she wanted Patient #1 to be a Full Code from the start and if her aunt and brothers would have honored her HCPOA status, she would have never allowed Patient #1 to become a DNR. She confirmed she was not contacted or visited by S3MD or any Hospice physician after she submitted the paperwork on 06/29/2026 to discuss changing Patient #1 from DNR to Full Code. She confirmed when Patient #1 was found unresponsive on 07/05/2026, she received CPR by hand then by a machine and had a tube placed down her throat which was hooked to a machine to make her breathe. An interview was conducted on 09/02/2026 at 11:35 a.m. with S7PRA. S7PRA confirmed she was familiar with Patient #1. S7PRA confirmed on 06/29/2026, she received the LaPOST from Patient #1’s HCPOA changing her from a DNR to a Full Code. S7PRA stated when she received it, she updated her facesheet then forwarded it to their Medical Records to obtain S3MD’s signature. An interview was conducted on 09/02/2026 at 7:32 a.m. with Patient #1’s referring physician to Hospice. He confirmed he was very familiar with Patient #1 and confirmed towards the end of Patient #1’s inpatient stay, while she was at full decision-making capacity, he had a very in-depth conversation with her where she told him she was “tired of all of it and ready”. He confirmed Patient #1 then refused any further lab draws and invasive treatments during her inpatient stay and stated she wanted to be discharged to home on Hospice as a DNR, so he made the referral and attended her Hospice admission meeting. He confirmed he attended the Hospice admission meeting to advocate for his patient’s wishes but was not the physician who signed her LaPOST, her Hospice physician did. He confirmed during Patient #1’s Hospice admission meeting on 06/19/2026, she made the official decision to change to DNR status and carried full decision-making capacity to do so at the time. He stated Patient #1 told he and S5CRM her sister could sign any paperwork necessary as her proxy due to her physical decline limiting signing capability. He stated Patient #1’s two sons were involved in some of the conversation, and she made them aware of her wishes, as well. He stated while Patient #1 was cognitive and at full capacity for medical decision making her HCPOA would not be in effect and her sister’s signature by proxy was valid, legal and no different than Patient #1 signing the document herself. He stated if Patient #1’s HCPOA were present during the meeting on 06/19/2026 and did not want DNR status, it would not have mattered. He confirmed Patient #1’s HCPOA could not override the patient’s wishes for DNR status since she was at full decision-making capacity when she completed the LaPOST. He confirmed a HCPOA was a surrogate decision maker, not a sole decision maker, meaning the HCPOA was responsible for carrying out the patient’s known wishes, not their own wishes. He confirmed a HCPOA would only come into effect if/when a patient became incapacitated, and if/when it occurred, the HCPOA must follow the patient’s previously stated and/or written wishes. He confirmed if/when Patient #1 was no longer at capacity, her HCPOA could not legally or ethically be allowed to impose their own wishes on the patient because the patient made her wishes clear while at full decision-making capacity. He confirmed in the event Patient #1’s HCPOA wished to change the patient’s code status based on the HCPOA’s own personal wishes and not Patient #1’s, her HCPOA should have been educated on Patient #1’s wishes, along with the legal responsibilities and limits a HCPOA was legally and ethically allowed in determining Patient #1’s level of care/treatment moving forward. He stated the only time a HCPOA was able to determine a patient’s code status was if the patient never verbalized or put their wishes for their code status in writing, which did not apply to Patient #1. He confirmed, in a court of law and per the state’s Medical Board, Patient #1’s LaPOST, dated 06/29/2026, indicating Full Code was not valid and she should not have received CPR or been intubated and placed on a ventilator because a patient’s code status could not be changed under the circumstances in which it was changed for Patient #1. An interview was conducted on 09/02/2026 at 12:43 p.m. with S3MD. S3MD confirmed she was familiar with Patient #1. S3MD confirmed she signed Patient #1’s LaPOST, dated 06/29/2026, making her a Full Code. S3MD confirmed she had never assessed Patient #1 nor had a conversation with her or her family to determine Patient #1’s decision-making capacity or to discuss her wishes to be a DNR and the request to change her to a Full Code. S3MD stated she received an email with Patient #1’s LaPOST from Medical Records on 06/29/2026, signed it on 07/01/2026, then emailed it back to Medical Records to go in her Clinical Record. S3MD confirmed when she received Patient #1’s LaPOST on 06/29/2026, changing her from DNR to Full Code, she was aware Patient #1 was at full decision-making capacity on 06/19/2026 when she made the decision to become a DNR independently with her sister signing for her by proxy. S3MD confirmed the signature by proxy was the same as Patient #1 signing herself. S3MD stated on 06/29/2026 when she received the LaPOST to change Patient #1’s code status from DNR to Full Code, she did not recall if she spoke with anyone at the Hospice agency to determine why and could have made an assumption the patient no longer wished to be a DNR. S3MD confirmed she did not speak to Patient #1 or her HCPOA prior to signing the LaPOST changing her from DNR to Full Code on 06/29/2026 and this was not part of the agency’s process to require her to do so. S3MD confirmed to her knowledge, if a patient were at full capacity and their HCPOA did not agree with the patient’s decision for treatment, the HCPOA’s wishes could and would be honored over the patient’s. S3MD confirmed if an incapacitated patient made their code status wishes known in writing while at full decision-making capacity, it was not her responsibility to ensure their HCPOA honored their wishes. S3MD confirmed if the HCPOA said the patient changed their mind, she would trust the HCPOA because it was not her responsibility to question a decision made by a patient’s HCPOA. An interview was conducted on 09/03/2026 at 11:58 a.m. with S2DOC. S2DOC confirmed she was not aware a HCPOA could not change a patient’s previously declared DNR status because they wanted different treatment than the patient. S2DOC confirmed she was not aware Patient #1 was cognitive and at full decision-making capacity when she completed her LaPOST on 06/19/2026 to become a DNR. S2DOC confirmed she was not aware Patient #1’s LaPOST upon admission was signed by her sister as the patient’s proxy, not as the patient’s decision maker. S2DOC confirmed by proxy was no different than the patient signing the paperwork herself which meant Patient #1’s LaPOST was valid and her own declared wishes. S2DOC confirmed prior to allowing Patient #1’s HCPOA to change her Code status on 06/29/2026, no one at the Hospice agency reached out to Patient #1’s referring physician to determine the level of her decision-making capacity when she indicated DNR on her LaPOST on 06/19/2026. S2DOC confirmed when Patient #1 was found unresponsive, she received CPR and advanced life support. An interview was conducted on 09/03/2026 at 11:54 a.m. with S1CEO. S1CEO stated all Hospice agencies deal with family members changing their mind about a patient’s code status all the time and if the person changing their mind was the legal decision maker, the Hospice agency could not stop them.”

“Based on interviews and record review, the Hospice agency failed to have a system in place to determine the presence of an existing Advance Directive(s) upon admission and obtained a copy of the legal document for 3 of 3 (#1, #2, #3) patients reviewed. This deficient practice had the potential to affect a current census of 404 patients. Cross Reference: L648. Findings: Review of the undated publication by the state’s Governor’s Office of Elderly Affairs titled Planning for Incapacity - Advance Directive Forms for Louisiana, revealed, in part, the following: A competent adult can communicate preferences about future medical treatment through a legal document called an Advance Directive. What are three types of Advance Directives? In Louisiana, there are three types of advance care planning documents available. These include the HCPOA, the Living Will, and the LaPOST document. Review of the Hospice agency’s Policy and Procedure(s) regarding Living Will and HCPOA Advance Directives was requested on 08/31/2026, 09/01/2026, 09/02/2026, and again on 09/03/2026 with no documented evidence made available for review. Patient #1Review of Patient #1’s Clinical Record revealed she was admitted to the Hospice agency on 06/22/2026 with an Initial Certification Period of 06/22/2026 through 09/19/2026. Further review revealed she was referred for admission while inpatient at a local hospital. Review of Patient #1’s Referral Packet submitted by the local hospital to the Hospice agency revealed no documented evidence of a HCPOA. Review of Patient #1’s Admission Packet and Initial Assessments for the Hospice agency revealed no documented evidence of a HCPOA prior to 06/29/2026. Further review revealed no documented evidence of attempts to obtain the legal document prior to 06/29/2026. Review of Patient #1’s Clinical Records obtained from the local hospital who referred her to the Hospice agency revealed she had a HCPOA in place which indicated her daughter was her legal decisionmaker in the event she became incapacitated. An interview was conducted on 09/02/2026 at 2:44 p.m. with Patient #1’s daughter. She confirmed Patient #1 had 3 adult children; herself and two brothers. She confirmed Patient #1 completed an HCPOA in 04/2026 indicating she was her HCPOA. She confirmed Patient #1’s HCPOA was on file at the local hospital prior to her admission to the Hospice agency. She confirmed the Hospice agency did not contact her to obtain a copy of Patient #1’s HCPOA. She confirmed she reached out to the Hospice agency on 06/29/2026 to make them aware of the legal document and submitted a copy to them electronically at that time. She confirmed the Hospice agency informed her they did not have a copy of this document prior to her submitting it to them. An interview was conducted on 09/02/2026 at 11:35 a.m. with S7PRA. S7PRA confirmed the Hospice agency received a call from Patient #1’s daughter on 06/29/2026 informing the Hospice agency she was the patient’s HCPOA. S7PRA confirmed Patient #1’s daughter provided them with her HCPOA electronically at that time. S7PRA confirmed prior to this, the agency had not obtained a copy of Patient #1’s HCPOA. An interview was conducted on 09/02/2026 at 12:00 p.m. with S4MSW. S4MSW confirmed she was the MSW assigned to Patient #1. S4MSW confirmed on 06/29/2026, Patient #1’s daughter contacted the agency and provided them with a copy of Patient #1’s HCPOA. S6DSW confirmed she was made aware of this because she was asked to perform a home visit to smooth things over on 06/29/2026 due to Patient #1’s daughter being upset about them not obtaining her HCPOA upon admission. Patient #2Review of Patient #2’s Clinical Record revealed she was admitted to the Hospice agency on 06/22/2026 with an Initial Certification Period of 06/22/2026 through 09/19/2026. Further review revealed she was referred for admission while inpatient at a local hospital and was incapacitated at the time of her admission to the Hospice agency. Review of Patient #2’s Informed Consent in her Hospice Admission Packet and Consents revealed she had a HCPOA and a Living Will which indicated her son was her legal decisionmaker in the event she became incapacitated. Review of Patient #2’s Referral Packet submitted by the local hospital revealed no documented evidence of a HCPOA. Review of Patient #2’s Clinical Record revealed no documented evidence of the aforementioned HCPOA and Living Will. Further review revealed no documented evidence of attempts to obtain the legal documents. An interview was conducted on 08/31/2026 at 3:30 p.m. with Patient #2’s son. He confirmed Patient #2 had two adult children, himself and another son. He confirmed Patient #2 completed an HCPOA in 03/2026 indicating he was her HCPOA. He confirmed he made the agency aware of Patient #2’s HCPOA and Living Will upon her admission to the agency and told them to contact the local nursing home where she resided if they needed a copy for their records. He confirmed the agency did not ask him about the documents again. He confirmed Patient #2 was incapacitated at the time of her admission to the Hospice agency. Patient #3Review of Patient #3’s Clinical Record revealed he was admitted to the Hospice agency on 06/27/2026 with an Initial Certification Period of 06/27/2026 through 07/10/2026. Further review revealed he was referred for admission from his physician’s office and was incapacitated at the time of his admission to the Hospice agency. Review of Patient #3’s Informed Consent in his Hospice Admission Packet and Consents revealed he had a HCPOA and a Living Will which indicated his spouse was his legal decisionmaker. Review of Patient #3’s Referral Packet submitted by his physician at the time of his admission to the Hospice agency revealed no documented evidence of a HCPOA. Review of Patient #3’s Clinical Record revealed no documented evidence of the aforementioned HCPOA and Living Will. Further review revealed no documented evidence of attempts to obtain the legal documents. An interview was conducted on 09/01/2026 at 5:04 p.m. with Patient #3’s spouse. She confirmed Patient #3 had a HCPOA and Living Will in place at the time of his admission to the Hospice agency which indicated she was his HCPOA. She confirmed she indicated this information when she completed his admission paperwork but the Hospice agency did not ask her about it or request a copy of the legal documents. She stated she was not aware they required copies of these legal documents or she would have provided them. She confirmed Patient #3 was incapacitated at the time of his admission to the Hospice agency. An interview was conducted on 09/02/2026 at 11:18 a.m. with S5CRM. S5CRM confirmed she was responsible for performing the agency’s pre-admission paperwork, which included determining the presence of an Advance Directive. S5CRM stated she typically reviewed a patient’s referral documents to determine the presence of an Advance Directive(s) prior to meeting with the patient/family and if there was one present, she would ask about it when she met with them. S5CRM confirmed Patient #1, #2 and #3’s referral documents did not include a copy of their Advance Directives and should have if there was one present. An interview was conducted on 09/02/2026 at 11:35 a.m. with S7PRA. S7PRA confirmed she received the agency’s patient referral paperwork and was responsible for contacting the patient/family to set up an appointment for S5CRM or another staff person to meet with them to complete their Admission Packet paperwork. S7PRA stated once the Admission Packet was completed, it came back to her to review, create their Clinical Record, and enter their demographics, which included the presence of a HCPOA. S7PRA stated the presence of a HCPOA was entered based off the information the patient/family documented in their Admission Packet paperwork, not based on the Hospice agency having the legal document(s) in-hand. S7PRA stated if she saw the boxes were checked indicating a HCPOA and/or Living Will, she would probably reach out to the patient/family to ask for it. S7PRA stated the patient/family would have been provided with the Hospice agency’s email address in their Admission Packet and should be made aware they needed to provide the documents via email. S7PRA confirmed the Hospice agency did not have a process to ensure the presence of Advance Directives identified upon admission were obtained following admission. S7PRA confirmed the Hospice agency did not have a way to track the missing legal documents and there was not one person she should pass this information along to for them to follow up. An interview was conducted on 09/02/2026 at 12:00 p.m. with S4MSW. S4MSW confirmed she was responsible for performing Initial MSW Assessments when patients she was assigned to were admitted to the Hospice agency. S4MSW confirmed Advance Directives were determined and obtained during the patient’s pre-admission process and she did not typically have anything to do with the process. An interview was conducted on 09/02/2026 at 3:11 p.m. with S8RN. S8RN confirmed she was responsible for performing Initial RN Assessments when patients she was assigned to were admitted to the Hospice agency. S8RN confirmed she was not involved in the Hospice agency’s process of determining the presence of an Advance Directive(s) and did not have any insight on how it was done or who was responsible. An interview 09/02/2026 at 11:04 a.m. with S2DOC. S2DOC confirmed she was not aware an HCPOA was an Advance Directive and it should be in a patient’s Clinical Record. S2DOC confirmed the Hospice agency did not have a process to review each patient’s admission paperwork to determine the presence of Advance Directives, nor was there a process in place to ensure the Hospice agency followed up to obtain a copy and place it in the patient’s Clinical Record. S2DOC confirmed the Hospice agency did not have a policy and procedure regarding HCPOA and/or Living Will Advance Directives. S2DOC confirmed Patient #1, #2 and #3’s Advance Directives were not obtained upon admission and placed in their Clinical Records because she was not aware they should. An interview was conducted on 09/03/2026 at 11:54 a.m. with S1CEO. S1CEO confirmed she was not aware an HCPOA was an Advance Directive. S1CEO confirmed she was not aware a copy of a patient’s Advance Directives should be maintained in their Clinical Record.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: Prescription and over-the-counter (OTC) Supplements; Herbal remedies; Other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; Actual or potential drug interactions; Duplicate drug therapy; Drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 1 of 26 (4%) clinical records reviewed revealed that the agency did not ensure the medication profile was updated with a full review of all medications that the patient was taking. CLINICAL RECORD 25: The patient’s election of benefits was 04/21/2025 with diagnosis of Pancreatic CA. The patient was admitted to IPU (inpatient unit) to GIP (general inpatient Care) on 04/21/2025 for pain and nausea with IVP (intravenous push) morphine [pain control], Phenergan [control of restlessness], and Zofran [control of nausea]. The use of a saline flush before and after medications would be required, but saline was not documented on the medication profile during the comprehensive assessment and consequently not reviewed. During the interview with the inpatient manager who jointly reviewed the records stated that the normal saline to flush the line should have been on the medication profile, where all medications are reviewed.”

“It is required that the hospice designates a registered nurse member of the IDG to: Provide coordination of care; Ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 23 (4%) Clinical records of routine patients were reviewed and revealed that the agency did not ensure that all care was coordinated and that the plan of care was followed as ordered. CLINICAL RECORD 23: The patient’s election of the hospice benefit was 12/27/2024. The initial comprehensive assessment 12/27/2024 included the patient had a tunneled PICC (peripherally inserted central catheter) line. The initial plan of care and updated plans of care documented an intervention, Central Line Dressing change to be performed every 7 days using sterile technique by a hospice nurse or caregiver. The PICC line dressing changes were documented 12/29/2024 and again 01/06/2025, then 01/16/2025 (10 days), then 01/24/2024 to 02/03/2025, this was 10 days, then 2/10/2025, then 02/26/2025, this was 16 days. Interview with the registered nurse, case manager stated that the dressing was changed every week by the nurse or the caregiver but stated that the specific documentation was not in the clinical record. There was no documented evidence that care was coordinated and that the plan of care was followed as ordered. During the joint record review with the Clinical Director and the Director of Compliance and Education, who stated that the coordination of care was not documented by the registered nurse.”

“It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 23 (9%) clinical records reviewed, for routine hospice patients, it was revealed that the agency did not ensure the plan of care was updated with interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 1: The hospice benefit of election was 05/30/2024. The updated nursing assessment identified sleep as an increasing problem for the patient on 12/31/2024 and noted in the updated nursing assessment as well as the face-to-face documented on 03/04/2025. There was no documented evidence for interventions on the plan of care for the sleep problem as of 04/22/2025. CLINICAL RECORD 3: The hospice benefit of election 12/13/2024 for senile dementia. The initial plan of care, 12/13/2024, and updated plans of care documented an intervention under GI/GU for patients’ catheter will be maintained without discomfort or signs or symptoms of infection. This intervention continued as of the last plan update 04/17/2025. Interview with the nurse, the patient does not have a catheter and had not had a catheter during care. During the interview with the Clinical Director, who stated that all interventions were not accurate and completely updated, but this was a current process improvement.”

“It is required that each patient’s individualized written plan of care included 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 4 of 26 (15%) clinical records reviewed revealed that the agency did not ensure that the plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 1: The hospice benefit of election was 05/30/2024. The updated nursing assessment identified pain as an increasing problem on 06/03/2024 and continued with multiple medication changes and instructions. The updated plan of care documented a goal, “Patient/Caregiver goals: pain rating of ( )/10 will be maintained by start date 6/3/2024. All updated plans through 04/22/2025 document the same goal with no clarification, individualization, or measurability. CLINICAL RECORD 11: The hospice benefit of election 01/25/2025. The updated plan of care 04/02/2025 for skin and wound care documented a goal “Patient will exhibit pain related to wound care acceptable to patient ( )/10 by 04/02/2025. The updated plan on 04/07/2025 and 04/16/2025 continued with the same goal, with no clarification, individualization, or measurability. CLINICAL RECORD 14: The hospice benefit of election was 01/10/2025 with an identified patient goal: “patient caregiver goals: pain rating of ( )/10 will be maintained by 01/10/2025. The updated plans 01/23/2025, 02/04/2025, 02/20/2025, 03/04/2025, 03/19/2025, and 04/02/2025 continue to document the same goal with no clarification of individualization or measurability. During the interview with the Director of Compliance and Education and the Clinical Director, who jointly reviewed the records, stated that the goals were not defined.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, interview, and observation. In 5 of 21 (24%) clinical records reviewed in which a hospice aide was accepted, the agency did not ensure that the registered nurse prepared a hospice aide plan of care that included clear and specific instructions for the patient’s required care. CLINICAL RECORD 2: The hospice aide assignment dated 11/11/2024 and updated 02/28/2025 documented for skin to “apply barrier cream as directed.” There were no documented specific instructions for where the cream should be applied. The aide visits 3 times a week and documents that barrier cream was applied but did not document where it was applied. CLINICAL RECORD 5/HOME VISIT 5: The hospice aide assignment dated 12/31/2024 assigned the task to “apply barrier cream as directed 3 times a week.” There were no documented specific instructions for where the cream should be applied. During the home visit with the hospice aide (Personnel Record 5) on 04/21/20225, the aide’s plan of care continued the assigned “apply barrier cream as directed”. Interview with the aide during the visit, she stated that she applies barrier cream to the perineum and coccyx area as the patient is incontinent, and that she had spoken and verified with the nurse. There was no documented evidence of the communication of the aide with the nurse. CLINICAL RECORD 3: The hospice aide assignment documented dated 12/13/2024 with no documented updates as of review 04/23/2025 documented the task for “ apply barrier cream as directed 3 times a week. “ There was no documented evidence of specific instructions for where the cream should be applied as of review 04/22/2025. CLINICAL RECORD 8: The hospice aide assignment document dated 02/26/2025 and updated 04/17/2025 with the task to “apply barrier cream as directed, “however There were no documented evidence of specific instructions for where the cream should be applied as of the review 04/23/2025. CLINICAL RECORD 14: The patient’s election of benefit was 01/10/2025 with diagnosis of Senile degeneration of the brain. The patient resided with a daughter. The hospice aide assignment updated 04/07/2025 included the tasks of shampoo prn and clean nails prn. The prn was not specific to frequency or who would be the decision maker for these assigned tasks. During the interview with the Director of Compliance and Education and the Clinical Director, who jointly reviewed the records and stated that direction for barrier cream was missing, as well as identified the decision maker.”

“It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group; Included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 21 (19%) Clinical records reviewed in which a hospice aide was accepted for care, the agency did not ensure that the hospice aide provided care according to the ordered plan of care. CLINICAL RECORD 2: The hospice aide assignment dated 11/11/2024 and updated 02/28/2025 with the task of shampooing every Monday. The following dates the shampoo was provided was 03/26/2025 (Wednesday), 03/28/2025 (Friday), 04/02/2025 (Wednesday and 04/04/2025 (Friday). These were not Monday dates, and no documented evidence why it was provided on days other than Monday as ordered. CLINICAL RECORD 15: The hospice aide assignment dated 01/26/2025 with no updates assigned the task of bed bath five times a week and shampoo one time a week. The week of 04/06/2025, with five aide visits documented there was no documented evidence that the shampoo was provided and no documented reason for not providing the shampoo. The week of 04/13/2025, with aide visits documented five times a week, the aide documented that the hair was shampooed on 04/15/2025, 04/17/2025, and 04/18/2025, which was three times that week. There was no documented evidence why the shampoo was provided three times the week of 04/13/2025. CLINICAL RECORD 9: The hospice aide’s plan of care assignment dated 01/15/2025, included the task for shampooing one time a week. The week beginning 03/02/2025 the aide documented shampooing on 03/06/2025 (Thursday) and 03/08/2025 (Saturday). This was two times during the week of 03/02/2025, not the one time assigned, and no reason why the plan of care was not followed. CLINICAL RECORD 18: The hospice aide assignment dated 03/07/2025 included the assigned tasks of bed bath, oral care, hair care, peri care to be provided three times a week, with visits ordered three times a week, and shampoo one time a week. For the aide visit notes dated 04/05/2025 and 04/19/2025, none of the care tasks were documented. There was no documented evidence as to why the assigned task were not completed or evidence of notification to the registered nurse. An interview on 04/23/2025 with the aide on 04/23/2025 revealed that the patient refused care on these dates and that the aide did call the hospice nurse and facility nurse, but agreed it was not documented. During the interview on 04/23/2025 with the Director of Compliance and Education, and with the Clinical Director stated that the documentation of the care was not as ordered on the aide assignment.”

“It is required that a hospice-operated inpatient care facility complies with all applicable federal, state, and local health and safety codes, including: The applicable provisions of the Life Safety Code (LSC) of the National Fire Protection Association NFPA 101, Life Safety Code 2012 edition; and, (L827-418.110(d)) Tentative Interim Amendments (TIA) 12-1, TIA 12–2, TIA 12–3, and TIA 12–4; and, The Health Care Facilities Code NFPA 99, 2012 edition and Tentative Interim Amendments TIA 12–2, TIA 12–3, TIA 12–4, TIA 12–5, TIA 12–6 – except Chapters 7, 8, 12, and 13 that do not apply to hospice. (L828-418.110(e)) This standard was not met as evidenced by document review, interview, and observation. An observation of the stored oxygen cylinders revealed that the agency did not ensure they were stored and labeled as required per regulation. Full, partial or empty cylinders. A critical aspect of oxygen uses, and storage is related to identifying each cylinder as full or empty. In an emergency, it is critical for staff to easily identify which cylinders are full. NFPA 99 section 11.6.5.3 specifically requires that empty cylinders be “marked to avoid confusion and delay if a full cylinder is needed in a rapid manner.” Tour of IPU (inpatient unit) on 4/23/2025 revealed that the agency had not maintained the storage room containing oxygen cylinders. There were 13 oxygen e-tanks total, 4 were empty, and 9 were full tanks. The Facility Clinical Manager was aware of which e-tanks were full, and which were empty, however, none of them were marked. 1 empty cylinder was secured in a cart, and 3 empty cylinders were standing with no security holding them up or securing them from falling. There were 5 full cylinders secured in carts, and 4 full cylinders were standing unsecured. During an interview with the Facility Clinical Manager on 4/23/2025, she agreed with the observation of unsecured cylinders in storage and the lack of labeling of oxygen cylinders. By the end of that day, full and empty cylinders were separated and labeled, and all cylinders were secure in racks or in carts. Tour of IPU (inpatient unit) on 4/23/2025 revealed that the agency had not maintained the storage room containing oxygen cylinders.. There were 13 oxygen e-tanks total, 4 were empty, and 9 were full tanks. The Facility Clinical Manager was aware of which e-tanks were full and which were empty, however, none of them were marked. 1 empty cylinder was secured in a cart, and 4 empty cylinders were standing with no security holding them up or securing them from falling. There were 5 full cylinders secured in carts, and 4 full cylinders were standing unsecured. During an interview with the Facility Clinical Manager on 4/23/2025, she agreed with the observation of unsecured cylinders in storage and the lack of labeling of oxygen cylinders. By the end of that day, full and empty cylinders were separated and labeled, and all cylinders were secure in racks or in carts.”

“It is required that the hospice inpatient facility has documented and dated written reports of Life Safety Code (LSC) fire drills at varied times on all shifts. This standard was not met as evidenced by document review and interview. The document review revealed that the agency did not ensure that fire drills were held at least quarterly for each clinical work shift. On 04/23/2025, a review of fire drill logs for years 2023, 2024, and 2025 revealed that fire drills were not conducted on each shift per quarter. For 2023 the documented fire drills were: 12/05/2023, 11/09/2023, 09/21/2023, 08/30/2023, and 07/12/2023 for the night shift only, with the night shift missing from the first and second quarter of 2023, and the day shift missing from the third and fourth quarter of 2023. All fire drills in 2024 and 2025 were conducted on the day shift, with the night shift missing all four quarters of 2024 and the first quarter of 2025. The unit utilized 12-hour shifts (7 am - 7 pm). When reviewed with the Hospice Facilities Manager they agreed that the fire drills have been primarily conducted on the day shift but said the night shift would be added. The agency did not ensure that fire drills were held at least quarterly for each clinical work shift. Document review: On 04/23/2025, a review of fire drill logs for years 2023, 2024, and 2025 revealed that fire drills were conducted on the day shift only, with the exception of 6 fire drills conducted on the night shift in 2023 only. Fire drills were conducted on 12/05/2023, 11/09/2023, 09/21/2023, 08/30/2023, and 07/12/2023 for the night shift only, with the night shift missing from the first and second quarter of 2023, and the day shift missing from the third and fourth quarter of 2023. All fire drills in 2024 and 2025 were conducted on the day shift, with the night shift missing all four quarters of 2024 and the first quarter of 2025. The unit utilized 12-hour shifts (7 am - 7 pm) Interview with the Hospice Facilities Manager indicated that drills have been primarily conducted on the day shift with the facility manager, but the night shift would be added.”