Modern Hospice

“Based on interviews, observations, and record reviews, the Hospice agency failed to organize, manage and administer its resources to provide all necessary Hospice care and services to patients, caregivers and families for the palliation and management of the terminal illness and related conditions. This deficient practice was evidenced by failure to meet the COP for the Organization and Administration of services by failing to have a system in place to:1. Protect patient’s rights by preventing the improper Revocation of Hospice Benefits when the patient/family chose to seek treatment and/or services which would not require the Revocation of Hospice Benefits for 3 (#6, #11, and #14) of 4 patients reviewed for Revocations. (See Findings in L505); 2. Ensure the patient’s POC was individualized with interventions which included all necessary services for the palliation and management of the patient’s terminal illness and related conditions for 4 (#7, #8, #10 and #11) of 10 live patients reviewed. (See Findings in L545); 3. Ensure ongoing communication and sharing of information with the IDG when staff identified communication barriers and/or missing orders for care and services for 5 (#7, #8, #10, #11, and #14) of 10 live patients reviewed. (See Findings in L557); 4. Ensure ongoing communication and sharing of information with the IDG when patients were identified as entering the active dying phase for 3 (#3, #4, and #5) of 3 expired patients reviewed. (See Findings in L557); 5. Ensure identified PIPs were implemented and evaluated for on-going improvement(s). (See Findings in L571);6. Ensure the Governing Body maintained responsibility for ensuring a QAPI Program was implemented, maintained, and evaluated for effectiveness/improvement. (See Findings in L574);7. Ensure the agency operated in accordance with all applicable state laws by ensuring a patient’s medical pronouncement of death by the coroner/physician was based on the personal observation, information and statements obtained by a qualified professional for 3 (#3, #4, and #5) of 3 expired patients reviewed. (See Findings in L585); 8. Ensure the Bereavement Program and associated services were provided under the direction and supervision of a qualified Bereavement Supervisor. (See Findings in L596);9. Ensure an individualized Bereavement POC was developed which identified the type and frequency of services required for 3 of 3 (#3, #4, and #5) patients reviewed for Bereavement. (See Findings in L596);10. Ensure the Bereavement Program was implemented according to the agency’s Bereavement Services Policy and Procedure for 3 of 3 (#3, #4, and #5) patients reviewed for Bereavement. (See Findings in L596);11. Develop and implement an effective Volunteer Program with a viable system in place to recruit and retain volunteers in order to provide volunteer services at a minimum of 5% of the agency’s total patient care hours. (See Findings in L645 and L647);12. Ensure the Governing Body and Administrator assumed full legal authority and responsibility for the management and provision of all Hospice services and a continuous QAPI Program. (See Findings in L651); 13. Ensure a patient’s Clinical Record contained a copy of their Advance Directive(s) for 4 (#6, #8, #9, and #18) of 4 patients identified by the agency as having an HCPOA. (See Findings in L677);14. Establish a written policy and procedure in accordance with accepted standards of practice which ensured the safe use, management and documented disposition of all controlled substances provided by the Hospice agency to the patient. (See Findings in L694);15. Ensure current and accurate records were maintained for the disposition of all controlled substances provided by the Hospice agency to the patient for 14 (#6, #7, #8, #9, #10, #11, #12, #13 #14, #15, #16, #17, #18, and #19) of 14 live patients reviewed. (See Findings in L694); and16. Ensure current and accurate records were maintained for the disposition and disposal of all controlled substances provided by the Hospice agency to the patient immediately following their death in the presence of a witness for 3 (#3, #4, #5) of 3 expired patients reviewed. (See Findings in L694). .”

“Based on interviews and record review, the Hospice agency failed to ensure the patient was free to exercise their right to be involved in decision making regarding their care, treatment and services without being compelled to revoke by the Hospice agency. This deficient practice was evidenced by the failure to have a system in place to prevent improper Revocation of Hospice Benefits when a patient/family chose to seek treatment and/or services which would not require a Revocation of Hospice Benefits for 3 (#6, #11, and #14) of 4 patients reviewed for Revocations.This deficient practice had the potential to affect any of the agency’s current census of 75 patients and any future admissions to the agency. Cross Reference: L648, L505, L545, L557, L571, L574, L585, L596, L645, L647, L651, L677, and L694. Findings: Review of the Hospice agency’s Patient’s Bill of Rights and Responsibilities in the Admission Packet revealed, in part, the following: Patient’s Bill of Rights and Responsibilities: The patient has the right to be informed of his/her right and the Hospice agency must: Protect and promote the exercise of these rights Consistent with state laws, the patient’s family or guardian may exercise the patient’s rights when the patient is unable to do so. Protect the rights of their patient, including the following:Dignity, Respect, and Decision Making – Patients and their hospice caregivers have a right to mutual respect and dignity and to exercise his/her rights as a patient of the hospice.Decision MakingPatients and caregivers have the right: To participate in the planning of his/her care of treatment.Review of the Hospice agency’s Choice of Care for Revocation/Transfer Policy in the Admission Packet revealed, in part, the following: I understand that I may choose care other than the care the Hospice agency provides at any time by signing a revocation statement and I will notify the Hospice agency immediately of a decision to revoke or transfer hospice services. Such a choice will immediately relieve the Hospice agency of any further responsibility of providing care to me. I also understand that I need approval from the Hospice agency before agreeing to or receiving treatments, supplies, equipment or any other services directly related to my terminal condition. I understand that if I do not receive approval from the Hospice agency or if I fail to sign a revocation statement and to notify the Hospice agency in a timely manner, then I may be financially responsible for any charges related to unauthorized treatment. This may include ambulance costs, emergency room or hospital costs, procedure and treatment costs and/or physician costs. I understand that I have the right to transfer my hospice care to another agency once during each election period or I may revoke the hospice benefit at any time for any reason, losing any days remaining in that hospice benefit period. Review of the Hospice agency’s Revoking the Election of Hospice Care Policy, revised June 2019, revealed, in part, the following: Policy: Hospice will follow applicable Medicare rules and honor a patient’s right to revoke Hospice care. Procedure: 1. To revoke the election of Hospice care, the patient or representative must file a statement with Hospice that includes the following information: a signed statement that the patient or representative revokes the patient’s election for Medicare coverage of Hospice care for the remained of that election period; The date that the revocations is to be effective. A patient or representative may not designate an effective date earlier than the date that the revocation is made.Review of the Hospice agency’s Live Discharge List, dated 04/20/2025 through 04/20/2026, revealed 35 patients revoked their Hospice benefits during the timeframe reviewed. Further review revealed 4 of the 35 revocations were re-admitted shortly after their first revocation then revoked benefits a second time. Patient #6Review of Patient #6’s Clinical Record for his Initial Admission revealed he was admitted to the Hospice agency on 12/19/2025 with a terminal diagnosis of Malignant Neoplasm of Left Kidney and in a Certification Period of 12/19/2025 through 01/27/2026. Further review revealed he was discharged from the Hospice agency on 01/27/2026 due to revocation. Review of Patient #6’s Revocation of Hospice Benefits Statement, dated 01/27/2026, revealed, in part, the form was signed by his sister- in law for an Oncology Visit and Scan. Review of Patient #6’s Nurse Revocation Statement, written by S2DON on 01/27/2026, revealed in part, the following: Patient revoked hospice services for follow- up initiated by doctor’s office. Review of Patient #6’s second admission revealed he was re-admitted to the Hospice agency on 01/30/2026 for a Certification Period of 01/30/2026 through 02/18/2026 after his aforementioned Revocation of Hospice Benefits on 01/27/2026. Review of Patient #6’s Revocation of Hospice Benefits Statement, dated 02/18/2026, revealed, in part the form was signed by his step-son for ER Visit after being found wandering.Review of Patient #6’s ER discharge notes dated 02/18/2026 revealed the following, in part: Patient #6 arrived to ER via ambulance transportation due to increased confusion. Family continued to desire hospice care, and did not desire any further chemotherapy. Diagnostic data collected during admission to local hospital revealed results were consistent with metastasis to brain. Review of Patient #6’s third admission revealed he was re-admitted to the Hospice agency on 02/20/2026 for a Certification Period of 02/20/2026 through 04/20/2026 after his second aforementioned Revocation of Hospice Benefits on 02/18/2026. An interview was conducted on 04/22/2026 at 2:50 p.m. with Patient #6’s sister in law. She confirmed Patient #6’s revoked Hospice Benefits on 01/27/2026 due to Patient’s Oncology appointment and the Oncologist performing a PET scan. She further confirmed the PET scan was not performed to seek curative treatments, and the family was aware that Patient #6 could no longer be treated curatively at that time. She stated the purpose of the PET scan was for the oncologist to determine if Patient #6’s palliative oral chemotherapy medication was helping from a palliative stand point. She stated Patient #6 had a second revocation on 02/18/2026 due to police finding patient #6 and calling 9-1-1 and ambulance transported Patient #6 to the ER. She further confirmed the revocation paperwork was signed after patient’s ER admission, when he was re-admitted to hospice on 02/20/2026 and back dated for 02/18/2026 which was his date of ER admission. An interview was conducted on 04/22/2026 at 3:33 p.m. with S5LPN. S5LPN confirmed she was responsible for obtaining a signature on Revocation of Benefits Forms. S5LPN confirmed the Hospice agency required patients/families to sign a Revocation of Benefits Form if they chose to take the patient to the ER for any reason. S5LPN stated it was so the patient’s insurance company would have to financially cover the ER visit instead of the Hospice agency. S5LPN confirmed the Hospice agency had patients/families sign an undated blank Revocation of Benefits Form to keep on hand in the event it was needed in the future, like if a patient was taken to the ER without contacting the agency first. S5LPN confirmed if a patient went to a specialist appointment of any kind, even if for palliation of symptoms, the agency required them to revoke their Hospice Benefits. S5LPN confirmed Patient #6’s family signed the aforementioned revocation due to him requiring an ER visit with ambulance transport in order to prevent the agency from having to cover the ambulance transport and ER Visit. S5LPN confirmed Patient #6 was readmitted to Hospice services after he left the hospital. Patient #11Review of Patient #11’s Clinical Record for his Initial Admission revealed he was admitted to the Hospice agency on 09/24/2025 with a terminal diagnosis of Cerebral Infarction and an Initial Certification Period of 09/24/2025 through 09/30/2025. Further review revealed he was discharged from the Hospice agency on 09/30/2025 due to revocation. Review of Patient #11’s Revocation of Hospice Benefits Statement, dated 09/30/2025, revealed, in part, the form was signed by his Legal Representative to Seek Acute Care.Review of Patient #11’s Medical Records from the local hospital, dated 09/30/2025 through 10/02/2025, revealed, in part, Patient noted to have Urinary Tract Infection and Acute Kidney Injury in the ER and started on antibiotics. Imaging also noted fecal impaction present. Review of Patient #11’s second Hospice admission revealed he was re-admitted to the Hospice agency on 10/02/2025 for a Certification Period of 10/02/2025 through 12/30/2025. An interview was conducted on 04/22/2026 at 3:33 p.m. with S5LPN. S5LPN reviewed Patient #11’s signed Revocation Statement, dated 09/30/2025, and confirmed the only documented reason for revocation was “seek acute treatment” and did not contain enough information to validate if a revocation was required so the form would not be valid. S5LPN stated a Revocation of Benefits Form should specify why acute treatment was being sought and if it was related to the terminal illness or not. Patient #14Review of Patient #14’s Clinical Record revealed she was admitted to the Hospice agency on 10/17/2025 with a terminal diagnosis of Parkinson’s Disease and was in was in a Certification Period of 01/15/2026 through 03/19/2026 when she was discharged due to revocation on 03/19/2026. Review of Patient #14’s Revocation of Hospice Benefits Statement, dated 03/19/2026, revealed, in part, the form was signed by her spouse for an ER Visit related to Right Hip Pain. Review of Patient #14’s Nurse Revocation Statement, written by S3RN on 03/19/2026, revealed in part, Spouse called 911. Review of Patient #14’s second Hospice admission revealed she was re-admitted to the Hospice agency on 04/03/2026 with a Current Certification Period of 04/03/2026 through 06/01/2026. An interview was conducted on 04/28/2026 at 5:05 p.m. with S2DON. S2DON confirmed Patient #6 was required to revoke his Hospice Benefits on 01/27/2026 in order to receive a PET scan during his oncology appointment. S2DON confirmed seeing an oncologist and/or receiving a PET scan was not an automatic requirement for revocation of Hospice Benefits because either could be intended for palliation of symptoms, not curative. S2DON reviewed Patient #11’s Clinical Record and confirmed a patient being seen in the ER for a UTI and Fecal Impaction should not have required a revocation of Hospice benefits. S2DON further confirmed the agency’s staff should have identified signs and symptoms of a UTI and Fecal Impaction and obtained orders for treatment prior to Patient #11’s signs and symptoms progressing to the point of his family calling an ambulance for transport to the ER. S2DON confirmed Patient #14 should not have been required to revoke hospice benefits to seek treatment for pain and/or therapy, because these services should have been provided through the Hospice agency. S2DON confirmed a Revocation of Hospice Benefits Form should only be signed at the time of revocation. S2DON confirmed a Revocation of Hospice Benefits Form should never be signed and not dated in advance then maintained on file in the office to be used at a later date. S2DON confirmed revocations were required any time a patient was taken to an ER the Hospice agency did not currently have a contract with. S2DON confirmed the agency did not have a current contract with any ERs/acute hospitals and should if they were going to require revocation any time a non-contracted facility was utilized. S2DON confirmed patients should not be required to revoke their Hospice Benefits when they sought treatment(s) which should be provided by the Hospice agency. S2DON confirmed she expected all of her staff to be aware of what required a patient to revoke their Hospice Benefits versus what didn’t and they did not.”

“Based on interviews and record reviews, the Hospice agency failed to have a system in place to ensure each patient’s POC was individualized with interventions which included all necessary services for the palliation and management of the patient’s terminal illness and related conditions for 4 (#7, #8, #10 and #11) of 10 live patients reviewed. This deficient practice had the potential to affect any of the agency’s current census of 75 patients and any future admissions to the agency. Cross Reference: L648, L505, L545, L557, L571, L574, L585, L596, L645, L647, L651, L677, and L694. Findings: Review of the Hospice agency’s IDG Care Planning Process Policy and Procedure, revised January 2020, revealed, in part, the following: Policy: In order to assure that care provided is appropriately planned to meet each patient’s specific needs and problems, Hospice will utilize data/information gathered during the comprehensive assessment, updates to the comprehensive assessment and reassessments, in the care planning process to provide care that is consistent with the patient and family needs, with patient’s needs and goals as a priority. The Hospice IDG develops a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Procedure: 2. The POC specifies the care and services necessary to meet the patient and family specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions. 3. IDG members provide the care and services offered by Hospice. 8. Standing or routine orders will be individualized to address the specific patient’s needs and signed by the patient’s physician. -Drugs and treatment necessary to meet the needs of the patient. -Medical supplies and appliances necessary to meet the needs of the patient. 9. The IDG reviews, revises and documents the individualize POC as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. -The revised POC includes information from the patient’s updated comprehensive assessment. Patient #7Review of Patient #7’s Clinical Record revealed a start of care date of 03/18/2026. Review of the plan of care for the current Certification Period 03/18/2026 through 06/15/2026 revealed a diagnosis of Senile Degeneration of Brain. Further review of the POC revealed orders for the following Frequency/Duration of Visits: SN 2wk1 with 2 PRN visits from 03/18/2026-04/16/2026 and SN 3wk1 with 2 PRN visits started 04/16/2026. Review of Patient #7’s SNV dated 04/15/2026 revealed the following wound care documentation for her right and left heel pressure ulcers:“SN cleansed both heels with wound cleanser and applied [Medihoney] cream and calcium alginate with dressing and secured with kerlix. Both heels wounds have declined. Black and yellow drainage noted with increased amount to both heels. Heel protectors were placed back on patient.Review of Patient #7’s SNV dated 04/20/2026 revealed the following wound care documentation for her right and left heel pressure ulcers:“Wound with eschar and slough on open areas.” “Barrier cream to peri wound areas. Calcium alginate or honey to slough areas. Cover with telfa and secure abdominal pad and kerlix offload. Potus boots or float heels. Review of Patient #7’s Physician Orders from 03/18/2026 through 04/22/2026 revealed the following: Start date: 03/18/2026. Hospice nurse to apply “Medihoney wound/burn dressing external gel” apply to eschar on bilateral heel wounds three times a week; andStart date: 04/16/2026. Due to wound declining increase SNV to three times per week.Further review revealed no physician orders including instructions for barrier cream to peri wound areas, calcium alginate, wound cleanser, wound dressing type with frequency of dressing changes, and/or Potus Boots.Review, as of 04/23/2026, of Patient #7’s most current POC dated 04/16/2026 revealed the following, in part, problems or concerns: Name: Wounds. Description: pressure ulcer to the right and left heels;Interventions: Educate and/or assess for signs and/or symptoms of infection;Provide pressure alleviating devices as needed; Assess for changes in skin integrity;Teach and/or demonstrate good preventive skin care (repositioning, keeping skin clean and dry, use of wedges, floating heels, etc.); andProvide/educate on wound care as ordered.Further review of Patient #7’s POC revealed no evidence of interventions which included wound care provided 3 times a week with specific orders, barrier cream to peri wound areas, calcium alginate, wound cleanser, wound dressing type, apply Medihoney to eschar on bilateral heel wounds three times a week, wound measurements and/or Potus Boots.An interview was conducted on 04/23/2026 at 2:34 p.m. with S2DON. S2DON reviewed Patient #7’s POC and confirmed the POC was not individualized to reflect Patient #7’s current wound and wound care status and should have been. S2DON stated Patient #7’s POC should have included the initial measurements for each heel wound and staging, if appropriate, specific descriptions of the wounds, specific wound treatment plan per physician orders, and heel protectors. S2DON reviewed Patient #7’s POC and physician orders as mentioned above and confirmed there were no physician orders which included instructions for barrier cream to peri wound areas, calcium alginate, wound cleanser, wound dressing type with frequency of dressing changes, and/or Potus Boots and should have been.Patient #8Review of Patient #8’s Clinical Record revealed she was admitted to the Hospice agency on 01/16/2026 with a current Certification Period of 04/16/2026 through 07/14/2026 and resided in a local nursing home. Further review revealed she was ordered to receive a SNV three times weekly and PRN. Review of Patient #8’s SNVs, dated 04/08/2026, revealed, in part, a Stage 2 Pressure Ulcer to her Sacrum was identified on 04/07/2026. Review of Patient #8’s Physician Orders, dated 04/07/2026 through 04/21/2026, revealed no documented evidence of an order for wound care related to her sacral pressure ulcer identified on 04/07/2026. Review of Patient #8’s POC and IDG Meetings, dated 04/07/2026 through 04/28/2026, revealed, in part, the following: Problem: Stage 2 Sacral Wound.Identified: 04/07/2026.Interventions: No documented evidence of an order for wound care and/or necessary supplies related to her sacral pressure ulcer identified on 04/07/2026. An interview was conducted on 04/28/2026 at 3:15 p.m. with S2DON. S2DON reviewed Patient #8’s Clinical Record and confirmed it did not contain any orders for wound care or any of the necessary supplies to perform her wound care and should. S2DON confirmed Patient #8’s nursing home staff managed her wounds, including obtaining orders for her wound care from their Wound Specialist. S2DON confirmed Patient #8’s POC should accurately reflect all necessary treatments, services and medications she received, not just what was provided to her by Hospice staff. Patient #10Review of Patient #10’s Clinical Record revealed she was admitted to the agency on 10/10/2025 with a terminal diagnosis of Cirrhosis of Liver and was in a current Certification Period of 04/08/2026 through 06/06/2026. Further review revealed Patient #10 was ordered to receive a SNV three times weekly since start of care on 10/10/2025. Review of Patient’s Certification of Terminal Illness dated 10/10/2025 revealed the following: Patient #10 admitted with a terminal diagnosis of Cirrhosis of the Liver with ascites requiring paracentesis. Patient #10 had a Pleurx drain to her right side that was placed on 10/06/2025, and will be drained as needed by hospice.Review of Patient #10’s POC dated 10/10/2025 revealed the following problems or concerns: intermittent pain, death impending, Altered Gastrointestinal/ Liver function, and emotional support. Further review of Patient #10’s POC revealed no evidence of Pleurx drain to be drained per hospice for patient’s comfort. Review of Patient #10’s Physician Orders as of 04/28/2026 at 11:00 a.m. from 10/10/2025 to 04/28/2026 revealed no evidence of clear, detailed physician orders to include: frequency to drain, amount to drain, indications/ parameters, techniques/ supplies, dressing care, who can perform the procedure, or when to notify the provider. An interview was conducted on 04/23/2026 at 2:42 p.m. with S12LPN. S12LPN confirmed patient has a Pleurx drain, which was drained approximately three times weekly for patient comfort due to shortness of breath and/or pain. S12LPN reported staff drained Patient #10’s Pleurx drain until she requested they stop. S12LPN stated Patient #10’s Pleurx drain dressing was changed three times weekly and any time the Pleurx was drained. S12LPN reported staff typically removed 1 to 1.5 Liters of fluid from Patient #10’s Pleurx drain every time it was accessed. An interview was conducted on 04/23/2026 at 3:16 p.m. with S14RN. S14RN reported Patient #10’s Pleurx drain was drained three times weekly. S14RN stated she determined how much to drain from Pleurx by allowing Patient #10 to tell her when to stop draining. S14RN stated she sometimes stopped if the drainage slowed. S14RN confirmed staff removed 1.3 Liters to 1.5 Liters of fluid from Patient #10’s Pleurx drain three times a week. S14RN confirmed the Hospice agency should have obtained physician orders and updated Patient #10’s POC with the parameters for amounts to be drained, frequency to drain, site/dressing care, who could perform the procedure, when to notify the provider, along with the typical amount drained and how she typically tolerated the process. S14RN confirmed she was not aware Patient #10 did not have physician orders in her POC related to the care and maintenance of her Pleurx drain. An interview was conducted on 04/23/2026 at 3:27 p.m. with S2DON. S2DON reviewed Patient #10’s POC and Physician’s Orders and confirmed she was not aware she did not have physician orders and/or interventions in her POC related to the care and maintenance of her Pleurx drain and she should. Patient #11Review of Patient #11’s Clinical Record revealed he was admitted to the agency on 10/02/2025, was in a current Certification Period of 03/01/2026 through 04/23/2026 and lived in a private home. Further review revealed he was ordered to receive a SNV three times a week. Review of Patient #11’s SNV Notes, dated 10/02/2025 through 04/23/2026, revealed, in part, he was admitted to the agency on 10/02/2025 with a foley catheter in place. Review of Patient #11’s POC and Physician Orders, 10/02/2025 through 04/23/2026, revealed, in part, no documented evidence of orders and/or interventions being implemented for the care of his foley catheter during the aforementioned timeframe.An interview and observation was conducted on 04/23/2026 at 12:46 p.m. during Patient #11’s IDG Meeting. The IDG agreed and confirmed Patient #11 was admitted on 10/02/2025 from the hospital with a foley catheter in place and a foley catheter had been in use since that time. An interview was conducted on 04/23/2026 at 3:35 p.m. with S2DON. S2DON confirmed Patient #11’s POC should reflect the presence of his foley catheter and should include interventions/orders for its care and necessary supplies and it did not.”

“Based on interviews and record reviews, the Hospice agency failed to have a system in place which ensured the ongoing communication and sharing of information between all disciplines. The Hospice agency failed to ensure communication with the IDG occurred in regards to: 1. Communication barriers identified for Patient #14’s spouse/caregiver for 1 (#14) of 10 live patients reviewed;2. Patients identified as entering the active dying phase for 3 (#3, #4, and #5) of 3 expired patients reviewed; and3. Patients identified as not having the necessary orders for care and services for 4 (#7, #8, #10, and #11) of 10 live patients reviewed. This deficient practice had the potential to affect any of the agency’s current census of 75 patients and any future admissions to the agency. Cross Reference: L648, L505, L545, L557, L571, L574, L585, L596, L645, L647, L651, L677, and L694. Findings: Review of the agency’s IDG Care Planning Process Policy and procedure, revised January 2020, revealed, in part, the following: Policy: In order to assure care provided is appropriately planned to meet each patient’s specific needs and problems, Hospice will utilize data/ information gathered during the comprehensive assessment, updates to the comprehensive assessment and reassessments, in the care planning process to provide care that is consistent with the patient and family needs, with patient’s needs and goals as a priority. The Hospice IDG develops a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.Procedure: 3. The IDG works together to meet the physical, medical, psychosocial, emotional, and spiritual needs of Hospice patients and families facing terminal illness and bereavement. IDG members provide the care and services offered by Hospice. IDG supervises the care and services. 1. Communication Barriers.Patient #14Review of Patient #14’s Clinical Record revealed she was admitted to the agency on 10/17/2025 with a terminal diagnosis of Parkinson’s Disease, with a current Certification Period of 04/03/2026 through 06/01/2026 and lived in a private home with her spouse/primary caregiver who provided assistance for all of her care. Review of Patient #14’s most recent POC revealed, in part, the following: SNV Frequency: twice weekly and as needed;Hospice Aide: three times weekly and as needed;Social Worker: once monthly and as needed; and Chaplain: once monthly and as needed.Further review revealed no documented evidence to indicate the IDG was made aware of any difficulties female staff members encountered when communicating with Patient #14’s spouse/caregiver. Review of Patient #14’s SNV’s, dated 03/10/2026 through 03/18/2026, revealed, in part, the following: 03/10/2026- Patient and spouse refused medications to treat signs/symptoms;03/14/2026-Patient’s daughter present during SNV, new order received for antibiotics;03/15/2026- symptoms continued with spouse refusing medications to treat;03/16/2026- symptoms continued with spouse refusing medications to treat, Mobile X ray taken; 03/17/2026- symptoms continued with spouse educated, but continued to refuse medications to treat symptoms; and 03/18/2026-symptoms continued with spouse educated, hospital bed offered but refused, spouse continued to refuse medications to treat symptoms.Further review revealed no documented evidence to indicate the IDG was made aware of any difficulties female staff members encountered when communicating with Patient #14’s spouse/caregiver during the aforementioned visits.An interview was conducted on 04/28/2026 at 11:05 a.m. with S7SW. S7SW confirmed Patient #14 and her spouse/caregiver required frequent education regarding the goals of symptom management during Hospice care. S7SW stated she often had to reinforce and remind spouse their nurse and doctor could provide assistance with addressing the pain and other symptoms she was having. S7SW confirmed Patient #14’s spouse remained very unreceptive to her education attempts and symptom management often needed to be readdressed each visit. An interview was conducted on 04/28/2206 at 11:57 a.m. with S3RN. S3RN confirmed to spite continued education attempts, Patient #14’s spouse/caregiver remained reluctant to treat patient’s symptoms as documented in the aforementioned SNVs. S3RN confirmed she was made aware by Patient #14’s children during SNV on 03/14/2026 that he was more receptive to taking instruction(s) and/or education from males than he was from females. S3RN confirmed even though she felt Patient #14’s spouse may have been more receptive to hearing information about his spouse’s care from a male staff member, she did not communicate this to or involve the IDG and did not know she should have.An interview was conducted 04/28/2026 at 5:05 p.m. with S2DON. S2DON confirmed the agency had multiple males on their staff and who were members of the IDG. S2DON confirmed if a patient’s family member was not receptive to taking instruction(s) and/or education from a female staff member, this information would be key and should have been brought to the IDG team as soon as staff were made aware of it and it was not. S2DON confirmed the IDG should have been made aware so they could have discussed it and worked out a plan to involve their male staff members moving forward. 2. Active Dying Phase. Patient #3Review of Patient #3’s Clinical Record revealed she was admitted to the agency on 01/28/2025 and expired on 03/08/2025. Review conducted on 04/28/2026 at 11:45 a.m. with S2DON of Patient #3’s Clinical Record revealed no documented evidence to indicate the IDG was notified when she was identified to be actively dying. Review conducted on 04/28/2026 at 11:45 a.m. with S2DON of Patient #3’s MSW Visits in the days leading up to her death revealed no MSW visits or communication occurred. Further review revealed no documented evidence to indicate she was notified when Patient #3 was identified to be actively dying. Review conducted on 04/28/2026 at 11:45 a.m. with S2DON of Patient #3’s Chaplain Visits in the days leading up to her death revealed no Chaplain visits or communication occurred. Further review revealed no documented evidence to indicate he was notified when Patient #3 was identified to be actively dying. Patient #4Review of Patient #4’s Clinical Record revealed she was admitted to the agency on 04/03/2025 and expired on 04/11/2025. Review conducted on 04/28/2026 at 11:45 a.m. with S2DON of Patient #4’s Clinical Record revealed no documented evidence to indicate the IDG was notified when he was identified to be actively dying. Review conducted on 04/28/2026 at 11:45 a.m. with S2DON of Patient #4’s MSW Visits in the days leading up to his death revealed no MSW visits or communication occurred. Further review revealed no documented evidence to indicate she was notified when Patient #4 was identified to be actively dying. Review conducted on 04/28/2026 at 11:45 a.m. with S2DON of Patient #4’s Chaplain Visits in the days leading up to his death revealed no Chaplain visits or communication occurred. Further review revealed no documented evidence to indicate he was notified when Patient #4 was identified to be actively dying. Patient #5Review of Patient #5’s Clinical Record revealed he was admitted to the agency on 03/17/2025 and expired on 03/27/2025. Review conducted on 04/28/2026 at 11:45 a.m. with S2DON of Patient #5’s Clinical Record revealed no documented evidence to indicate the IDG was notified when he was identified to be actively dying. Review conducted on 04/28/2026 at 11:45 a.m. with S2DON of Patient #5’s MSW Visits in the days leading up to his death revealed no MSW visits or communication occurred from 03/21/2025 through 03/27/2025. Further review revealed no documented evidence to indicate she was notified when Patient #4 was identified to be actively dying. Review conducted on 04/28/2026 at 11:45 a.m. with S2DON of Patient #4’s Chaplain Visits in the days leading up to his death revealed no Chaplain visits or communication occurred from 03/21/2025 through 03/27/2025. Further review revealed no documented evidence to indicate he was notified when Patient #4 was identified to be actively dying. An interview was conducted on 04/28/2025 at 12:00 p.m. with S2DON. S2DON confirmed she expected the SN to make all members of the IDG aware when a patient was actively dying so all of the patient and family needs could be met. S2DON confirmed she could not provide any documented evidence to indicate the IDG was notified when the aforementioned patients were identified to be in the active dying phase and she should be able to. 3. Missing Physician Orders.Patient #7Review of Patient #7’s Clinical Record revealed she was admitted to the agency on 03/18/2026 with a diagnosis of Senile Degeneration of Brain and was in a current Certification Period 03/18/2026 through 06/15/2026.Review of Patient #7’s POC revealed the following orders for visit frequency:SN: 03/18/2026-04/16/2026: twice weekly and as needed; and starting 04/16/2026: three visits weekly and as needed. Review of Patient #7’s SNV dated 04/15/2026 revealed the following wound care documentation for her right and left heel pressure ulcers identified on 03/18/2026:“SN cleansed both heels with wound cleanser and applied [Medihoney] cream and calcium alginate with dressing and secured with kerlex. Both heels wounds have declined… Heel protectors were placed back on patient.”Review of Patient #7’s SNV dated 04/20/2026 revealed the following wound care documentation for her right and left heel pressure ulcers identified on 03/18/2026:“Wound with eschar and slough on open areas.” “Barrier cream to peri wound areas. Calcium alginate or honey to slough areas. Cover with telfa and secure abdominal pad and kerlix offload. Potus boots or float heels.”Review, as of 04/23/2026, of Patient #7’s most current IDG meeting/ POC dated 04/16/2026 revealed the following, in part, problems or concerns: Name: Wounds. Description: pressure ulcer to the right and left heels;Further review revealed no evidence of physician orders which included detailed wound care, barrier cream to peri wound areas, calcium alginate, wound cleanser, wound dressing type and frequency of changing and/or heel boots.An interview was conducted on 04/23/2026 at 2:34 p.m. with S2DON. S2DON reviewed Patient #7’s IDG meeting/POC dated 04/16/2026 and confirmed the POC did not include physician orders to reflect Patient #7’s current wound care provided by the SNs and should have been. S2DON stated Patient #7’s POC should have been reviewed in the IDG meetings and specific wound care physician orders added for Patient #7’s bilateral heel pressure ulcers. S2DON reviewed Patient #7’s physician orders as mentioned above and confirmed there were no physician orders which included instructions for barrier cream to peri wound areas, calcium alginate, wound cleanser, wound dressing type with frequency of dressing changes, and/or heel boots which reflected SN provided wound care and should have been.Patient #10Review of Patient #10’s Clinical Record revealed a Start of Care date of 10/10/2025 with a terminal diagnosis of Cirrhosis of Liver. Patient #10 had a current Certification Period of 04/08/2026 through 06/06/2026. Further review revealed patient #10 received Nursing services three times weekly since start of care on 10/10/2025. Review of Patient’s Certification of Terminal Illness dated 10/10/2025 revealed the following: Patient #10 admitted with a terminal diagnosis of Cirrhosis of the Liver with ascites requiring paracentesis. Patient #10 had a Pleurex Drain to her right side that was placed on 10/06/2025, and will be drained as needed by hospice.Review of Patient #10’s Physician Orders as of 04/28/2026 at 11:00 a.m. from 10/10/2025 to 04/28/2026 revealed no evidence of clear, detailed physician orders to include: frequency to drain, amount to drain, indications/ parameters, techniques/ supplies, dressing care, who can perform the care to the Pleurex Drain, or when to notify the provider. An interview was conducted on 04/23/2026 at 3:16 p.m. with S14RN. S14RN reported Patient #10’s Pleurex drain is drained three times weekly. S14RN confirmed there were no Physician Orders for parameters to drain, frequency to drain, dressing care, who can perform the procedure, and when to notify the provider. S14RN confirmed the Hospice agency should have obtained Physician Orders for the Pleurex drain and care prior to providing nursing care to the drain. An interview was conducted on 04/23/2026 at 3:27 p.m. with S2 DON. S2DON confirmed the agency had no evidence of Physician Orders to care for Patient #10’s Pleurex Drain. S2DON stated nursing staff were expected to obtain Physician Orders for draining of Pleurex Drain prior to providing those nursing services. Patient #11Review of Patient #11’s Clinical Record revealed he was admitted to the agency on 10/02/2025, was in a current Certification Period of 03/01/2026 through 04/23/2026 and lived in a private home. Further review revealed he was ordered to receive a SNV three times a week. Review of Patient #11’s SNV Notes, dated 10/02/2025 through 04/23/2026, revealed, in part, he was admitted to the agency on 10/02/2025 with a foley catheter in place. Further review revealed his foley catheter was only documented as being changed 4 times during the aforementioned timeframe on 11/14/2025; 01/09/2026; 03/06/2026; and 04/14/2026.Review of Patient #8’s Physician Orders, 10/02/2025 through 04/23/2026, revealed, in part, no documented evidence of orders and/or interventions for the care of his foley catheter during the aforementioned timeframe.Review of Patient #8’s IDG Meeting Notes and POC Updates, 10/02/2025 through 04/23/2026, revealed, in part, no documented evidence the team discussed the presence of a foley catheter or the need for orders and/or interventions to provide care for his foley catheter during the aforementioned timeframe.An interview was conducted on 04/23/2026 at 3:35 p.m. with S2DON. S2DON confirmed Patient #11’s SN should have communicated with the IDG to ensure his physician was aware he admitted with a foley catheter and obtained orders for care. S2DON confirmed the SN should have also communicated with the IDG once they realized they did not have Physician’s Orders for his foley catheter and they did not.”

“Based on interviews and record reviews, the Hospice agency failed to have a system in place to ensure identified PIPs were fully developed, implemented and evaluated for on-going improvement(s). This deficient practice had the potential to affect any of the bereaved family members/caregivers of the 237 patients who expired during the past 12 months, a current census of 75 patients, any future admissions to the agency, and any future patient deaths. Cross Reference: L648, L505, L545, L557, L571, L574, L585, L596, L645, L647, L651, L677, and L694. Findings: Review of the agency’s PIP for Improving Volunteer Services, opened 03/02/2026, revealed, in part, the following: Initial PIP Committee Meeting Date: 03/02/2026Committee Members: S2DON (Organizer), S8VC, S7SW, S10CEOStatement of Problem and Supporting Data: Agency’s status report reflected volunteer usage under the required 5%. Goals and Objectives: Provide training for Volunteer Coordinator. Reassess current volunteer recruitment and application process. Reassess current volunteer orientation and training process. Monitor volunteer numbers monthly. Project Activities:Committee to meet, track and review percentage of volunteers per agency status report. Audit employee records. Recruit task specific to volunteers. Project Progress/Findings: Volunteer Coordinator scheduled for Orientation/Shadowing on 03/03/2026.Volunteer Coordinator will continue to do outreach with different civic groups for recruitment purposes.Project Outcomes: Blank.Project Completion Date: Blank. Further review revealed no documented evidence of any additional Committee Meetings and no documented evidence of any progress and/or completion of Project Activities identified during the initial meeting.Review conducted on 04/28/2026 at 2:06 p.m. of the agency’s Documentation of Volunteer Services Provided and Volunteer Cost Savings Reports, dated 01/01/2026 through 04/28/2026, revealed no documented evidence available for review. Review conducted on 04/28/2026 at 2:06 p.m. of the agency’s current List of Volunteers revealed no new volunteers had been added to the list since 03/02/2026. An interview was conducted on 04/28/2026 at 2:06 p.m. with S8VC. S8VC confirmed she became the agency’s Volunteer Coordinator in January 2026. S8VC confirmed she had not received any training and/or performed any job shadowing since taking this job. S8VC confirmed the agency had not met the required 5% for volunteer cost savings in over a year. S8VC confirmed during March 2026, she and S2DON recognized volunteer services were an issue and developed a PIP. S8VC confirmed none of the PIP Activities had been implemented since the PIP was created on 03/02/2026. S8VC confirmed the committee had not held any additional meetings since the PIP was created on 03/02/2026. S8VC confirmed the agency had not seen any improvement in the number of volunteers nor had the agency completed any volunteer hours since the PIP was created on 03/02/2026. S8VC confirmed S1ADM was only present in the building once or twice a month and typically not the entire day. S8VC confirmed S1ADM had not been involved in the PIP for Volunteer Services in any way and to her knowledge, neither had any members of the Governing Body. An interview was conducted on 04/28/2026 at 3:15 p.m. with S2DON. S2DON confirmed she was responsible for the agency’s QAPI Program, including the identification, development, implementation, monitoring and evaluation of PIPs. S2DON confirmed she began this role in October 2025 and the only PIP the agency opened since then was on 03/02/2026 for Volunteer Services. S2DON confirmed the PIP Committee held a meeting the day the PIP was opened but had not done anything with it since that time. S2DON confirmed since the PIP was opened, the agency’s number of volunteers had not increased and the number of volunteer hours remained at zero. S2DON confirmed if a PIP was opened on 03/02/2026 and implemented appropriately, there should be measurable progress and improvement by 04/28/2026 and there was not.”

“Based on interviews and record reviews, the Hospice agency’s Governing Body failed to maintain responsibility for ensuring a QAPI Program was implemented, maintained, and evaluated for effectiveness/improvement. This deficient practice had the potential to affect any of the bereaved family members/caregivers of the 237 patients who expired during the past 12 months, a current census of 75 patients, any future admissions to the agency, and any future patient deaths. Cross Reference: L648, L505, L545, L557, L571, L574, L585, L596, L645, L647, L651, L677, and L694. Findings: Review of the Hospice agency’s QAPI Plan, revised January 2020, revealed, in part, the following: Responsibility/Accountability:1. The Governing Body is ultimately responsible for QAPI and implementation of QAPI. 2. The Governing Body has designated responsibility for operating the QAPI program to the Administrator, who, in turn, assigns certain QAPI activities to other staff members. The Administrator will be responsible for ensuring adequate resources are available, assigning adequate number of staff, allowing staff sufficient time to participate in QAPI activities and instituting appropriate information systems for collecting and analyzing data. 3. The Administrator is responsible for assigning staff to the QAPI Committee. The QAPI Committee will be responsible for coordinating all QAPI activities, reviewing collection of data, analyzing data, assisting staff in developing design or improvement activities, planning actions, collecting data, analyzing the effectiveness of actions and implementing effective actions. 4. The QAPI Committee will meet on a regular basis and will report findings to the ADM, who, in turn, will report to the Governing Body. Results will also be communicated by the QAPI committee to staff. Review conducted on 04/28/2026 of the Hospice agency’s QAPI and/or PIPs, dated 10/01/2025 through 04/28/2026, revealed one PIP was produced for review and it was created on 03/02/2026 in regards to the agency’s Volunteer Program. Review conducted on 04/28/2026 of the Hospice agency’s PIP for their Volunteer Program revealed an initial PIP Committee Meeting was conducted on 03/02/2026 with S2DON-Organizer, S8VC, S7SW, and S10CEO in attendance. The committee identified their volunteer usage was under the required 5% and identified the following goals, objectives, and activities: provide training for S8VC (scheduled 03/03/2026); reassess current volunteer recruitment and application process; reassess current volunteer orientation and training process; monitor number of volunteers monthly; committee to meet/track/review percentage of volunteer usage per agency status report; perform an audit of employee records; and identify/implement recruitment tasks specific to volunteers, including outreach with civic groups. Further review revealed no documented evidence to indicate any of the aforementioned PIP activities were implemented and no documented evidence to indicate any of the goals, objectives and activities were met, completed, and/or monitored. Review conducted on 04/28/2026 of the Hospice agency’s Governing Body’s Board Meeting Minutes, dated 04/10/2026, revealed no documented evidence to indicate they were made aware of the aforementioned PIP and/or involved to ensure it was implemented, assessed and/or monitored for improvement. Review attempted on 04/28/2026 of any additional documentation to indicate the Hospice agency’s Governing Body was notified and/or involved in the aforementioned PIP to ensure it was implemented, assessed and/or monitored for improvement with no documented evidence produce for review. An interview was conducted on 04/28/2026 at 2:06 p.m. with S8VC. S8VC confirmed she became the agency’s Volunteer Coordinator in January 2026 and had not received any training and/or job shadowing. S8VC confirmed none of the aforementioned PIP Activities were implemented since 03/02/2026. S8VC confirmed S1ADM was not involved in the aforementioned PIP or PIP Committee Meeting and was only present in the building once or twice a month. S8VC confirmed she was not aware of any involvement by the agency’s Governing Body in regards to the aforementioned PIP. An interview was conducted on 04/28/2026 at 3:15 p.m. with S2DON. S2DON confirmed she became responsible for the agency’s QAPI Program in October 2025 when she became the agency’s Director of Nursing and back-up Administrator. S2DON confirmed S1ADM was only present in the agency maybe once or twice a month. S2DON confirmed she did not receive any training from S1ADM or their Governing Body on the agency’s QAPI/PIP Program. S2DON confirmed when she created the aforementioned PIP, she did so by performing an internet search to find an outline which showed her what to do. S2DON confirmed the agency’s QAPI Program had not identified and/or created any additional PIPs since she assumed this role and she could not provide documentation to indicate any additional PIPs were created during the 2025 Fiscal Year. S2DON confirmed the agency’s Advisory Board was not involved in the aforementioned PIP and should have been. S2DON confirmed during the agency’s Advisory Board Meeting on 04/10/2026, they were not made aware of the aforementioned PIP and/or its status and should have been. S2DON confirmed if a PIP was opened on 03/02/2026 and if the agency’s QAPI/PIP was being implemented appropriately, there should be measurable progress and improvement by 04/28/2026 and there was not. S2DON confirmed if the agency’s QAPI Program were being implemented and monitored appropriately, they should have identified, created and implemented more than one PIP during the past 12 months and they had not.”

“Based on observations, interviews and record review, the Hospice Agency’s SN failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases. This deficient practice was evidenced by the SN’s failure to follow proper hand hygiene and glove usage during wound care for 1 (#7) of 1 patients observed for wound care. Findings:Review of the Hospice agency’s Infection Control Plan, revised June 2019, revealed, in part, Hospice has developed, and implemented infection control practices that conform to CDC guidelines and currently accepted standards of practice to prevent or decrease the exposure of patients to diseases and infections. Review of CDC’s Clinical Safety: Hand Hygiene for Healthcare Workers, dated 02/27/2024, revealed, in part, change gloves and clean hands if gloves become soiled with blood or body fluids after a task.Review of Patient #7’s Clinical Record revealed she admitted to the agency on 03/18/2026 with a terminal diagnosis of Senile Degeneration of the Brain and was in a current Certification Period of 03/18/2026 through 06/15/2026. Further review revealed she was ordered to receive a SNV twice weekly from 03/18/2026 through 04/15/2026 then three times weekly starting on 04/16/2026.Review of Patient #7’s Physician Orders, dated 03/18/2026 through 04/22/2026, revealed the following orders related to her wounds: 03/18/2026 – Apply Medihoney wound/burn dressing external gel to eschar on bilateral heel wounds three times a week; and04/16/2026 – Increase SNV to three times a week due to wound decline. Review, as of 04/23/2026, of Patient #7’s most current POC Update, dated 04/16/2026, revealed the following:Problem: Pressure Ulcer to Right and Left Heels – currently declining. Goal: Wound to remain free of infection. An observation was made on 4/22/2026 at 9:15 a.m. of S11RN performing wound care for Patient #7. S11RN used hand sanitizer and applied gloves. S11RN removed the soiled dressing from Patient #7’s right heel, sprayed the wound with wound cleanser, and cleaned the yellow/tan/gray drainage from the wound. S11RN grabbed the tub of Medihoney gel and with her initial pair of gloves still in place, dipped her fingers inside the tub, removed her fingers with gel on them, and then applied the gel to Patient #7’s right heel wound. S11RN then grabbed Patient #7’s clean dressings and applied the dressing to her right heel wound. S11RN removed her gloves and used hand sanitizer. S11RN applied gloves. S11RN removed the soiled dressing from Patient #7’s left heel, sprayed the wound with wound cleanser, and cleaned the yellow/tan/gray drainage from the wound. S11RN grabbed the tub of Medihoney gel, dipped her fingers inside the tube, removed her fingers with gel on them, and then applied the gel to the left heel wound. S11RN grabbed Patient #7’s clean dressings and applied the dressing to her left heel wound. S11RN removed her gloves and used hand sanitizer. S11RN only used two pair of gloves during the entire observation. An interview was conducted on 04/23/2026 at 9:37 a.m. with S11RN. S11RN stated when she performed wound care, she only changed gloves before starting another body part’s wound care. An interview was conducted on 04/23/2026 at 2:34 p.m. with S2DON. S2DON confirmed she expected nursing staff to utilize standard infection control practices when providing wound care to patients. S2DON confirmed this should include changing soiled gloves then using hand sanitizer after removing a dressing and cleaning the wound, and always before handling and/or applying clean items/dressings.”

“Based on interviews and record reviews, the Hospice agency failed to ensure licensed professionals actively participated in all aspects of the patient’s Hospice care in accordance with current professional standards, including all applicable state laws. The Hospice agency failed to ensure a patient’s medical pronouncement of death by a coroner was based on personal observation or information and statements obtained from a qualified professional for 3 (#3, #4, and #5) of 3 death records reviewed. This deficient practice had the potential to affect any of the 237 patients who expired during the past 12 months any of the current census of 75 patients who expired in the future. Cross Reference: L648, L505, L545, L557, L571, L574, L585, L596, L645, L647, L651, L677, and L694. Findings: Review of the Hospice agency’s undated Death at Home Policy and Procedure revealed, in part, the following: Procedure: 2. Pronouncement of Death:Pronouncement of death will be conducted in accordance with state laws and agency policy. Review of the state’s RS 9:111, effective 07/01/2010, revealed, in part, the following: A. A person will be considered dead if in the announced opinion of a physician, duly licensed in the state of Louisiana based on ordinary standards of approved medical practice, the person has experienced an irreversible cessation of spontaneous respiratory and circulatory functions….B. The medical pronouncement of death by a coroner may also be based on personal observation, information, or statements obtained from coroner investigators, RN, physician assistants, or emergency medical technicians at the scene who are reporting from firsthand observation of the physical condition of the deceased. …Patient #3Review of Patient #3’s Clinical Record revealed she was admitted to the agency on 01/28/2025, was in a current Certification Period of 01/28/2025 through 03/08/2025 and expired on 03/08/2025. Review of Patient #3’s Death Visit performed by S5LPN, dated 03/08/2025 at 1:25 a.m., revealed no documented evidence to indicate an RN was present during the Death Visit to perform the assessment to confirm death on behalf of the coroner/physician.Review of Patient #3’s Clinical Record, as of 04/28/2026, revealed no documented evidence to indicate an RN was present during the Death Visit to perform the assessment to confirm death on behalf of the coroner/physician.Patient #4Review of Patient #4’s Clinical Record revealed she was admitted to the agency on 04/03/2025, was in a current Certification Period of 04/03/2025 through 04/11/2025 and expired on 04/11/2025. Review of Patient #4’s Death Visit performed by S16LPN, dated 04/11/2025 at 1:40 a.m., revealed no documented evidence to indicate an RN was present during the Death Visit to perform the assessment to confirm death on behalf of the coroner/physician.Review of Patient #4’s Clinical Record, as of 04/28/2026, revealed no documented evidence to indicate an RN was present during the Death Visit to perform the assessment to confirm death on behalf of the coroner/physician.Patient #5Review of Patient #5’s Clinical Record revealed he was admitted to the agency on 03/17/2025, was in a Certification Period of 02/23/2025 through 03/27/2025 and expired on 03/27/2025. Review of Patient #5’s Death Visit performed by S5LPN, dated 03/27/2025 at 5:30 p.m. revealed no documented evidence to indicate an RN was present during the Death Visit to perform the assessment to confirm death on behalf of the coroner/physician.Review of Patient #5’s Clinical Record, as of 04/28/2026, revealed no documented evidence to indicate an RN was present during the Death Visit to perform the assessment to confirm death on behalf of the coroner/physician.An interview was conducted on 04/28/2025 at 5:10 p.m. with S2DON. S2DON confirmed she was aware state law required an RN to perform a patient’s assessment to confirm death on behalf of the coroner/physician, not an LPN. S2DON reviewed the aforementioned Death Visits and confirmed an LPN performed their death assessments and should not have.”

“Based on interviews and record review, the hospice agency failed to ensure nursing services met the need of the patient by or under the supervision of a Registered Nurse for 1 (#7) of 3 patients reviewed for pressure wounds. The agency failed to follow acceptable wound care standards of practice by not conducting and/or documenting complete weekly wound assessments for Patient #7. Review of the Louisiana State Board of Nursing Declaratory Statement Scope of Practice for Registered Nurses - Wound Care Management adapted 02/1999 revealed the following in part: Registered nurses render care that is directed towards the prevention and treatment of wounds. Wounds are a common health care challenge that often occur with or result from Chronic disorders such as impaired circulation and malnutrition. Nursing care of skin/wound conditions involves the identification, assessment, management, and ongoing evaluation of patients with alterations in skin/tissue integrity that includes but is not limited to draining wounds, pressure ulcers, and vascular ulcers, and conditions resulting from incontinence, surgical procedures, and/or trauma. Scope of Practice - The Louisiana State Board of Nursing recognizes that assessment, planning, intervention, teaching, evaluation, and supervision are the major responsibilities of the registered nurse in the practice setting. The registered nurse is responsible for performing a nursing assessment and physical examination for preventative and restorative nursing and for providing patient/family teaching. Recognizing that the physician must always prescribe wound care, the following roles are defined to delineate the scope of practice for each member of the nursing team members. The registered nurse initiates appropriate wound preventative measures, stages wounds and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by an authorized prescriber. Review of the National Pressure Ulcer Advisory Panel Prevention and Treatment of Pressure Ulcers; Quick Reference Guide revealed, in part, the following:Pressure Ulcer Assessment:1. Assess the pressure ulcer initially and assess it at least weekly.1.1. Document the results of all wound assessments.Assess and document physical characteristics including: location, Category/Stage, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. Review of Patient #7’s clinical record revealed a start of care date of 03/18/2026. Review of the plan of care for the current certification period 03/18/2026 through 06/15/2026 revealed a diagnosis of Senile Degeneration of Brain. Further review of the plan of care revealed orders for the followingFrequency/Duration of Visits: SN 2wk1 with 2 PRN visits from 03/18/2026-04/16/2026 and SN 3wk1 with 2 PRN visits started 04/16/2026.Orders of Discipline and Treatment included the following: Start date: 03/18/2026. Hospice nurse to apply honey to wound dressing external gel to eschar on bilateral heel wounds three times a week; andStart date: 04/16/2026. Due to wound declining increase SN visit to three times per week. Review of Patient #7’s SN visit wound documentation from 03/18/2026 through 04/22/2026 revealed the week of 03/30/2026 and 04/06/2026 the hospice nurses conducted visits two times per week. Further review revealed there were no complete weekly wound assessments with wound measurements, category/stage, tissue type, color, peri-wound condition, wound edges, sinus tracts, undermining, and/or tunneling documented for Patient #7’s bilateral heel pressure wounds. An interview was conducted on 04/22/2026 at 9:44 a.m. with S11RN. S11RN stated she conducted SN visits for Patient #7. S11RN stated she only documented a complete wound care assessment when a change in wound status was identified. She confirmed she was not aware of how often a complete wound assessment was required to be conducted. An interview was conducted on 04/23/2026 at 2:34 p.m. with S2DON. S2DON reviewed Patient #7’s clinical record and SN visits from 03/18/2026 through 04/22/2026 and confirmed on the weeks listed above there were no complete wound assessments documented for Patient #7’s bilateral heel pressure wounds. S2DON further confirmed she expected the Registered Nurse to conduct complete wound assessments and documentation in the SN visits at least weekly.”

“Based on interviews and record reviews, the Hospice agency failed to have a system in place to ensure the bereavement needs of patients and their family members/caregivers were met. This deficient practice was evidenced by failure to have an effective Bereavement Program which ensured: 1. The Bereavement Program and associated services were provided under the direction and supervision of a qualified Bereavement Supervisor;2. An individualized Bereavement POC was developed which identified the type and frequency of services required for 3 of 3 (#3, #4, and #5) patients reviewed for Bereavement; and 3. The Bereavement Program was implemented according to the agency’s Bereavement Services Policy and Procedure for 3 of 3 (#3, #4, and #5) patients reviewed for Bereavement.This deficient practice had the potential to affect any of the bereaved family members/caregivers of the 237 patients who expired during the past 12 months, a current census of 75 patients, any future admissions and any future patient deaths. Cross Reference: L648, L505, L545, L557, L571, L574, L585, L596, L645, L647, L651, L677, and L694. Findings: Review of the Hospice agency’s Bereavement Services Policy and Procedure, revised June 2019, revealed, in part, the following: Policy: Hospice provides an organized Bereavement Program supervised by qualified Bereavement Counselor, who has documented evidence of education or experience and dealing with grief or loss counseling. Procedure:1. Hospice will provide bereavement services to the families/caregivers of Hospice patients both before, and after the patient’s death, the purpose of the services is to facilitate a normal grieving process and identify and appropriately refer those persons who may be experiencing pathological grief reactions, which may interfere with the eventual resolution and integration of their losses. Bereavement services will be coordinated with the individual spiritual counselor or Hospice Chaplain, as well as with other community resources judged to be useful and beneficial to the family caregiver.2. A Plan of Care will be developed to include specific counseling to patient and family members to be provided by the Social Worker, Chaplain, or Bereavement Counselor. The Plan of Care will reflect family needs, as well as a clear delineation of services to be provided in the frequency of service delivery.4. After a patient death has occurred, recommendations for bereavement services will be made based on the severity of grief and determined by the family members consent for further services. Bereavement services must reflect the needs of the bereaved. 5. Unless bereavement services have been refused, a Bereavement Counselor, Chaplain, or Social Worker will call designated bereaved to continue bereavement supportive or counseling services. A Bereavement Plan of Care will be initiated, which may include telephone support, letters, and cards, referral to other community services, memorial services, bereavement, camps, telephone contacts, and/or individual or family, counseling and bereavement groups. 6. For those family members whose grief may be complicated, or who require counseling in a specific area, a referral may be made to the appropriate resource.7. A Bereavement Volunteer may be assigned to provide bereavement support to family members who are experiencing normal grief without serious risk factors. Support may include telephone calls or personal visits and is supervised by the bereavement coordinator.8. Ongoing individual bereavement support and counseling is concluded at the wishes of the family or at the end of 12 months. If there’s a need for further services, bereavement groups continue to be available. Counseling may be extended as deemed appropriate by the bereavement coordinator. A referral to another community resource may also be advised when Hospice is unable to meet bereavement needs.9. Bereavement Assessment and Clinical Notes are documented in the patient’s permanent clinical record.1. Bereavement Supervisor. An interview was conducted on 04/28/2026 at 11:15 a.m. with S2DON. S2DON stated S6OM was the agency’s Bereavement Supervisor. An interview was conducted on 04/28/2026 at 11:25 a.m. with S6OM. S6OM confirmed she was the agency’s Office Manager and was not experienced and/or trained in grief or loss counseling and was not the agency’s Bereavement Supervisor. S6OM stated she thought either S2DON, S7SW or S9CH would be the agency’s Bereavement Supervisor. An interview was conducted on 04/28/2026 at 10:59 a.m. with S7SW. S7SW confirmed she was not the agency’s Bereavement Supervisor, and was not sure who was. An interview was conducted on 04/28/2026 at 2:38 p.m. with S9CH. S9CH confirmed he was not the agency’s Bereavement Supervisor. An interview was conducted on 04/28/2026 at 5:05 p.m. with S2DON. S2DON confirmed she was the agency’s DON and acting Administrator. S2DON confirmed she was not aware there were qualifications for a Bereavement Supervisor and was not aware S6OM did not meet them. S2DON confirmed the agency did not ensure bereavement services were provided under the direction and supervision of a qualified Bereavement Supervisor and should have. 2. Development of Bereavement Plan of Care. Patient #3Review of Patient #3’s Clinical Record revealed she was admitted to the agency on 01/28/2025 and expired on 03/08/2025. Review conducted on 04/28/2026 at 11:15 a.m. of Patient #3’s Clinical Record revealed no documented evidence a Bereavement Plan of Care was developed following her death. Patient #4Review of Patient #4’s Clinical Record revealed he was admitted to the agency on 04/03/2025 and expired on 04/11/2025. Review conducted on 04/28/2026 at 11:15 a.m. of Patient #4’s Clinical Record revealed no documented evidence a Bereavement Plan of Care was developed following his death. Patient #5Review of Patient #5’s Clinical Record revealed he was admitted to the agency on 03/17/2025 and expired on 03/27/2025. Review conducted on 04/28/2026 at 11:15 a.m. of Patient #5’s Clinical Record revealed no documented evidence a Bereavement Plan of Care was developed following his death. An interview was conducted on 04/28/2026 at 11:15 a.m. with S2DON. S2DON reviewed Patient #3, #4, and #5’s Clinical Record and confirmed they did not contain a Bereavement Plan of Care. S2DON confirmed the agency did not currently have a system in place to ensure an individualized Bereavement Plan of Care was developed following the patient’s death which outlined the type and frequency of services necessary to meet the individualized needs of the bereaved and she was not aware they should. 3. Bereavement services provided per the agency’s Bereavement Services Policy and Procedure. Patient #3Review of Patient #3’s Bereavement Period Manager, dated 03/09/2025 through 04/09/2026, revealed her family did not refuse Bereavement Services. Further review revealed no documented evidence to indicate involvement of the MSW, Chaplain/Counselor, and/or Volunteer(s) and the only documented evidence of bereavement services were mailings sent on 03/10/2025, 04/08/2025, 07/08/2025, 10/08/2025, 01/08/2026, 03/09/2026, and 04/09/2026.Review conducted on 04/28/2026 at 11:30 a.m. of Patient #3’s Clinical Record revealed no documented evidence of an assessment for bereavement needs following her death to determine the bereaved’s level of grief and/or services necessary to meet their needs. Further review revealed no documented evidence to indicate the agency discussed the bereavement services available for their family/caregiver’s bereavement needs.Patient #4Review of Patient #4’s Bereavement Period Manager, dated 04/12/2025 through 05/12/2026, revealed her family did not refuse Bereavement Services. Further review revealed no documented evidence to indicate involvement of the MSW, Chaplain/Counselor, and/or Volunteer(s) and the only documented evidence of bereavement services were mailings sent on 04/14/2025, 04/21/2025, 05/12/2025, 08/12/2025, 11/12/2025, 02/12/2026, and 04/13/2026.Review conducted on 04/28/2026 at 11:30 a.m. of Patient #4’s Clinical Record revealed no documented evidence of an assessment for bereavement needs following her death to determine the bereaved’s level of grief and/or services necessary to meet their needs. Further review revealed no documented evidence to indicate the agency discussed the bereavement services available for their family/caregiver’s bereavement needs.Patient #5Review of Patient #5’s Bereavement Period Manager, dated 03/28/2025 through 04/28/2026, revealed her family did not refuse Bereavement Services. Further review revealed no documented evidence to indicate involvement of the MSW, Chaplain/Counselor, and/or Volunteer(s) and the only documented evidence of bereavement services were mailings sent on 03/28/2025, 04/04/2025, 04/28/2025, 07/28/2025, 10/28/2025, 01/28/2026, 03/27/2026, and 04/28/2026. Review conducted on 04/28/2026 at 11:30 a.m. of Patient #5’s Clinical Record revealed no documented evidence of an assessment for bereavement needs following her death to determine the bereaved’s level of grief and/or services necessary to meet their needs. Further review revealed no documented evidence to indicate the agency discussed the bereavement services available for their family/caregiver’s bereavement needs.An interview was conducted on 04/28/2026 at 11:15 a.m. with S2DON. S2DON confirmed the agency had not had anyone refuse Bereavement Services. S2DON stated S7SW performed the Initial Bereavement Assessment upon admission and S6OM ensured all bereavement mailing were mailed out per the policy. S2DON confirmed no bereavement counseling services were offered after the patient’s death. An interview was conducted on 04/28/2026 at 11:25 a.m. with S6OM. S6OM confirmed she was responsible for ensuring all bereavement mailings were mailed out per the policy. S6OM confirmed the mailings were standardized forms and were sent out at standardized times following a patient’s death. S6OM confirmed she did not conduct any telephone calls to the bereaved or provide any type of grief counseling. An interview was conducted on 04/28/2026 at 10:59 a.m. with S7SW. S7SW confirmed she was responsible for performing the Initial Bereavement Assessment upon admission but that was the extent of her involvement with the Bereavement Program. An interview was conducted on 04/28/2026 at 2:38 p.m. with S9CH. S9CH confirmed he was not involved in the agency’s Bereavement Program and did not provide bereavement counseling following the patient’s death. An interview was conducted on 04/28/2026 at 5:05 p.m. with S2DON. S2DON confirmed the Bereavement Program was a Core Service the agency was required to provide and the agency did not currently have a system in place to ensure bereavement services were provided in a way that ensured all of the bereaved’s needs were met throughout the grieving process. S2DON confirmed they did not provide bereavement services, which included telephone support/contact, referrals to other community services, memorial services, bereavement camps, and/or individual or family, counseling and bereavement groups following a patient’s death. S2DON confirmed the agency did not have a method for determining if the bereavement services they provided were effective and was not aware they should.”

“Based on interviews and record reviews, the Hospice agency failed to have a viable system in place to recruit and retain volunteers. This deficient practice had the potential to affect any of the bereaved family members/caregivers of the 237 patients who expired during the past 12 months, a current census of 75 patients, any future admissions to the agency, and any future patient deaths. Cross Reference: L648, L505, L545, L557, L571, L574, L585, L596, L645, L647, L651, L677, and L694. Findings:Review conducted on 04/28/2026 at 2:06 p.m. of the agency’s current List of Volunteers revealed the agency currently had one volunteer and no new volunteers had been added to the list during 2026. Review conducted on 04/28/2026 at 2:06 p.m. of the agency’s Documentation of Volunteer Services Provided and Volunteer Cost Savings Reports, dated 01/01/2025 through 04/28/2026, revealed the agency’s volunteer hours did not meet the required 5% minimum hours. Review attempted on 04/28/2026 at 2:06 p.m. of the agency’s Volunteer Recruitment efforts revealed no documented evidence was available for review. An interview was conducted on 04/28/2026 at 2:06 p.m. with S8VC. S8VC confirmed she became the agency’s Volunteer Coordinator in January 2026. S8VC confirmed she had not received any training and/or performed any job shadowing since taking this job. S8VC confirmed prior to her taking over this position, the previous Volunteer Coordinator’s recruitment efforts consisted of placing a flyer to recruit volunteers in one location in a nearby city. S8VC confirmed she and S2DON sat down and made a list of ways to recruit new volunteers earlier this year but she had not implemented any of them. S8VC confirmed the agency had one volunteer when she began her role and they had not successfully recruited any additional volunteers since that time. An interview was conducted on 04/28/2026 at 3:15 p.m. with S2DON. S2DON confirmed she and S8VC sat down and made a list of ways the agency could recruit new volunteers earlier this year but S8VC had not implemented any of them yet. S2DON confirmed the agency had one volunteer during 2025 and the agency had not successfully recruited any additional volunteers since that time. S2DON confirmed the agency should have a viable system in place to recruit and retain volunteers and they did not.”

“Based on interviews and record review, the Hospice agency failed to have a system in place to ensure volunteer services provided a minimum of 5% of the agency’s total patient care hours.This deficient practice had the potential to affect any of the bereaved family members/caregivers of the 237 patients who expired during the past 12 months, a current census of 75 patients, any future admissions to the agency, and any future patient deaths. Cross Reference: L648, L505, L545, L557, L571, L574, L585, L596, L645, L647, L651, L677, and L694. Findings: Review conducted on 04/28/2026 at 2:06 p.m. of the agency’s Documentation of Volunteer Services Provided and Volunteer Cost Savings Reports, dated 01/01/2025 through 12/31/2025, revealed the agency’s volunteer hours did not meet the required 5% minimum hours. Review conducted on 04/28/2026 at 2:06 p.m. of the agency’s Documentation of Volunteer Services Provided and Volunteer Cost Savings Reports, dated 01/01/2026 through 04/28/2026, revealed no documented evidence available for review. An interview was conducted on 04/28/2026 at 2:06 p.m. with S8VC. S8VC confirmed she was the agency’s Volunteer Coordinator. S8VC confirmed the agency did not meet the required 5% volunteer hours during the previous year and had not provided any volunteer hours during the current year. An interview was conducted on 04/28/2026 at 3:15 p.m. with S2DON. S2DON confirmed the agency did not meet the required 5% volunteer hours during the previous year and had not provided any volunteer hours during the current year.”

“Based on interviews, observations and record review, the Hospice agency’s Governing Body and Administrator failed to assume full legal authority and responsibility for the management and provision of all Hospice services and continuous quality assurance and performance improvement. This deficient practice was evidenced by failure to be responsible for ensuring:1. The Administrator appointed by the Governing Body was aware of their responsibility for the day-to-day operations of the agency; 2. When the Administrator was unavailable and/or not physically housed at the agency, a qualified back up was aware of their responsibility to assume the Administrator’s duties and responsibilities; and 3. The Administrator met all requirements for the position by not being employed by more than two licensed agencies.This deficient practice had the potential to affect any of the agency’s current census of 75 patients and any future admissions to the agency. Cross Reference: L648, L505, L545, L557, L571, L574, L585, L596, L645, L647, L651, L677, and L694. Findings: Review conducted on 04/28/2026 of the Hospice agency’s undated Job Description for the Administrator revealed, in part, the following: Responsibilities: 19. Maintains compliance with applicable state rules and regulations.39. Appoints a similarly qualified alternate to be available at all times during operating hours in the absence of the Administrator. Review conducted on 04/28/2026 of the Hospice agency’s undated Job Description for the Director of Clinical Services (DON) revealed, in part, the following: Responsibilities: 29. Ensures compliance with applicable state rules and regulations.1. Administrator aware of their responsibility for the day-to-day operations of the agency. An interview was conducted on 04/20/2026 at 12:00 p.m. with S15HRD. S15HRD confirmed she was the agency’s Human Resources Director. S15HRD confirmed she was not aware of who was the agency’s Administrator. An interview was conducted on 04/20/2026 at 12:15 p.m. with S2DON. S2DON confirmed she was the agency’s DON and she was not aware of who was the agency’s ADM. S2DON stated she may be the Administrator but she didn’t think so and she would have to check to be sure. Observations conducted on 04/20/2026 from 12:00 p.m. through 4:30 p.m. revealed S1ADM was not present in the building at any time. An interview was conducted on 04/21/2026 at 10:00 a.m. with S1ADM when she arrived to the agency’s office. S1ADM approached the survey team, introduced herself, and confirmed she was not sure if she or S2DON was the agency’s Administrator. S1ADM requested the survey team look in their database to see if she was the identified Administrator and let her know. Review conducted on 04/21/2026 at 10:20 a.m. of the state’s licensed provider database revealed S1ADM was identified as the agency’s Administrator. An interview was conducted on 04/21/2026 at 10:25 a.m. with S1ADM when she was informed she was the agency’s Administrator. S1ADM stated “well, good to know.” S1ADM confirmed she became the Administrator many years ago but was not sure if that was still in effect or not. 2. Administrator Backup aware they were assuming Administrator duties and responsibilities.Review conducted on 04/28/2026 of the Hospice agency’s Administrator Backup, dated 10/06/2025, revealed, in part, Statement of Responsibility: In compliance with established policy, and in the event S1ADM is not available, the designated, qualified backup, S2DON, will assume the duties and responsibilities of the Administrator. An interview was conducted on 04/20/2026 at 12:15 p.m. with S2DON. S2DON confirmed she was the agency’s DON and she was not sure if she was the agency’s Backup Administrator and she would have to check to be sure. An interview was conducted on 04/21/2026 at 10:35 a.m. with S1ADM when she provided a copy of the aforementioned ADM Backup form and confirmed S2DON was her backup. S1ADM confirmed she did not work out of this agency frequently or on a routine basis. S1ADM confirmed S2DON was responsible for assuming her job duties and responsibilities when she was unavailable and/or not present in the office. An interview was conducted on 04/28/2026 at 3:15 p.m. with S2DON. S2DON confirmed S1ADM was the agency’s ADM on paper but she was not physically present in the office on a regular basis. S2DON reviewed the aforementioned ADM Backup and confirmed she was responsible for assuming S1ADM’s job duties and responsibilities when she was unavailable and/or not present in the office. S2DON confirmed S1ADM was only physically present in the building one or two days a month and was typically not in the Hospice agency’s office when she was in the building. 3. Administrator not employed by more than 2 licensed agencies. An interview was conducted on 04/28/2026 at 3:30 p.m. with S1ADM. S1ADM confirmed she was the Administrator of at least 3 licensed agencies and could not recall if there were more. Review conducted on 04/28/2026 at 3:35 p.m. of the state’s licensed provider database revealed S1ADM was identified as the Administrator for 4 licensed agencies; this Hospice agency and three Home Health agencies. An interview was conducted on 04/28/2026 at 3:37 p.m. with S1ADM. S1ADM confirmed the aforementioned review was accurate, she was currently the Administrator for 4 licensed agencies, and was not aware she could not be.”

“Based on interviews, observation and record reviews, the Hospice agency failed to have a system in place to ensure nursing care and services were provided in a manner which was consistent with accepted standards of practice for 3 (#7, #10, and #11) of 10 live patients reviewed. This deficient practice had the potential to affect any of the 270 admissions during the last 12 months, a current cents of 75 patients, and any future admissions to the agency. Findings: Review of the Hospice agency’s policy titled “IDG Care Planning Process”, revised on January 2020, revealed, in part, the following: 3. IDG members provide the care and services offered by Hospice. 8. Standing or routine orders will be individualized to address the specific patient’s needs and signed by the patient’s physician. -Drugs and treatment necessary to meet the needs of the patient. -Medical supplies and appliances necessary to meet the needs of the patient. Patient#7Review of Patient #7’s Clinical Record revealed she was admitted to the agency on 03/18/2026 with a diagnosis of Senile Degeneration of Brain and was in a current Certification Period 03/18/2026 through 06/15/2026. Further review revealed she was identified to have Pressure Ulcers to her Right and Left Heels on 03/18/2026. Review of Patient #7’s POC revealed the following Visit Frequency orders:SN: 03/18/2026-04/16/2026: twice weekly and as needed; and starting 04/16/2026: three visits weekly and as needed. Review of Patient #7’s SNVs, dated 04/15/2026 through 04/202026, revealed, in part, the following:04/15/2026 – SN cleansed both heels with wound cleanser and applied Medihoney cream and calcium alginate with dressing and secured with kerlex. Both heel wounds have declined. Heel protectors were placed back on patient.04/20/2026 – Wound noted with eschar and slough on open areas. Barrier cream to peri-wound areas. Calcium alginate or honey to slough areas. Cover with telfa and secure abdominal pad and kerlix offload. Potus boots or float heels.Review of Patient #7’s Physician Orders, dated 03/18/2026 through 04/22/2026, revealed, in part, the following: Start date: 03/18/2026. SN to apply Medihoney wound/burn dressing external gel to eschar on bilateral heel wounds three times a week; andStart date: 04/16/2026. Due to wound declining increase SNV to three times per week.Further review revealed no physician orders including instructions for barrier cream to peri wound areas, calcium alginate, wound cleanser, wound dressing type with frequency of dressing changes, and/or heel boots.An interview was conducted on 04/23/2026 at 2:34 p.m. with S2DON. S2DON reviewed Patient #7’s aforementioned SNV’s and physician’s orders then confirmed there were no physician’s orders which included instructions for barrier cream to peri-wound areas, calcium alginate, wound cleanser, wound dressing type with frequency of dressing changes, and/or heel boots to reflect SN wound care provided to Patient #7 and should have been.Patient #10Review of Patient #10’s Clinical Record revealed she was admitted to the agency on 0/10/2025 with a terminal diagnosis of Cirrhosis of Liver and in a current Certification Period of 04/08/2026 through 06/06/2026. Further review revealed patient #10 received SNVs three times weekly. Review of Patient #10’s Hospice Certification of Terminal Illness, dated 10/10/2025, revealed the following: Patient #10 admitted with a terminal diagnosis of Cirrhosis of the Liver with ascites requiring paracentesis. Patient #10 currently with a Pleurex drain to her right side, which was placed on 10/06/2025, and will be drained as needed by Hospice.Review conducted on 04/28/2026 at 11:00 a.m. of Patient #10’s Physician Orders, dated 10/10/2025 to 04/28/2026, revealed no documented evidence of clear, detailed physician’s orders for the care of her Pleurex to include: frequency to drain, amount to drain, indications/ parameters, techniques/ supplies, dressing care, who can perform the procedure, or when to notify the provider. An interview was conducted on 04/23/2026 at 3:16 p.m. with S14RN. S14RN reported Patient #10’s Pleurex drain is drained three times weekly. S14RN confirmed there were no Physician Orders for parameters to drain, frequency to drain, dressing care, who can perform the procedure, and when to notify the provider. S14RN confirmed the Hospice agency should have obtained Physician Orders for the Pleurex drain and care prior to providing nursing care to the drain. An interview was conducted on 04/23/2026 at 3:27 p.m. with S2DON. S2DON confirmed the agency had no evidence of Physician Orders for draining of Patient #10’s Pleurex Drain. S2DON stated nursing staff were expected to obtain Physician Orders for wound care and draining of Pleurex Drain prior to providing these nursing services. Patient #11Review of Patient #11’s Clinical Record revealed he was admitted to the agency on 10/02/2025, was in a current Certification Period of 03/01/2026 through 04/23/2026 and his medical history included multiple recent Urinary Tract Infections and Acute Kidney Injuries. Further review revealed he was ordered to receive a SNV three times a week and as needed.Review of Patient #11’s SNV Notes, dated 10/02/2025 through 04/23/2026, revealed he was admitted to the agency with a Foley catheter in place. Further review revealed his Foley was only changed during the aforementioned timeframe on the following dates: 11/14/2025;01/09/2026;03/06/2026; and 04/14/2026.Review of Patient #11’s Physician Orders, POC Updates and IDG Meeting Notes, dated 10/02/2025 through 04/23/2026, revealed, in part, no documented evidence of orders and/or interventions for the care of his Foley catheter during the aforementioned timeframe.An interview and observation was conducted on 04/23/2026 at 12:46 p.m. during Patient #11’s IDG Meeting. The IDG agreed and confirmed Patient #11 was admitted on 10/02/2025 from the hospital with a Foley catheter in place and a Foley catheter had been in use since that time. The IDG also agreed and confirmed the agency’s policy was for Foley catheters to be changed every 30 days and doing so required a physician’s order. An interview was conducted on 04/23/2026 at 3:35 p.m. with S2DON. S2DON confirmed a Foley catheter should be changed every 30 days. S2DON confirmed Patient #11’s Foley catheter was not changed every 30 days and should have been. S2DON confirmed Patient #11 did not have a physician’s order for his Foley catheter to be changed every 30 days and he should have. S2DON confirmed when the SN changed his Foley catheter on 11/14/2025, 01/09/2026, 03/06/2026, and 04/14/2026, they did so without a physician’s order and should not have.”

“Based on interviews and record reviews, the Hospice agency failed to ensure the patients’ Clinical Records contained completed and accurate documentation of their assessments and clinical notes. The facility failed to ensure Skilled Nurse Visits (SNV) were documented as performed for 4 Patients (#15 #17, #18 and #19) of 19 patients in the sample who had record reviews. Review of the Hospice agency’s policy titled “Patient Record Content”, Revised June 2019, revealed the following, in part: Purpose: To ensure documentation of patient status, services, and outcomes.Procedure: Hospice will initiate and maintain an individual and accurate patient record containing past and current findings for each patient receiving care in compliance with all federal/ state laws and regulations. The record must contain correct clinical information that is available to the patient’s attending physician and Hospice staff. Patient #15Review of Patient #15’s Clinical Record revealed she was admitted to the agency on 04/03/2026 with a Certification Period of 04/03/2026 through 07/01/2026. Further review revealed Patient #15 received Nursing services three times weekly. Review of Patient #15’s SNV documentation as of 04/28/2026 at 4:44 p.m. revealed the following SNV’s made per S3RN were not started or documented: 04/08/2026, 04/10/2026, 04/13/2026, 04/15/2026, 04/17/2026, and 04/20/2026. Patient #17Review of Patient #17’s Clinical Record revealed she was admitted to the agency on 03/28/2022 with a Certification Period of 04/06/2026 through 06/04/2026. Further review revealed Patient #17 received Nursing services two times weekly. Review of Patient #17’s SNV documentation as of 04/28/2026 at 3:30 p.m. revealed the following SNV’s made per S3RN were not started or documented: 04/09/2026, 04/16/2026, and 04/23/2026. Patient #18Review of Patient #18’s Clinical Record revealed she was admitted to the agency on 07/29/2025 with a Certification Period of 03/26/2026 through 05/24/2026. Further review revealed Patient #18 received Nursing services seven times weekly. Review of Patient #18’s SNV documentation as of 04/28/2026 at 3:38 p.m. revealed the following SNV’s made per S5LPN were not started or documented: 04/20/2026, 04/21/2026, 04/22/2026, 04/23/2026, and 04/26/2026.Patient #19Review of Patient #19’s Clinical Record revealed she was admitted to the agency on 01/14/2026 with a Certification Period of 04/14/2026 through 07/12/2026. Further review revealed Patient #19 received Nursing services two times weekly. Review of Patient #19’s SNV documentation as of 04/28/2026 at 4:00 p.m. revealed the following SNV’s made per S3RN were not started or documented: 04/24/2026.An interview was conducted on 04/28/2026 at 1:23 p.m. with S3RN. S3RN stated she conducted the above mentioned SNV’s for Patient #15, #17, and #19 and did not complete the SNV’s documentation timely and should have.An interview was conducted on 04/28/2026 at 3:45 p.m. with S5LPN. S5LPN stated she conducted the above mentioned SNV’s for Patient #18 and did not complete the SNV’s documentation timely and should have.An interview was conducted on 04/28/2026 at 9:15 a.m. with S2DON. S2DON reviewed Patient #15, #17, #18 and #19’s Clinical Record and confirmed the above mentioned SNV’s documentation was not completed in the expected 48 hours completion time and should have.”

“Based on interviews and record review, the Hospice agency failed to have a system in place to ensure patients’ Clinical Records contained their Advance Directive(s) in a location accessible by the patients’ attending physician and/or all agency staff for 4 (#6, #8, #9, and #18) of 4 live patients identified to have a HCPOA. This deficient practice had the potential to affect any of the agency’s current census of 75 patients and any future admissions to the agency. Cross Reference: L648, L505, L545, L557, L571, L574, L585, L596, L645, L647, L651, L677, and L694. 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 Advance Directives Policy, revised June 2019, revealed, in part, the following: Purpose: To define and assure the rights of adult patients in health care decision-making. Review of the agency’s Advance Directive Policy in the Admission Packet revealed, in part, the following: Advance Directive - A Living Will, a HCPOA, and/or other signed/dated written document that expresses an individual’s healthcare treatment decisions. This document provides the individual an opportunity to state his/her/their healthcare wishes should the individual become incapacitated. When executing advance directives, individuals should… Be as specific as possible about wishes; Discuss wishes with family members, physicians or other person/organization that provides healthcare services; and Provide copies of advanced directives to Hospice and any other person/organization that provides healthcare services.Patient #6Review of Patient #6’s Clinical Record revealed he was admitted to the agency on 12/19/2025 with a terminal diagnosis of Malignant Neoplasm of Left Kidney and was in a current Certification Period of 02/20/2026 through 04/20/2026. Further review revealed Patient #6 was not always cognitive. Review of Patient #6’s Patient Information as of 04/21/2026 at 9:00 a.m. revealed, in part, the following: POA Financial – Yes; and POA Medical - Yes. Review of Patient #6’s MSW Assessment dated 02/23/2026 revealed, in part Primary Caregiver- Family/ Sister in law/ HCPOA.Review of Patient #6’s EHR as of 04/20/2026 at 9:00 a.m. and on 04/21/2026 at 9:00 a.m. revealed no documented evidence of a HCPOA available for review. Request made on 04/22/2026 at 11:00 a.m. to S2DON for Patient #6’s aforementioned HCPOA with no documented evidence available for review. An interview was conducted on 04/22/2026 at 11:39 a.m. with Patient #6’s step-son. He confirmed he and his aunt, Patient #6’s sister in law, had HCPOA for Patient #6. An interview was conducted on 04/22/2026 at 2:50 p.m. with Patient #6’s sister in law. She confirmed she and her nephew, Patient #6’s step-son, had HCPOA for Patient #6. She confirmed since he was admitted in December 2025, no one from the agency had contacted her to obtain a copy of his HCPOA so there would not be a copy of it on file in his Clinical Record.Patient #8Review of Patient #8’s Clinical Record revealed she was admitted to the agency on 01/16/2026 with a terminal diagnosis of Chronic Myeloid Leukemia, not in remission, and was in a current Certification Period of 04/16/2026 through 07/14/2026. Further review revealed Patient #8 had expressive aphasia and was not cognitive.Review of Patient #8’s Patient Information revealed she was not identified by the agency as having a HCPOA. Review of Patient #8’s RN Initial Assessment, dated 01/16/2026, revealed the box indicating she had a “Financial agent, HCPOA, or conservator of finance” was selected and her brother was documented as being her HCPOA. Further review revealed Patient #8 had multiple living sons and other living family members. Review of Patient #8’s MSW Initial Assessment, dated 01/20/2026, revealed, in part, she had multiple living sons and other living family members but her brother was her legal HCPOA.Review of Patient #8’s Admission Paperwork, Consents and LaPOST, dated 01/16/2026, revealed in part, all documents were signed by someone other than her brother. Further review revealed no documented evidence to indicate the agency obtained her HCPOA upon admission to ensure the paperwork was being signed by the proper person. Request made on 04/21/2026 at 1:30 p.m. and again at 2:00 p.m. to S2DON for Patient #8’s aforementioned HCPOA with no documented evidence available for review. An interview was conducted on 04/22/2026 at 1:45 p.m. with Patient #8’s brother. He confirmed Patient #8 was not cognitive and was unable to make any decisions for herself. He confirmed he and his spouse were her legal HCPOAs. He confirmed when Patient #8 was admitted to the Hospice agency, his spouse signed all of the admission paperwork, consent documents and her LaPOST, changing her from Full Code to DNR status. He confirmed no one from the agency called him during admission to verify if his spouse had legal authority to sign the documents nor did they request a copy of her HCPOA to verify she had legal authority to sign the documents. He confirmed since she was admitted in January, no one from the agency had contacted them to obtain a copy of her HCPOA. An interview was conducted on 04/22/2026 at 2:28 p.m. with S7SW. S7SW confirmed she performed Patient #8’s MSW Initial Assessment and was familiar with her situation. S7SW confirmed Patient #8 had multiple living children and other living family members. S7SW confirmed in the state of Louisiana, if a patient did not have an HCPOA, their next living relative would be their legal decision maker, in her case, her eldest child but it could vary depending on if they wanted to assume the responsibility or not. S7SW confirmed Patient #8 was not cognitive and was unable to communicate for the most part but she had an HCPOA in place indicating her brother and sister in law were her legal decision makers. S7SW stated when she arrived to perform her Initial Assessment, she asked her nursing home to print her a copy of her facility information sheet, which indicated her brother and sister in law were her HCPOA.An interview was conducted on 04/22/2026 at 1:10 p.m. with S6OM. S6OM confirmed on 01/16/2026 when Patient #8 was admitted, she was responsible for ensuring all necessary documents had been obtained and were added to their EHR upon admission. S6OM confirmed she would not have added Patient #8’s brother’s name and number as the HCPOA on her information sheet because it was not included in the referral paperwork. S6OM confirmed looking for HCPOA and contact information within the RN and MSW’s Initial Assessments was S13RN’s responsibility then she would notify her to add them to the information sheet and she had not for Patient #8. Patient #9Review of Patient #9’s Clinical Record revealed she was admitted to the agency on 12/09/2024 with a terminal diagnosis of Hypertensive Heart Disease with heart failure and was in a current Certification Period of 04/03/2026 through 06/01/2026. Further review revealed Patient #9’s cognition status was disoriented, alert, with episodes of agitation and hallucinations. Review of Patient #9’s POC dated 12/09/2024 and 04/09/2026 revealed documentation of the coordination of care provided by the family which included the description of the following:Son was the POA and he signed consent and was in agreement with Hospice POC. Review, as of 04/28/2026 at 12:36 p.m., of Patient #9’s Registered Nurse Initial Assessment dated 12/09/2024 revealed the primary care giver was the son and was marked yes for primary caregiver as the “financial agent, HCPOA, or conservator of finance”. Further review revealed in the SN’s narrative the son was the POA. Review of Patient #9’s EHR as of 04/21/2026 at 9:00 a.m. and on 04/27/2026 at 9:00 a.m. revealed no documented evidence of a HCPOA or Financial POA available for review. On 04/23/2026 at 2:20 p.m., an interview was conducted with Patient #9’s son. He stated for Patient #9 he was the POA for financial and medical care. He stated he did not recall the Hospice agency asking for their POA documents upon admission and he had a copy of the POA ready for them to receive if they needed them.Patient #18Review of Patient #18’s Clinical Record revealed she was admitted to the agency on 07/29/2025 with a terminal diagnosis of Malignant Neoplasm of Unspecified Part of Right Bronchus or Lung and was in a current Certification Period of 03/26/2026 through 05/24/2026. Further review revealed Patient #18 was currently minimally responsive to stimuli. Review of Patient #18’s POC dated 07/29/2025 revealed documentation in the comments the son is the POA. Review of Patient #18’s EHR as of 04/28/2026 at 9:00 a.m. and on 04/28/2026 at 2:00 p.m. revealed no documented evidence of a HCPOA or Financial POA available for review. On 04/28/2026 at 3:20 p.m., an interview was conducted with Patient #18’s son. He stated for Patient #18 he had been the HCPOA since 09/29/2016. He stated he did not recall the Hospice agency asking for the HCPOA documents on admission and he had a copy of it ready for them to receive if they asked for them.On 04/28/2026 at 3:45 p.m., an interview was conducted with S5LPN. She confirmed Patient #18’s son was his HCPOA and the HCPOA was not obtained upon admission and should have been.On 04/28/2026 at 2:30 p.m., an interview was conducted with S15HRD. S15HRD stated she reviewed Patient #9’s and Patient #18’s Clinical Record and they did not have a HCPOA on file in the EHR and/or hard copy.An interview was conducted on 04/22/2026 at 11:00 a.m. with S2DON. S2DON confirmed if the agency obtained a HCPOA during admission it would be located in the patient’s EHR under their Miscellaneous Tab with all of their scanned documents. S2DON confirmed she verified with her office staff and there were no paper charts in the office waiting to be scanned into the EHR so any HCPOAs the agency obtained were already located in the patient’s EHR. S2DON confirmed the agency could not provide copies of the aforementioned HCPOAs and she was not aware they should be able to. S2DON confirmed the agency did not have a process to ensure a patient’s HCPOA was obtained and/or verified for the appropriate decision maker upon admission or at any point thereafter. S2DON stated she was not sure if a HCPOA was an Advance Directive or not and she was not sure if it was a document required to be in a patient’s Clinical Record. S2DON stated she would expect Admission staff to enquire about the presence of a HCPOA when they asked about the presence of an LaPOST during admission but she would not expect them to push or ask for a copy to be provided if it was not readily available or easily discussed at the time. S2DON confirmed she was not aware of a process the agency utilized to ensure the person signing a patient’s admission paperwork and/or a legal document which determined Code Status moving forward was the appropriate person legally identified to have the authority to make those decisions. S2DON stated that would be up to S4RN when she completed the consents and other legal documents prior to admission. An interview was conducted on 04/22/2026 at 12:36 p.m. with S4RN. S4RN confirmed she was responsible for completing the agency’s admission screening process. S4RN stated when she first met with a patient/family, if the patient was cognitive, she asked them who their decision maker was. S4RN stated if the patient was not cognitive, she reviewed their referral documents to see who was identified as the decision maker. S4RN stated she then contacted the person identified as the decision maker and asked them if there was an HCPOA in place naming them as the legal decision maker. S4RN stated if a copy of the HCPOA was available, she asked to look at it but if they didn’t have it, she moved on and took their word for it. S4RN stated she did ask them to provide a copy to the agency when they could but if they couldn’t, it wasn’t a big deal. S4RN stated if they didn’t have a copy of the HCPOA she could keep, she tried to remember to let the admitting nurse know to ask for it when they went for their initial assessment. S4RN confirmed there was no list or official notification process to alert anyone they were waiting on a copy of the HCPOA in order to ensure it was obtained and added to their record. S4RN confirmed the agency had not obtained copies of all of their patient’s HCPOAs. S4RN confirmed a HCPOA was an Advance Directive. S4RN confirmed the agency was not required to have/maintain copies of patient’s Advance Directives within their Clinical Records. S4RN confirmed she was not responsible for obtaining a copy of a patient’s HCPOA nor was she responsible for tracking and ensuring a copy was obtained and added to their Clinical Record and she was not sure who was. An interview was conducted on 04/22/2026 at 12:50 p.m. with S13RN. S13RN stated she was the agency’s medical records Compliance/QA nurse. S13RN stated she was responsible for reviewing documentation and coordinating any necessary education needs she identified. S13RN stated when she reviewed EHRs, she was looking to ensure consent forms were signed and uploaded. S13RN stated if the consent form indicated there was a HCPOA, she checked the EHR to see if it was uploaded/scanned in. S13RN stated if it was not scanned in, she followed up with someone in the office staff or the patient’s nurse. S13RN confirmed she had not identified anyone noted as having a HCPOA that was not present in their EHR since she started this role in January 2025. S13RN reviewed the aforementioned patient’s documentation and confirmed she did not look at the RN’s Initial Assessment or the MSW’s Initial Assessment to determine if there should be an HCPOA on file, she only looked in the admission consent packet. S13RN confirmed if a patient was not cognitive and had an HCPOA in place, the agency should ensure the person signing to admit them to Hospice and signing to change their Code Status was legally able to do so prior to allowing them to do it. S13RN confirmed she had no responsibility in regards to obtaining an Advance Directive or ensuring an Advance Directive was obtained and added to the record. S13RN confirmed she was not responsible for following up to ensure a missing HCPOA was obtained and added to a patient’s EHR. S13RN confirmed the agency did not currently have a process to ensure Advance Directives were obtained and maintained on file for patients who have one in place. An interview was conducted on 04/22/2026 at 1:10 p.m. with S6OM. S6OM confirmed she was responsible for handling patient intake, which included receiving a referral through admission then uploading admission documents and orders into their EHR. S6OM confirmed there were no paper files in the office with documents that had not been scanned into a patient’s EHR, everything the agency had was scanned and ready for review. S6OM stated she typically received signed consents from S4RN and their referral documents and admission orders came from the referral source. S4RN stated she was responsible for adding the information to the patient’s information sheet after their admission was completed. S6OM stated when she added contact information on the information sheet, she was responsible for indicating if there was an HCPOA and who it was but she was not responsible for reviewing the RN or MSW’s Initial Assessments to determine if there was an HCPOA. S6OM stated S13RN was responsible for doing that then informing her if one should be added to the information sheet. S6OM confirmed she was not responsible for obtaining or ensuring an Advance Directive was obtained and added to the EHR. S6OM stated if a patient was identified as having a HCPOA, it was S4RN’s responsibility to ensure the HCPOA was obtained so she could add it to the EHR. S6OM confirmed no one person within the agency was responsible for following up or ensuring a HCPOA was obtained and added to the patient’s chart. S6OM confirmed a HCPOA was not listed on the Admission Checklist she utilized to ensure everything was present as it should be. An interview was conducted on 04/22/2026 at 2:28 p.m. with S7SW. S7SW confirmed it was not her responsibility to discuss or determine if a patient had an HCPOA or to obtain a copy of it during her Initial Assessment. S7SW stated the person who completed the patient’s intake should obtain a copy of any Advance Directives they may have in place. S7SW stated a HCPOA was not an Advance Directive and the agency was not required to maintain copies in the patient’s Clinical Record. An interview was conducted on 04/28/2026 at 5:06 p.m. with S2DON. S2DON confirmed the agency did not have a system in place to ensure Advance Directives were obtained and added to a patient’s EHR and they should.”

“Based on record review and interviews, the Hospice agency failed to implement a system for the safe use and management of controlled drugs in the patient’s home in accordance with accepted standards of practice. The Hospice agency failed to: 1. Develop a policy and procedure which ensured the safe use and management of controlled drugs in the patient’s home in accordance with accepted standards of practice; 2. Ensure current and accurate records were maintained for the disposition of all controlled substances provided by the Hospice agency to the patient for 14 (#6, #7, #8, #9, #10, #11, #12, #13 #14, #15, #16, #17, #18, and #19) of 14 live patients reviewed; and3. Ensure current and accurate records were maintained for the disposition and disposal of all controlled substances provided by the Hospice agency to the patient in the presence of a witness immediately following the patient’s death for 3 (#3, #4, #5) of 3 expired patients reviewed. This deficient practice had the potential to affect any of the agency’s current census of 75 patients, any future admissions to the agency and any future patient deaths. Cross Reference: L648, L505, L545, L557, L571, L574, L585, L596, L645, L647, L651, L677, and L694. Findings: Review of the United States GAO’s Report titled Preventing Drug Diversion, published 04/2020, revealed, in part, the following: Misuse of controlled substances continues to be a serious public health problem in the United States.1 National survey data from the Substance Abuse and Mental Health Services Administration show that in 2017, 53 percent of people 12 years of age and older in the United States who misused prescription pain relievers in the past year, obtained the drugs from friends and family. The most commonly misused controlled substances include opioids (such as oxycodone), which are used to treat pain, and central nervous system depressants (such as diazepam), which are used to treat anxiety and sleep disorders. These types of drugs are prescribed for a large portion of patients in hospice care. Patients select hospice care when they no longer want treatment for their terminal illness, but rather choose a hospice team to provide symptom management and control. In 2017, approximately 1.5 million Medicare beneficiaries received hospice services, and 56 percent of those patients received care in the patient’s home. Medicare is the largest payer for hospice services.The Controlled Substances Act regulates the manufacture, distribution, use, and disposal of controlled substances.13 In general, the Controlled Substances Act was enacted to facilitate the use of controlled substances for legitimate medical, scientific, research, and industrial purposes while preventing them from being diverted for illegal uses.What GAO Found: Best Practices for Reducing the Risk of DiversionHospice officials identified best practices for preventing diversion of controlled substances. Best practices include routine prescription drug counts performed by hospice employees to determine if controlled substances are being used properly.Narcotic counts can also help ensure that unused or expired medications are properly disposed of, preventing potential misuse or accidental ingestion. 1. Policy and Procedure.Review of the agency’s undated Drugs and Biologicals Medical Supplies, and DME Policy and Procedure, as of 01/27/2026, revealed, in part, the following: V. Labeling, disposing, and storing of drugs and biologicals:C. The agency must have written policies and procedures for the management of controlled drugs in the patient’s home. Review was attempted on 04/22/2026 at 1:46 p.m. and 04/27/2026 at 9:30 a.m. of the agency’s policy and procedure regarding the safe management of controlled drugs in the patient’s home which would require the nurse to count and document controlled substances during a SNV with no documented evidence available for review. 2. Current and accurate records for the disposition of controlled drugs in living patients.Patient #6Review of Patient #6’s Clinical Record revealed he was admitted to the Hospice agency on 12/17/2025 and in a current Certification Period of 04/21/2026 through 06/19/2026. Further review revealed he had an ordered SNV frequency of twice weekly and as needed.Review of Patient #6’s current Hospice Medication Profile, as of 04/28/2026, revealed, in part, the following 2 active medication orders for controlled substances:12/17/2025- Lorazepam 2mg/mL Oral Concentrate. Give 0.5 mL by mouth every 4 hours PRN for anxiety; and 12/17/2025- Morphine Sulfate 100mg/5mL Oral Concentrate. Give 1 mL by mouth every 2 hours as needed for pain/dyspnea. Review of Patient #6’s Visit Notes and Coordination Notes, dated 02/20/2026 through 04/17/2026, revealed no documented evidence of the remaining count for all controlled substances currently in the home during the following visits:02/20/2026; 02/21/2026; 02/23/2026; 02/25/2026;02/27/2026; 03/02/2026; 03/04/2026; 03/06/2026;03/09/2026; 03/11/2026; 03/13/2026; 03/14/2026; 03/18/2026;03/20/2026; 03/23/2026; 03/25/2026;03/27/2026; 03/30/2026;04/01/2026;04/03/2026; 04/06/2026;04/08/2026;04/10/2026;04/13/2026; 04/15/2026; and04/17/2026.Review of Patient #6’s Clinical Record, dated 02/20/2026 through 04/17/2026, as of 04/28/2026 at 9:00 a.m. revealed no documented evidence to indicate the SN performed a count of his controlled substances during any of the aforementioned SNVs. Patient #7 Review of Patient #7’s Clinical Record revealed she was admitted to the agency on 03/18/2026 and in current Certification Period from 03/18/2026 through 06/15/2026.Review of Patient #7’s POC and Physician’s Orders dated 03/18/2026 through 04/27/2026, revealed, in part, the following active orders for controlled substances: 03/18/2026 - Lorazepam Oral Concentrate - 2mg/mL. 0.5 mL sublingually every 4 hours as needed for anxiety. Amount Dispensed: 30 mL; 03/18/2026 - Morphine Sulfate Oral Concentrate – 20mg/mL. 1 mL sublingually every 2 hours as needed for pain. Amount Dispensed: 30 mL; and04/14/2026 – Hydrocodone-Acetaminophen- 7.5/325 oral solution. 15 mL by mouth every 6 hours as needed for pain. Review of Patient #7’s SNV’s dated 03/18/2026 through 04/27/2026, revealed in part, no documented evidence the SN performed a count of controlled substances during the following scheduled SNVs: 03/18/2026;03/27/2026;03/30/2026;04/02/2026;04/06/2026;04/09/2026;04/13/2026;04/15/2026;04/17/2026; and 04/20/2026.Patient #8Review of Patient #8’s Clinical Record revealed she was admitted to the Hospice agency on 01/16/2026 and in a current Certification Period of 04/16/2026 through 07/14/2026. Further review revealed she was ordered to receive a SNV three times a week and as needed. Review of Patient #8’s current Hospice Medication Profile, as of 04/21/2026, revealed, in part, the following active medication orders for controlled substances:01/16/2026 – Lyrica Capsule 100 mg. 1 capsule twice daily; and 01/16/2026 – Morphine Sulfate Oral Solution 20mg/mL. 1 mL every 2 hours as needed.Review of Patient #8’s SNVs, dated 01/16/2026 through 04/22/2026, revealed, in part, no documented evidence to indicate the SN performed a count of controlled substances during the SNVs conducted since his admission on the following dates: 01/16/2026;01/19/2026;01/20/2026;01/21/2026;01/23/2026;01/24/2026;01/25/2026;01/26/2026;01/27/2026;01/28/2026;01/29/2026;01/30/2026;02/02/2026;02/04/2026;02/06/2026;02/09/2026;02/11/2026;02/13/2026;02/16/2026;02/18/2026;02/20/2026;02/23/2026;02/25/2026;02/27/2026;03/02/2026;03/04/2026;03/06/2026;03/09/2026;03/11/2026;03/13/2026;03/16/2026;03/18/2026;03/20/2026;04/16/2026;04/17/2026;04/18/2026;04/19/2026;04/20/2026; and 04/22/2026.Patient #9Review of Patient #9’s Clinical Record revealed she was admitted to the agency on 12/09/2024 and had a Certification of Period of 02/02/2026 - 04/02/2026 and current Certification Period of 04/03/2026 - 06/01/2026.Review of Patient #9’s POC and Physician’s Orders, dated 12/09/2024 through 04/27/2026, revealed, in part, the following active orders for controlled substances: 12/09/2024 - Lorazepam Oral Concentrate - 2mg/mL. 0.5 mL sublingually every 4 hours as needed for anxiety. Amount Dispensed: 30 mL; 12/09/2024 - Morphine Sulfate Oral Concentrate – 20mg/mL. 1 mL sublingually every 2 hours as needed for pain. Amount Dispensed: 30 mL;12/09/2024- Alprazolam Oral Tablet 0.5 mg. 1 tablet by mouth at bedtime as needed for anxiety; and04/13/2026 - Hycet- 7.5/325 oral solution. 15 mL by mouth every 6 hours as needed for pain. Amount Dispensed: 300 mL.Review of Patient #9’s SNV’s dated 03/30/2026 through 04/27/2026, revealed in part, no documented evidence the SN performed a count of controlled substances during the following scheduled SNVs: 03/30/2026;04/03/2026;04/06/2026;04/10/2026;04/13/2026;04/17/2026; and 04/20/2026.Patient #10Review of Patient #10’s Clinical Record revealed she was admitted to the Hospice agency on 10/10/2025 and in a current Certification Period of 04/08/2026 through 06/06/2026. Further review revealed she had an ordered SNV frequency of three times weekly and as needed.Review of Patient #10’s current Hospice Medication Profile, as of 04/28/2026 at 11:00 a.m., revealed, in part, the following active medication orders for controlled substances: 10/10/2025-Lorazepam 2mg/mL Oral Concentrate. Give 0.5 mL by mouth every 4 hours as needed for anxiety; and10/10/2025 - Morphine Sulfate Oral Concentrate – 20mg/mL give 1 mL sublingually every 2 hours as needed for pain. Amount Dispensed: 30 mL;Review of Patient #10’s Visit Notes and Coordination Notes, dated 02/02/2026 through 04/06/2026, revealed no documented evidence of the remaining count for all controlled substances currently during the following visits:02/02/2026; 02/06/2026; 02/09/2026; 02/12/2026;02/16/2026; 02/19/2026; 02/23/2026; 02/26/2026;03/02/2026;03/05/2026; 03/09/2026; 03/12/2026; 03/16/2026; 03/19/2026; 03/23/2026;03/26/2026; 03/30/2026; 03/31/2026;04/01/2026;04/03/2026; and 04/06/2026. Review of Patient #10’s Clinical Record, dated 02/02/2026 through 04/06/2026, revealed no documented evidence to indicate the SN performed a count of his controlled substances during any of the aforementioned SNVs. Patient #11Review of Patient #11’s Clinical Record revealed he was admitted to the agency on 10/02/2025, was in a current Certification Period of 03/01/2026 through 04/23/2026 and was ordered to receive a SNV three times a week. Review of Patient #11’s POC and Physician’s Orders, dated 03/01/2026 through 04/23/2026, revealed, in part, the following active orders for controlled substances: 03/01/2026 – Lorazepam Oral Concentrate 2mg/mL give 0.5 mL sublingually every 4 hours as needed. Amount Dispensed: 30 mL; and03/01/2026 - Morphine Sulfate Oral Concentrate 20mg/mL give 1 mL sublingually every 2 hours as needed. Amount Dispensed: 30mL.Review of Patient #11’s SNV’s dated 03/01/2026 through 04/23/2026, revealed in part, no documented evidence the SN performed a count of controlled substances during the following scheduled SNVs: 03/02/2026;03/06/2026;03/10/2026;03/13/2026;03/16/2026;03/20/2026;03/24/2026;03/27/2026;03/31/2026;04/03/2026;04/07/2026;04/10/2026;04/14/2026;04/17/2026; and 04/21/2026.Patient #12Review of Patient #12’s Clinical Record revealed she was admitted to the agency on 06/11/2025 and had a Certification period of 02/06/2026 - 04/06/2026 and a current Certification Period of 04/07/2026 through 06/05/2026.Review of Patient #12’s POC and Physician’s Orders, dated 06/11/2025 through 04/27/2026, revealed, in part, the following active orders for controlled substances: 06/11/2025 - Lorazepam Oral Concentrate - 2mg/mL give 0.5 mL sublingually every 4 hours as needed for anxiety. Amount Dispensed: 30 mL;06/11/2025 – Xanax Oral Tablet 0.5 mg. 1 Tablet every 12 hours as needed for anxiety. 06/11/2025 - Morphine Sulfate Oral Concentrate – 20mg/mL give 1 mL sublingually every 2 hours as needed for pain. Amount Dispensed: 30 mL.Review of Patient #12’s SNV’s dated 03/30/2026 through 04/27/2026, revealed in part, no documented evidence the SN performed a count of controlled substances during the following scheduled SNVs: 03/30/2026;04/06/2026;04/10/2026;04/13/2026;04/16/2026; and 04/19/2026.Patient #13Review of Patient #13’s Clinical Record revealed she was admitted to the agency on 10/17/2023 and had a Certification Period of 02/03/2026 - 04/03/2026 and a current Certification Period of 04/04/2026 - 06/02/2026.Review of Patient #13’s POC and Physician’s Orders, dated 10/17/2023 through 04/27/2026, revealed, in part, the following active orders for controlled substances: 10/17/2023 - Lorazepam Oral Concentrate - 2mg/mL. 0.5 mL sublingually every 4 hours as needed for anxiety. Amount Dispensed: 30 mL; and 10/17/2023 - Morphine Sulfate Oral Concentrate – 20mg/mL. 1 mL sublingually every 2 hours as needed for pain. Amount Dispensed: 30 mL.Review of Patient #13’s SNV’s dated 03/30/2026 through 04/27/2026, revealed in part, no documented evidence the SN performed a count of controlled substances during the following scheduled SNVs: 03/30/2026;04/02/2026;04/06/2026;04/09/2026;04/13/2026; 04/16/2026; and04/21/2026.Patient #14Review of Patient #14’s Clinical Record revealed she was admitted to the Hospice agency on 10/17/2025 and in a current Certification Period of 04/02/2026 through 06/01/2026. Further review revealed she had an ordered SNV frequency of twice weekly and as needed.Review of Patient #14’s current Hospice Medication Profile, as of 04/28/2026 at 11:30 a.m., revealed, in part, the following active medication orders for controlled substances:03/13/2026- Tramadol HCL 50 mg tablet by mouth every 4 hours as needed for pain;10/17/2025- Lorazepam Oral Concentrate - 2mg/mL Give 0.5 mL sublingually every 4 hours as needed for anxiety; and 10/17/2025- Morphine Sulfate 20mg/mL Oral Solution. Give 1 mL by mouth every 2 hours as needed for pain/dyspnea.Review of Patient #14’s Visit Notes and Coordination Notes, dated 01/15/2026 through 03/19/2026, as of 04/28/2026 at 12:00 p.m. revealed no documented evidence of the remaining count for all controlled substances currently during the following visits:01/16/2026;01/19/2026;01/22/2026; 01/26/2026;01/30/2026;02/02/2026;02/05/2026;02/09/202602/13/2026;02/14/2026;02/16/2026;02/19/2026;02/23/2026;02/27/2026;03/02/2026;03/05/2026;03/10/2026;03/13/2026;03/14/2026;03/15/2026;03/16/2026;03/17/2026;03/18/2026; and 03/19/2026Patient #15Review of Patient #15’s Clinical Record revealed she was admitted to the Hospice agency on 04/03/2026 and in a current Certification Period of 04/03/2026 through 07/01/2026. Further review revealed she had an ordered SNV frequency of three times weekly and as needed.Review of Patient #15’s current Hospice Medication Profile, as of 04/28/2026 at1:00 p.m., revealed, in part, the following active medication orders for controlled substances:04/03/2026- Lorazepam Oral Concentrate - 2mg/mL give 0.5 mL sublingually every 4 hours as needed for anxiety; and 04/03/2026- Morphine Sulfate 20mg/mL Oral Solution give 1 mL by mouth every 2 hours as needed for pain/dyspnea. Review of Patient #15’s Visit Notes and Coordination Notes, dated 04/03/2026 through 04/06/2026, revealed no documented evidence of the remaining count for all controlled substances: currently during the following visits:04/03/2026;04/04/2026; and 04/06/2026. Patient #16Review of Patient #16’s Clinical Record revealed he was admitted to the agency on 07/18/2025 and in a current Certification Period of 03/15/2026 through 05/13/2026.Review of Patient #16’s POC and Physician’s Orders, dated 07/18/2025 through 04/27/2026, revealed, in part, the following active orders for controlled substances: 07/18/2025- Lorazepam Oral Concentrate - 2mg/mL. 0.5 mL sublingually every 4 hours as needed for anxiety. Amount Dispensed: 30 mL; 07/18/2025- Morphine Sulfate Oral Concentrate – 20mg/mL. 1 mL sublingually every 2 hours as needed for pain. Amount Dispensed: 30 mL;07/29/2025- Hydromorphone HCL Oral liquid 1 mg/mL 1 mL sublingually every 2 hours as needed for pain or shortness of breath;10/09/2025- Fentanyl Transdermal Patch 72 hour 100mcg/hr. 1 patch topically every 72 hours; and 10/14/2025- Alprazolam Oral Tablet – 1 mg. 1 tablet by mouth three times a day as needed for anxiety. Review of Patient #16’s SNV’s dated 03/26/2026 through 04/27/2026, revealed in part, no documented evidence the SN performed a count of controlled substances during the following scheduled SNVs: 03/26/202603/30/2026;04/02/2026;04/06/2026;04/07/2026;04/13/2026; and04/21/2026.Patient #17Review of Patient #17’s Clinical Record revealed she was admitted to the agency on 03/28/2022 and had a Certification Period 02/05/2026 - 04/05/2026 and a current Certification Period of 04/06/2026 through 06/04/2026.Review of Patient #17’s POC and Physician’s Orders, dated 03/28/2022 through 04/27/2026, revealed, in part, the following active orders for controlled substances: 10/06/2023- Lorazepam Oral Concentrate - 2mg/mL. 0.5 mL sublingually every 4 hours as needed for anxiety. Amount Dispensed: 30 mL; and 10/06/2023- Morphine Sulfate Oral Concentrate – 20mg/mL. 1 mL sublingually every 2 hours as needed for pain. Amount Dispensed: 30 mL.Review of Patient #17’s SNV’s dated 03/31/2026 through 04/27/2026, revealed in part, no documented evidence the SN performed a count of controlled substances during the following scheduled SNVs: 03/31/2026;04/02/2026;04/07/2026;04/14/2026; and04/21/2026.Patient #18Review of Patient #18’s Clinical Record revealed she was admitted to the agency on 07/29/2025 and in a current Certification Period of 03/26/2026 through 05/24/2026. Review of Patient #18’s POC and Physician’s Orders, dated 07/29/2025 through 04/28/2026, revealed, in part, the following active orders for controlled substances: 07/29/2025- Lorazepam Oral Concentrate - 2mg/mL. 0.5 mL sublingually every 4 hours as needed for anxiety and shortness of breath. Amount Dispensed: 30 mL; 07/29/2025- Morphine Sulfate Oral Concentrate – 20mg/mL. 1 mL sublingually every 2 hours as needed for pain and shortness of breath. Amount Dispensed: 30 mL;09/02/2025- MS Contin Oral Tablet Extended Release 15 mg– 0.25 mg. 1 tablet by mouth twice daily as needed for pain;02/03/2026- Alprazolam Oral Tablet – 0.25 mg. 1 tablet by mouth every 8 hours as needed for anxiety; and04/21/2026- Fentanyl Transdermal Patch 72 hour – 50mcg/hr. 1 patch topically every 72 hours for pain.Review of Patient #18’s SNV’s dated 03/27/2026 through 04/27/2026, revealed in part, no documented evidence the SN performed a count of controlled substances during the following scheduled SNVs: 03/27/2026;03/30/2026;04/01/2026;04/03/2026;04/06/2026; 04/08/2026;04/13/2026;04/15/2026;04/17/2026;04/22/2026;04/24/2026; and04/25/2026.Patient #19Review of Patient #19’s Clinical Record revealed he was admitted to the agency on 01/14/2026 and had a Certification Period of 01/14/2026 – 04/13/2026 and a current Certification Period of 04/14/2026-07/12/2026. Review of Patient #19’s POC and Physician’s Orders, dated 01/14/2026 through 04/28/2026, revealed, in part, the following active orders for controlled substances: 01/14/2026- Lorazepam Oral Concentrate - 2mg/mL. 0.5 mL sublingually every 4 hours as needed for agitation and anxiety. Amount Dispensed: 30 mL; 01/14/2026- Morphine Sulfate Oral Concentrate – 20mg/mL. 1 mL sublingually every 2 hours as needed for pain or shortness of breath. Amount Dispensed: 30 mL;01/27/2026- Norco 5/325 mg. 1 tablet by mouth every 4 hours as needed for pain. Amount Dispensed: #30;02/25/2026- Norco 5/325 mg. 1 tablet by mouth every 4 hours as needed for pain. Amount Dispensed: #30; and03/26/2026- Norco 5/325 mg. 1 tablet by mouth every 4 hours as needed for pain. Amount Dispensed: #30. Review of Patient #19’s SNV’s dated 03/31/2026 through 04/28/2026, revealed in part, no documented evidence the SN performed a count of controlled substances during the following scheduled SNVs: 03/31/2026;04/02/2026;04/07/2026;04/10/2026;04/14/2026; 04/16/2026; and04/21/2026.3. Current and accurate records for the disposition and disposal of controlled drugs upon death.Review of the agency’s undated Death at Home Policy and Procedure revealed, in part, the following: 6. Medication Disposal – All medications, including controlled substances, will be disposed of in accordance with federal and state regulations.Review of the agency’s undated Controlled Substance Disposal Policy revealed, in part, the following: Pursuant to the state’s revised statute 40:2191, in the event of patient death, the ownership of the patient’s unused controlled substances shall immediately transfer to the Hospice agency for immediate disposal and/or destruction. The patient’s SN shall, in the presence of a witness, record in the patient’s medical record the name and quantity of each unused controlled substance and shall perform the disposal at the site of care in the presence of a witness. The witness shall sign a document indicating their witnessing of the disposal of the controlled substances. The SN shall record this information in the patient’s medical record. Patient #3Review of Patient #3’s Clinical Record revealed she was admitted to the agency on 01/28/2025, was in a Certification Period of 01/28/2025 through 03/08/2025 and expired in a private home on 03/08/2025.Review of Patient #3’s POC and Physician’s Orders, dated 01/28/2025 through 03/08/2025, revealed the following active orders for controlled substances: 01/28/2025 – Lorazepam Oral Concentrate 2mg/mL. 0.5 mL sublingually every 4 hours as needed. Amount Dispensed: 30 mL; 01/28/2025 - Morphine Sulfate Oral Solution 20mg/mL. 1 mL sublingually every 2 hours as needed. Amount Dispensed: 30 mL; and 02/18/2025 – Tramadol HCl Tablet 50 mg. 1 tablet by mouth twice daily as needed. Review of Patient #3’s Death Visit Note, dated 03/08/2025 at 1:25 a.m., revealed the following: Medication Disposal (indicate name and quantity of all medications disposed): Disposed of per facility protocol. Medication Disposal Witness: blankDisposed of per facility protocol. Comments: No documented evidence to indicate the SN performed a count and/or wasted all remaining controlled substances in the presence of a witness immediately following her death. Review of Patient #3’s Clinical Record revealed no documented evidence to indicate the SN performed a count and/or wasted all remaining controlled substances in the presence of a witness immediately following her death. Patient #4Review of Patient #4’s Clinical Record revealed he was admitted to the agency on 04/03/2025, was in a Certification Period of 04/03/2025 through 04/11/2025 and expired in a private home on 04/11/2025.Review of Patient #4’s POC and Physician’s Orders, dated 04/03/2025 through 04/11/2025, revealed the following active orders for controlled substances: 04/04/2025 – Diazepam Oral Solution – 5mg/5mL. 5 mLs every 8 hrs as needed.04/03/2025 – Lorazepam Oral Concentrate 2mg/mL. 0.5 mL sublingually every 4 hours as needed. Amount Dispensed: 30 mL;04/03/2025 - Morphine Sulfate (Concentrate) Oral Solution 20 mg/mL. 1 mL sublingually every 2 hours as needed.Review of Patient #4’s Death Visit Note, dated 04/11/2025 at 1:40 a.m., revealed the following: Medication Disposal (indicate name and quantity of all medications disposed): Morphine-16 mL; Diazepam-30 mL; Lorazepam-30 mL. Medication Disposal Witness: blankPatient #4’s family member (typed into the note).Comments: No documented evidence of the witness’ signature to authenticate their presence when the SN performed a count and/or wasted all remaining controlled substances immediately following his death. Review of Patient #4’s Clinical Record revealed no documented evidence of the witness’ signature to authenticate their presence when the SN performed a count and/or wasted all remaining controlled substances immediately following his death. Patient #5Review of Patient #5’s Clinical Record revealed he was admitted to the agency on 03/17/2025, was in a Certification Period of 02/23/2025 through 03/27/2025 and expired in a local nursing home on 03/27/2025.Review of Patient #5’s POC and Physician’s Orders, dated 03/17/2025 through 03/27/2025, revealed the following active orders for controlled substances: 03/17/2025 – Lorazepam Oral Suspension - 2mg/mL. 0.5 mL sublingually every 4 hours as needed;03/17/2025 – Lyrica Capsule 75 mg. 1 capsule by mouth twice daily;03/17/2025 – Morphine Sulfate (Concentrate) Oral Solution 20mg/mL. 1 mL sublingually every 2 hours as needed; 03/17/2025 – Temazepam Capsule 30 mg. 1 capsule by mouth every night; and 03/27/2025 – Lorazepam Oral Suspension 2mg/mL. 0.5 mL sublingually twice daily.Review of Patient #5’s Death Visit Note, dated 03/27/2025 at 4:32 p.m., revealed the following: Medication Disposal (indicate name and quantity of all medications disposed.): Disposed per facility protocol.Medication Disposal Witness: blankDisposed per facility protocol.Comments: No documented evidence to indicate the SN performed a count of all remaining controlled substances in the presence of a witness immediately following his death and prior to allowing the nursing home to dispose of the narcotics.Review of Patient #5’s Clinical Record, dated 03/27/2025, revealed no documented evidence the nurse conducted a count of all remaining controlled substances in the presence of a witness immediately following his death and prior to allowing the nursing home to dispose of the narcotics.An interview was conducted on 4/22/2026 at 9:44 a.m. with S11RN. S11RN confirmed she did not document the current count of a patient’s controlled substances during her SNVs and was not required to. An interview was conducted on 04/28/2026 at 1:23 p.m. with S3RN. S3RN confirmed she did not document the current count of a patient’s controlled substances during her SNVs and was not required to. An interview was conducted on 04/28/2026 at 5:05 p.m. with S2DON. S2DON confirmed the agency did not have a written policy and procedure requiring their SNs to perform a count of all controlled substances present in the patient’s home during every SNV but she expected them to do so. S2DON confirmed all of the agency’s SNs were aware of this expectation. S2DON confirmed she expected the SN to document the remaining counts in their SNV under their medication reconciliation section or under their free text comments. S2DON confirmed she was not aware the SNs were not doing this and should have been. S2DON confirmed when a patient died in a private home, she expected the SN to perform a count and waste all remaining controlled substances in the presence of a witness immediately following the patient’s death. S2DON confirmed she expected the remaining counts and the name of the witness to be documented in the patient’s Death Visit Note. S2DON confirmed the agency’s policy and procedures required the signature of the witness authenticating their presence during the final count and disposal of controlled substances to be maintained in the patient’s clinical record. S2DON confirmed the agency did not currently have a process for obtaining the witness’ signature and should.”

“Based on interview and record review, the Hospice agency failed to ensure a patient’s Hospice POC was maintained in consultation with the patient’s local NH by failing to ensure the Hospice POC matched the NH Physician Orders for 1 (#8) of 2 patients reviewed with home visits in a local NH. Findings: Review of Patient #8’s Clinical Record revealed she was admitted to the Hospice agency on 01/16/2026, was in a current Certification Period of 04/16/2026 through 07/14/2026 and resided at a local NH. Further review revealed she was ordered to receive a SNV three times a week and as needed and had a Stage 2 Pressure Ulcer to the Sacrum. Review conducted on 04/21/2026 of Patient #8’s Physician Orders from her NH revealed, in part, the following orders for medication: Start date: 08/19/2025 - Abilify 5mg. Give 1 tablet at bedtime for Major Depressive Disorder; Start date: 08/19/2025 - Cymbalta 30mg. Give 1 tablet twice daily for Major Depressive Disorder; andStart Date: 04/07/2026 - Wound Care (Stage 2 Pressure Ulcer to the Sacrum) – Cleanse with Wound Cleanser. Pat dry. Apply Calcium Alginate to wound bed. Cover with Duoderm every Tuesday, Friday and as needed. (End Date: 04/21/2026); and Start date: 04/21/2026 - Wound Care (Stage 2 Pressure Ulcer to the Sacrum) – Cleanse with Wound Cleanser. Apply Dakins soaked gauze to wound bed. Cover with Duoderm every Monday, Wednesday, Friday and as needed. Further review revealed no active orders for: Start Date: 01/16/2026 - Cymbalta 60mg. Give 1 tablet twice daily for Major Depressive Disorder.Review conducted on 04/21/2026 of Patient #8’s active Hospice Physician Orders revealed, in part, the following order for medication: Start Date: 01/16/2026 - Cymbalta 60mg. Give 1 capsule twice daily. Further review revealed no active orders present for Abilify 5mg; and Wound Care (Stage 2 Pressure Ulcer to the Sacrum). Review of Patient #8’s IDG Meeting Notes and POC Updates, dated 04/09/2026 and 04/20/2026, revealed, in part, the following:Problem: Sacral Wound. Interventions: No documented evidence of wound care orders. An interview was conducted on 04/28/2026 at 3:05 p.m. with S2DON. S2DON confirmed Patient #8 currently resided in a local NH and was currently receiving treatment for a Stage 2 Pressure Ulcer to the Sacrum. S2DON reviewed Patient #8’s Clinical Record and confirmed it did not contain Physician’s Orders/Interventions for the care of her Stage 2 Pressure Ulcer to the Sacrum. S2DON confirmed Patient #8’s wound care orders should be reflected in the Hospice POC and they were not. S2DON confirmed a patient’s Hospice medication orders should be reconciled and updated during each SNV to ensure they matched the local NH’s medication orders, and Patient #8’s did not.”

“Based on interviews and record review, the Hospice agency failed to have a system in place to ensure a patient’s Hospice POC clearly identified which provider was responsible for managing and providing care for a patient’s wounds for 1 (#8) of 1 patient reviewed for wounds who resided in a local NH. Findings:Review of Patient #8’s Clinical Record revealed she was admitted to the Hospice agency on 01/16/2026, was in a current Certification Period of 04/16/2026 through 07/14/2026 and resided at a local NH. Further review revealed she was ordered to receive a SNV three times a week and as needed and had a Stage 2 Pressure Ulcer to the Sacrum. Review conducted on 04/21/2026 of Patient #8’s Physician Orders from her NH revealed, in part, the following orders for Wound Care written by the local NH’s Wound Specialist: 04/07/2026 - Wound Care (Stage 2 Pressure Ulcer to the Sacrum) – Cleanse with Wound Cleanser. Pat dry. Apply Calcium Alginate to wound bed. Cover with Duoderm every Tuesday, Friday and as needed. (Stop Date: 04/21/2026); and04/21/2026 - Wound Care (Stage 2 Pressure Ulcer to the Sacrum) – Cleanse with Wound Cleanser. Apply Dakins soaked gauze to wound bed. Cover with Duoderm every Monday, Wednesday, Friday and as needed. Review conducted on 04/21/2026 of Patient #8’s Hospice Physician Orders revealed no indication of which provider was responsible for managing and providing Patient #8’s Wound Care. Review of Patient #8’s IDG Meeting Notes and POC Updates, dated 04/09/2026 and 04/20/2026, revealed, in part, Problem: Sacral Wound. Further review revealed no indication of which provider was responsible for managing and providing Patient #8’s Wound Care. An interview was conducted on 04/21/2026 at 2:20 p.m. with S14RN. S14RN confirmed Patient #8 resided in a local NH and was currently receiving treatment for a Stage 2 Pressure Ulcer to the Sacrum. S14RN confirmed the Wound Care Specialist at the local NH where Patient #8 resided was responsible for managing all of her orders for Wound Care. S14RN confirmed she was not responsible for providing Patient #8’s Wound Care, her NH staff were. An interview was conducted on 04/28/2026 at 3:05 p.m. with S2DON. S2DON confirmed Patient #8 resided in a local NH and was currently receiving treatment for a Stage 2 Pressure Ulcer to the Sacrum. S2DON confirmed the Wound Care Specialist at the local NH where Patient #8 resided was responsible for managing all of her orders for Wound Care. S2DON confirmed Patient #8’s NH staff were responsible for providing all of her Wound Care, not the Hospice nurses. S2DON reviewed Patient #8’s Clinical Record and confirmed it did not indicate which provider was responsible for managing and providing Patient #8’s Wound Care and it should.”