Hospice Compassus - Greater New Orleans

“It is required that each patient’s individualized written plan of care reflect the patient and family goals and identify planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 27 (7%) clinical records reviewed, the hospice did not ensure that the patient’s plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 11: The patient elected hospice on 09/17/2025 with diagnoses of acute systolic congestive heart failure and dementia. On 12/25/2025, the Registered Nurse (RN) provided a PRN (as needed) visit following a reported fall. The RN’s assessment dated 12/25/2025 documented no injury, and a (Missouri Alliance for Home Care Fall Risk Assessment) MAHC-10 Fall Risk Assessment was completed, with a score of 6, indicating the patient is at risk for falls. The patient was noted to have an unsteady gait and ambulated with a walker. The patient’s medication list included Eliquis (anticoagulant) 5 mg twice daily. The Interdisciplinary Group (IDG) Meetings on 12/30/2025 and 01/13/2026 documented the patient’s fall; however, there was no evidence of alerts, safety interventions, or caregiver/patient education regarding the patient’s increased risk for bleeding secondary to Eliquis use. On 01/07/2026, the RN documented “Patient was confused, stating she thinks her spouse threw away her medication mistakenly while cleaning.” The caregiver reported that medications were being kept at their home due to the patient’s confusion. The RN instructed the caregiver on the need for a medication lockbox, and the caregiver was reported to be accepting of this solution. The patient’s medication profile documented: Eliquis 5 mg twice daily, Seroquel 25 mg at bedtime, gabapentin 300 mg every 8 hours, hydrocodone/acetaminophen 7.5 mg / 325 mg, one (1) tablet every 6 hours as needed, losartan 50 mg daily, lorazepam 0.5 mg every 4 hours as needed, and morphine sulfate 20 mg/mL: 0.25 mL (5 mg) every 2 hours as needed. The IDG Meetings on 12/30/2025 or 01/13/2026 did not address the patient’s documented problems: identified confusion, use of high-risk medications, the need for a lockbox, and medication safety in the home. The initial plan of care (POC) for the benefit period from 09/17/2025 to 12/15/2025 documented safety measures, including clear pathways, removal of throw rugs, removal of clutter, and fall precautions. The POC did not include interventions to address the patient’s use of anticoagulant medication (bleeding precautions). The subsequent POC for 12/16/2025 to 03/15/2026 did not document interventions to address the problems: anticoagulant therapy, confusion, and use of multiple high-risk medications. CLINICAL RECORD 15: The patient elected hospice care on 09/29/2025 with diagnoses of senile degeneration of the brain and congestive heart failure. The Admission Registered Nurse (RN) visit on 09/29/2025 documented that the patient had experienced 1–2 falls in the prior month, including an emergency department visit on 09/15/2025 for confusion and a fall with head injury. The RN documented that the patient could ambulate in the home but had become weaker. The patient’s medication profile at admission documented: Eliquis (anticoagulant) 2.5 mg twice daily and Plavix (antiplatelet) 75 mg daily. The Interdisciplinary Team (IDT) Meeting on 10/08/2025 did not address fall risk, safety concerns, or bleeding precautions, and no related problem or interventions were incorporated into the plan of care. On 12/11/2025, the RN documented a fall and that the patient was “found fully clothed and face down on the bedroom floor at 0200, with bruising to the left side of the face and balance problems while walking.” The IDT Meeting on 12/16/2025 documented the fall with significant facial bruising and noted that a walker was encouraged; however, the team conference record documented “No safety concerns,” despite the fall with injury and the patient’s continued use of Eliquis and Plavix. The patient’s Palliative Performance Scale (PPS) was documented to have decreased from 50% to 40% on 12/05/2025, reflecting functional decline. The plans of care for the benefit periods from 09/29/2025 to 12/27/2025 and 12/28/2025 to 03/27/2026 did not include bleeding precautions within the listed safety measures. In addition, the plans of care did not identify problems or interventions addressing the patient’s history of recurrent falls or the increased bleeding risk associated with the anticoagulant and antiplatelet therapy. During a joint clinical record review and interviews on 01/15/2026, the Area Executive of Clinical Operations and the Director of Clinical Services confirmed an increased risk of bleeding for both patients and medication safety concerns for Clinical Record 11, which should have been identified and addressed in the plans of care. They further acknowledged that these elements were not adequately reflected at the time the care was provided and stated that the clinical records were updated and brought into compliance prior to the conclusion of the site visit.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan: as frequently as the patient’s condition requires; but no less frequently than every 15 calendar days. A revised plan of care includes: information from the patient’s updated comprehensive assessment; This standard was not met as evidenced by clinical record review and interview. In 1 of 27 (3%) clinical records reviewed, the hospice did not ensure that the patient’s plan of care included revised information based on the comprehensive assessment. CLINICAL RECORD 11: The patient elected hospice on 09/17/2025 with diagnoses of acute systolic congestive heart failure and dementia. On 12/25/2025, the Registered Nurse (RN) provided a PRN (as needed) visit following a reported fall. The RN’s assessment dated 12/25/2025 documented no injury, and a (Missouri Alliance for Home Care Fall Risk Assessment) MAHC-10 Fall Risk Assessment was completed, with a score of 6, indicating the patient is at risk for falls. The patient was noted to have an unsteady gait and ambulated with a walker. The patient’s medication list included Eliquis (anticoagulant) 5 mg twice daily. The Interdisciplinary Group (IDG) Meetings on 12/30/2025 documented the patient’s fall; however, the revised plan of care did not document safety interventions or caregiver/patient education regarding the patient’s increased risk for bleeding secondary to Eliquis use. On 01/07/2026, the RN documented “Patient was confused, stating she thinks her spouse threw away her medication mistakenly while cleaning.” The caregiver reported that medications were being kept at their home due to the patient’s confusion. The RN instructed the caregiver on the need for a medication lockbox, and the caregiver was reported to be accepting of this solution. The patient’s medication profile documented: Eliquis 5 mg twice daily, Seroquel 25 mg at bedtime, gabapentin 300 mg every 8 hours, hydrocodone/acetaminophen 7.5 mg / 325 mg, one (1) tablet every 6 hours as needed, losartan 50 mg daily, lorazepam 0.5 mg every 4 hours as needed, and morphine sulfate 20 mg/mL: 0.25 mL (5 mg) every 2 hours as needed. The IDG Meetings on 01/13/2026 did not address the patient’s documented problems: identified confusion, use of high-risk medications, the need for a lockbox, and medication safety in the home. The revised plan of care did not document bleeding precautions, medication safety interventions, or medication security measures to address the identified problems: anticoagulant therapy, confusion, and use of multiple high-risk medications. During a joint clinical record review and interviews on 01/15/2026, the Area Executive of Clinical Operations and the Director of Clinical Services confirmed an increased risk of bleeding and medication safety concerns for Clinical Record 11, which should have been identified and addressed in the plans of care. They stated that the clinical record was updated and brought into compliance prior to the conclusion of the site”

“Based on interviews and record review, 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 ensure current and accurate records were maintained for the disposition of all controlled substances provided by the Hospice agency to the patient for 1 (#3) of 3 patients in the sample. This deficient practice had the potential to affect a current census of 209 patients and any future admissions to the agency. 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 proportion 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 we spoke to identified best practices for preventing diversion of controlled substances. Best practices include 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. Review of the agency’s Medication Reconciliation and Management Policy and Procedure #HOS-C_15C, reviewed and revised 10/28/2025, as of 01/07/2026, revealed, in part, the following: For patients residing in their own residence, it is the responsibility of the Hospice nurse to perform the following steps at each scheduled nursing visit: 1. Nurse obtains the most current copy of the medications list. 2. Nurse visually reviews the patient’s medication list in the home, comparing it to the medication list from the medical record. 3. If the medication lists match, the nurse continues with the medication reconciliation process. b. Identify the number of any controlled medications on hand for Schedule II, III, IV, or V drugs ordered or present. Patient #3Review of Patient #3’s Clinical Record revealed he was admitted to the Hospice agency on 08/28/2025 with a terminal diagnosis of Senile Degeneration of the Brain. Further review revealed he was in a current Certification Period of 11/26/2025 through 02/23/2026 and was ordered to receive a SNV weekly. Review of Patient #3’s Client Medication Report, as of 01/06/2026 at 2:38 p.m., revealed, in part, the following active medication orders for controlled substances:08/29/2025 - Lorazepam 2mg.mL Oral Concentrate. 0.5mL PO every 4 hours PRN for anxiety;08/29/2025 - Morphine Concentrate 100mg/5mL Oral Solution. 0.25mL PO every 4 hours PRN for pain;09/12/2025 – Percocet-Acetaminophen 5/325mg. 1 tablet PO every 6 hours PRN for pain; and 08/29/2025 - Tramadol 50mg. 1 tablet PO every 6 hours PRN for pain. Review of Patient #3’s SNV Note Reports, dated 11/24/2025 through 01/06/2026, as of 01/06/2026, revealed, in part, the following 10 missed opportunities for controlled substance counts: 11/24/2025 – SNV by S6LPN: Is patient taking any medications or have any prescriptions which are listed in the Schedule II, III, IV or V categories for controlled substances requiring monitoring to reduce diversion? Yes. Further review revealed, in part, the following 3 medications were not listed as an active controlled substance and no count was documented:Lorazepam 2mg.mL Oral Concentrate; Morphine Concentrate 100mg/5mL Oral Solution; andTramadol 50mg.12/17/2025 – SNV by S6LPN: Is patient taking any medications or have any prescriptions which are listed in the Schedule II, III, IV or V categories for controlled substances requiring monitoring to reduce diversion? No. Further review revealed, in part, the following 4 medications were not listed as an active controlled substance and no count was documented:Lorazepam 2mg.mL Oral Concentrate; Morphine Concentrate 100mg/5mL Oral Solution; Percocet-Acetaminophen 5/325mg; andTramadol 50mg.12/31/2025 – SNV by S6LPN:Is patient taking any medications or have any prescriptions which are listed in the Schedule II, III, IV or V categories for controlled substances requiring monitoring to reduce diversion? Yes.Further review revealed, in part, the following 3 medications were not listed as an active controlled substance and no count was documented:Lorazepam 2mg.mL Oral Concentrate; Morphine Concentrate 100mg/5mL Oral Solution; andTramadol 50mg.Review of Patient #3’s Communication Notes, dated 11/24/2025 through 01/06/2026, as of 01/06/2026, revealed, in part, no documented evidence to indicate the nurse performed the aforementioned controlled substance counts.An interview was conducted on 01/07/2026 at 2:45 p.m. with S6LPN. S6LPN confirmed nurses were expected to count and document all controlled substances present in a patient’s private home during every SNV they conducted. An interview was conducted on 01/07/2026 at 11:55 a.m. with S1ED. S1ED confirmed she expected their nurses to count and document all controlled substances present in a patient’s private home during every SNV conducted. S1ED confirmed the name of the medication and the remaining count, even if zero, should be documented in the SNV Note Report under the medications section. S1ED reviewed the aforementioned SNV Note Reports for Patient #3 and confirmed they did not contain documented evidence to indicate the nurse performed the required count of all controlled substances and should have.”

“Based on interviews and record review, the Hospice agency failed to meet the terms of agreement for the provision of Hospice services for residents within a contracted NH IPU. This deficient practice was evidenced by failure to have a system in place to ensure the provision of drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions for patients receiving respite care within a contracted NH IPU for 1 (#3) of 2 patients reviewed for respite care. This deficient practice had the potential to affect 1 current patient receiving respite care within a contracted NH IPU and any future patients admitted for respite care to a contracted NH IPU. Review of the agency’s Respite Care Services Agreement, effective 04/12/2022, as of 01/07/2026, revealed, in part, the following: This agreement is made and entered into by and between the Hospice agency and the NH IPU facility. Recitals: Now, therefore, in consideration of the mutual covenants and agreements set forth herein, the parties hereby agree as follows: Part II: Services to be provided by the facility: E. NH IPU will provide respite care to Hospice patients that is palliative in nature to control pain and mange symptoms of terminal illness, including, but not limited to, treatments and medications. Part III: Services to be provided by Hospice: D. Hospice shall retain administrative and financial management responsibility for all services provided to Hospice and its patients by the NH IPU under this Agreement, including the responsibility for the planning, coordinating and prescribing of such services, and shall maintain oversight of the staff and services provided by the NH IPU hereunder to ensure the provision of quality care. E. The IDG shall be responsible for directing, coordinating, and supervising the care and services provided to the Hospice patient hereunder. Part IX: Term and TerminationA. This agreement shall remain in effect for one (1) year from the Effective Date and will automatically renew on each anniversary of the Effective Date. Review of the agency’s Respite Level of Care Policy and Procedure #HOS-C_09D, reviewed 12/27/2024, as of 01/07/2026, revealed, in part, the following: Procedure: A patient’s POC during an inpatient respite stay would be the same as if the patient were receiving care in their home. The established POC is followed by the Hospice IDG and the facility staff would give care that the caregiver would provide in the home setting. Patient #3Review of Patient #3’s Clinical Record revealed he was admitted to the Hospice agency on 08/28/2025 with a terminal diagnosis of Senile Degeneration of the Brain and comorbidities which included, in part, Dementia with Behavioral Disturbances. Further review revealed he was in a current Certification Period of 11/26/2025 through 02/23/2026 and was ordered to receive a SNV weekly. Review of Patient #3’s current Physician Orders, as of 01/06/2026, revealed, in part, the following: 01/02/2026 – Admit to Respite Level of Care at contracted NH IPU (01/02/2026 - 01/06/2026).Review of Patient #3’s NH IPU Clinical Record revealed he arrived for admission to the facility for Respite Care on 01/02/2026 at 10:40 a.m. Review of Patient #3’s Client Medication Report, as of 01/06/2026, revealed, in part, the following active medication orders at the time he was admitted for respite:08/29/2025 - Acetaminophen 500mg. 2 tablets PO three times daily for fever or pain;08/29/2025 - Albuterol Sulfate 2.5mg/3mL Solution. 3mL Nebulized every 4 hours PRN for SOB;08/30/2025 - Lidocaine 4% Topical Patch. Apply 2 patches topically every day to back for pain;08/29/2025 - Dulcolax 10mg Suppository. 1 suppository rectally every day for constipation; 08/29/2025 - Eliquis 5mg. 1 tablet PO twice daily for blood clots;08/29/2025 - Lorazepam 2mg.mL Oral Concentrate. 0.5mL PO every 4 hours PRN for anxiety;08/29/2025 - Metoprolol Succinate ER 25mg. 1 tablet PO daily for hypertension;08/29/2025 - Morphine Concentrate 100mg/5mL Oral Solution. 0.25mL PO every 4 hours PRN for pain;08/29/2025 - Oxygen. 2-4L/min inhaled PRN for SOB;09/12/2025 – Percocet-Acetaminophen 5/325mg. 1 tablet PO every 6 hours PRN for pain;08/29/2025 - Miralax 17g Packet. 1 packet PO daily for constipation;08/29/2025 - Risperidone 1mg/mL Oral Solution. 0.25mL PO twice daily for behaviors;09/27/2025 - Seroquel 25mg. 1 tablet PO twice daily for agitation, restlessness and behaviors; and 08/29/2025 - Tramadol 50mg. 1 tablet PO every 6 hours PRN for pain. Review of the agency’s Triage Call Log, dated 01/02/2026 through 01/07/2026, as of 01/07/2026, revealed, in part, the following: 01/03/2026 around 12:00 p.m. - Triage Nurse received a call from a nurse at the NH IPU informing them Patient #3’s medications were not available in the facility for administration. Review of the NH IPU’s Medication Administration Record for Patient #3, dated 01/02/2026 through 01/06/2026, as of 01/06/2026, revealed, in part, the following:Risperidone 1mg/mL Oral Solution – The 3 following doses were documented as not administered due to “9” which indicated a Progress Note was entered to explain why the dose was not administered:01/03/2026 at 9:00 a.m.;01/04/2026 at 9:00 a.m.; and 01/05/2026 at 9:00 a.m.Seroquel 25mg – The 8 following doses were documented as not administered due to “9” which indicated a Progress Note was entered to explain why the dose01/02/2026 at 6:00 p.m.;01/03/2026 at 9:00 a.m.;01/03/2026 at 6:00 p.m.;01/04/2026 at 9:00 a.m.;01/04/2026 at 6:00 p.m.;01/05/2026 at 9:00 a.m.;01/05/2026 at 6:00 p.m.; and 01/06/2026 at 9:00 a.m.Review of Patient #3’s NH IPU’s Progress Notes, dated 01/02/2026 through 01/05/2026, as of 01/07/2026, revealed, in part, the following: 01/03/2026 at 11:58 a.m. – Medication Administration Note: Risperidone Oral Solution not given, pending pharmacy delivery; 01/03/2026 at 1:18 p.m. – Hospice contacted regarding missing medications, awaiting return call; 01/04/2026 at 10:31 a.m. – Medication Administration Note: Risperidone Oral Solution not given, pending pharmacy delivery; and01/05/2026 at 10:14 a.m. – Medication Administration Note: Risperidone Oral Solution not given, pending pharmacy delivery.Review of Patient #3’s PRN SNV Note Report, dated 01/02/2026, as of 01/06/2026, revealed, in part, the following: Visit Date/Time: 01/02/2026 at 12:42 p.m.Visit conducted by: S7RN.Assessment – Medications: Is patient taking any medications or have any prescriptions which are listed in the Schedule II, III, IV or V categories for controlled substances requiring monitoring to reduce diversion? No. Patient has adequate supply of medications on hand? Yes. Patient has 7 days of medications on hand and no refills are needed. Review of medication list completed. Yes. Patient resides in a nursing facility and current facility medication list is accurate. Did you complete a medication reconciliation to include all elements from previous questions? Yes. Narrative: Patient #3 now at NH IPU. Report received from NH IPU nurse with no problems or concerns reported. Interventions Provided: Admission RN will complete a medication inventory at time of admission. Details/Comments: All medication reconciled. An interview was conducted on 01/07/2026 at 2:48 p.m. with S7RN. S7RN confirmed she performed Patient #3’s “tuck in visit” on 01/02/2026 after he arrived to the NH IPU for his respite stay and did not visualize any of Patient #3’s medications during the visit. S7RN confirmed during her visit, the NH IPU’s nurse informed her the facility did not have any of Patient #3’s medications because his family did not bring them when he arrived. S7RN confirmed the NH IPU’s nurse told her Patient #3’s family was supposed to bring them later. S7RN confirmed she did not follow up or inform anyone of this information. An interview was conducted on 01/07/2026 at 2:55 p.m. with the Director of Nursing for Patient #3’s NH IPU. She confirmed Patient #3 received respite care in their facility from 01/02/2026 through 01/06/2026. She confirmed Patient #3 arrived for admission to the facility on 01/02/2026 at 10:40 a.m. without any of his medications. She confirmed Patient #3’s medications did not arrive to the facility until the afternoon of 01/05/2026. She confirmed Patient #3 missed all doses from the time he was admitted until they arrived. She confirmed her nurses reached out to the Hospice agency to request a status update on the medications but did not receive a response. She confirmed she spoke with the nurses who documented the medication was given and they confirmed it was a documentation error. An interview was conducted on 01/07/2026 at 3:32 p.m. with S5RN. S5RN confirmed on 01/05/2026, she was made aware Patient #3 had not had any medications available for administration at the NH IPU since his admission on 01/02/2026 and still did not have them at this time. An interview was conducted on 01/07/2026 at 3:21 p.m. with the Hospice agency’s Pharmacist. She confirmed the pharmacy received a call from S5RN on 01/05/2026 requesting to have all of Patient #3’s ordered medications filled and delivered same day to the NH IPU. She confirmed Patient #3’s medications were filled and delivered to the NH IPU on the afternoon of 01/05/2026. An interview was conducted on 01/07/2026 at 11:55 a.m. with S1ED. S1ED confirmed the Hospice agency was responsible for ensuring a patient had all medications available for administration when they were receiving respite care in a contracted NH IPU. S1ED confirmed a patient receiving respite care in a NH IPU should receive the same care and services from the Hospice agency as they would if they were in their own private home; including the provision of medications. S1ED confirmed when a patient was admitted to a NH IPU for respite care, the family typically brought their medications from home to be administered during their respite stay. S1ED stated if the family were unable to do so, the Hospice agency should contact the pharmacy to fill and deliver more immediately. S1ED confirmed she was not made aware Patient #3’s medications were not brought to the NH IPU by his family when he was admitted on 01/02/2026 or that they were still unavailable on 01/05/2026 and should have been. S1ED confirmed there should have been more follow up from Hospice staff when they were made aware Patient #3’s family did not bring his medications at the time of admission to the NH IPU. S1ED confirmed there should have been more follow up when the Hospice agency was contacted on 01/03/2026 with issues regarding Patient #3’s medications. S1ED confirmed Patient #3 should have received all of his medications as ordered during his respite stay and he did not.”

“Based on observations, interviews and record reviews, the Hospice agency failed to meet the Condition of Participation for Organization and Administration of Services as evidenced by failure to have a system in place to ensure each patient’s medications were administered in a safe and effective manner. The Hospice agency failed to have a system in place to ensure the contracted inpatient unit (IPU): 1. Had a licensed nurse present to administer routine and as needed (PRN) medications. This deficient practice was evidenced by the administration of medications, including Morphine, Ativan and Fentanyl, by an unlicensed CNA/sitter, without the supervision of an onsite licensed nurse for 4 of 4 (#1, #2, #3 and #4) patients in the sample (See Findings in tag L660).; 2. Performed proper patient assessments prior to the administration of PRN narcotic medications. This deficient practice was evidenced by the administration of PRN Morphine and Ativan based on an assessment of need performed by an unlicensed CNA/sitter without the supervision of an onsite licensed nurse for 4 of 4 (#1, #2, #3 and #4) patients in the sample (See Findings in tag L660). ; and3. Provided secure storage of patient medications, including Morphine and Ativan. This deficient practice was evidenced by the CNA/sitter maintaining sole possession of the key to the locked medication closet where all patient medications were stored (See Findings in tag L660). This deficient practice resulted in an Immediate Jeopardy situation on 04/09/2025 at 12:05 p.m., when an interview with the IPU’s Assistant Director confirmed Patient #2, #3, and #4 were currently living in the IPU and were patients of the contracted Hospice agency. She confirmed the IPU “contracted caregivers, who were sometimes CNAs,” through an outside staffing agency. She confirmed the IPU did not contract or have a nurse on staff in the home 24/7. She confirmed the Hospice agency nurse was responsible for performing nurse duties for patients in the home when they performed their routine and/or PRN SN visits. On 04/09/2025 at 12:11 p.m., interview with the contracted CNA for the IPU confirmed she was a CNA, was responsible for administering routinely ordered medications and PRN medications, including Morphine and Ativan, to patients in the home, and was not under the supervision of a licensed nurse when she administered medications. She confirmed the Hospice agency nurse made her aware PRN medications could be given every 2 hours if the patient “moaned, groaned, or became restless”. She confirmed she administered patient medications from IPU’s locked medication closet which she maintained possession of the keys throughout her shift. She confirmed she administered PRN Morphine and Ativan from syringes which were pre-filled by the Hospice agency’s nurse during their visits then stored in the medication closet until the CNA administered them. She confirmed the Hospice agency nurse pre-filled around 10 syringes with the ordered amount of Morphine and Ativan then placed them into plastic sandwich bags with the patient’s name, medication name and dose. She confirmed she documented patient medication administration on their MAR located inside their patient binder. She confirmed when they were running low on the pre-filled syringes, they contacted the Hospice agency nurse to come fill more for them. On 04/09/2025 at 12:20 p.m., observation conducted of the IPU’s medication closet confirmed all of the above information.S1ED was notified of the Immediate Jeopardy on 04/09/2025 at 4:30 p.m.Onsite verification was conducted through observations, interviews and record reviews to ensure the agency had implemented an acceptable Plan of Removal: April 6, 2025 at 11:23 p.m. - Patient #1 expired.April 9, 2025 at 10:52 a.m. - Patient #2 expired.April 9, 2025 at 12:33 p.m. - Patient #3 expired.April 9, 2025 at 4:56 p.m. - The Hospice agency’s Social Worker contacted Patient #4’s family to facilitate the transfer of Patient #4 from the contracted IPU to the patient’s daughter’s home.April 9, 2025 at 5:03 p.m. – Hospice agency conducted an Emergency Meeting of the Governing Body. Decision made to initiate immediate termination of existing service contract with the IPU.April 9, 2025 at 5:27 p.m. - DME ordered for delivery to Patient #4’s daughter’s home.April 9, 2025 at 5:30 p.m. - Mandatory staff meeting to inform all staff of the immediate termination of the IPU contract and the transfer of Patient #4 to her daughter’s home.April 9, 2025 at 5:51 p.m. – S1ED notified by Corporate that the provider agreement with the contracted IPU was being terminated due to findings of unlicensed personnel having unauthorized access to and administration of medications, including controlled substances.April 9, 2025 at 10:08 p.m. – Patient #4 transported by ambulance from the contracted IPU to her daughter’s home with S1ED and S2DCO on site to assist. April 9, 2025 at 10:23 p.m. - Tuck-in visit initiated for Patient #4 to confirm patient was comfortable, with no change in condition, and current needs met. S1ED and S2DCO arrived o Patient #4’s daughter’s home to validate the safe transfer. April 9, 2025 at 10:00 p.m. – Updated the Hospice agency’s procedure for Medication Reconciliation and Management to include: All medications must be labeled and dispensed by a licensed pharmacy. If a patient’s POC requires pre-filled medications, these must be prepared and dispensed by a licensed pharmacist, not by hospice personnel.April 10, 2025 at 8:00 a.m. - Policy & Procedure Committee approved the update to the above procedure. April 10, 2025 at 8:30 a.m. – Mandatory All-Staff Meeting conducted with training by the S3DQO on the updated procedure for medication Reconciliation and Management.What is the monitoring process we will put into place to ensure implementation and effectiveness of the corrective action plan?Item #1:1. The ACO, or the clinical supervisor overseeing the ACC, will conduct a comprehensive review of 100% of active contracts with facilities to validate the contracted facilities ensure that all personnel providing services to the Hospice and its patients on behalf of Facility hereunder, provide such services in conformance with generally accepted standards of professional practice and in accordance with all applicable Federal, State, and local laws, rules, and regulations, to hospice patients. This will be evidenced by on-site visits to ensure that licensed nurses are administering medications to hospice patients as per hospice plan of care. Each contract review will be documented using the Annual Contract Review Form. Weekly reviews will continue until full (100%) compliance is validated by 4/16/2025.2. Upon validation of 100% of contracted facilities, a sample of 20% of contracted facilities will undergo site visits over a period of three additional months. These visits will serve to validate continued compliance, ensuring that licensed nurses consistently administer medications in accordance will all applicable Federal, State, and local laws, rules, and regulations, to hospice patients.3. If any discrepancies or errors are identified during contract audits or facility site visits, the ACO, or the clinical supervisor overseeing the ACO, will convene an immediate meeting of the governing body to evaluate the findings. Corrective training will be initiated with the contracted facility. If the governing body determines there is a pattern of non-compliance with safe medication administration practices, termination of the contract may be considered.4. All findings from contract reviews and site visits will be submitted to the Regional Executive of Clinical Operations (RCO) and/or the independent Director of Quality Outcomes (DQO) for further oversight and guidance.5. The ACO will present progress and corrective actions to the Quality Assessment and Performance Improvement (QAPI) Committee on a quarterly basis to ensure accountability and continued quality improvement until POC resolved.Item #2:1. The DCS or clinical supervisor overseeing the DCS will review 100% of active patient’s medications in the home settings or contracted facilities to ensure that all active medications have been labeled by a licensed pharmacy and aligned with the plan of care. Reviews will continue weekly until 100% compliance is sustained for 4 consecutive weeks.2. Once sustained compliance is achieved for 4 consecutive weeks, reviews will be reduced to 20% of applicable patients in the home setting and contracted facilities for an additional 3 months of sustained compliance to validate ongoing compliance.3. In the event that any errors are identified during these reviews, the clinical team member responsible will receive 1:1 counseling with the DCS or clinical supervisor above the ACO to align practice with policy. Progressive disciplinary action may be initiated if warranted as determined by the DCS or clinical supervisor above the DCS.4. The results of all record reviews and any counseling or disciplinary action will be reported to the Regional Clinical Operator (RCO)/independent Director of Quality Outcomes (DQO) for additional oversight and recommendations.5. The ACO will report plan of correction activities and progress to the QAPI committee quarterly for oversight.The Immediate Jeopardy was lifted on 04/10/2025 at 11:30 a.m. prior to the survey exit and deficient practice remained at a Condition level. This deficient practice had the potential to cause harm to any of the Hospice agency’s 30 patients who resided at the contracted IPU during the past 12 months, a current census of 43 patients and any future admissions to the Hospice agency.(See Findings in tag L660). See Findings in L660.”

“Based on observations, interviews and record reviews, the Hospice agency failed to have a system in place to ensure each patient’s medications were administered in a safe and effective manner. The Hospice agency failed to ensure the contracted IPU: 1. Had a licensed nurse present to administer routine and as needed (PRN) medications. This deficient practice was evidenced by the administration of medications, including Morphine, Ativan and Fentanyl, by an unlicensed CNA/sitter, without the supervision of an onsite licensed nurse for 4 of 4 (#1, #2, #3 and #4) patients in the sample; 2. Performed proper patient assessments prior to the administration of PRN narcotic medications. This deficient practice was evidenced by the administration of PRN Morphine and Ativan based on an assessment of need performed by an unlicensed CNA/sitter without the supervision of an onsite licensed nurse for 4 of 4 (#1, #2, #3 and #4) patients in the sample; and3. Provided secure storage of patient medications, including Morphine and Ativan. This deficient practice was evidenced by the CNA/sitter maintaining sole possession of the key to the locked medication closet where all patient medications were stored.This deficient practice had the potential to cause harm to any of the Hospice agency’s 30 patients who resided at the contracted IPU during the past 12 months, a current census of 43 patients and any future admissions to the Hospice agency.Cross Reference: L648. Review of the Hospice agency’s signed contract with the IPU revealed the contract was signed on 11/14/2024 by S1ED. Further review revealed, in part, the following: This agreement provides the terms required of Hospice providers who desire to have patients placed into Hospice House. Inconsideration of the mutual covenants hereinafter, set forth, it is hereby agreed that this Agreement shall cover a collaboration between HFOS and provider, beginning upon due execution by both parties, to provide Hospice care and residential care for terminally ill persons mutually accepted by both parties pursuant to the following terms and conditions: Provider understands that the costs of operating the House are substantial to HFOS and provider agrees to work with HFOS in conjunction with its fundraising efforts. Criteria for admission to the house includes: The patient’s Hospice provider has executed the contract with HFOS; and Provider’s agreement to follow HFOS House Rules.HFOS shall provide residential services to HFOS residents. Hospice agency shall provide Hospice services to HFOS residents. Residential services shall include the following: assistance with the administration of medication. Hospice services shall provide: pharmacy, oxygen, medical supplies related to the care of the terminal illness. Hospice services must follow State of Louisiana, Medicare and/or Medicaid regulations regarding Hospice care. Each party to this Agreement shall be responsible for the direct employment and supervision of its employees performing services pursuant to this Agreement. Notwithstanding any other provision in this Agreement, the Hospice agency remains solely responsible for: Ensuring any Hospice services provided comply with all pertinent provisions of any federal, state and local statutes, rules and regulations; Planning and coordinating and ensuring the quality of all Hospice services provided; and Ensuring adherence to the POC established for patients. Review of the contracted IPU’s House Rules referenced in the Contract above revealed, in part, the following: 3. Family members are not allowed to administer any type of medications. All medicines must be ordered by the Hospice nurse and given by HH caregivers. Review of the contracted IPU’s webpage, https://thehospicehouse.org/about-us-1, revealed, in part, the following: Physical Address: 141 Pleasant Drive; Slidell, LA 70460; and Currently Contracted Partners: the Hospice agency.Review of the Hospice agency’s list of patients who resided at the contracted IPU during the past 12 month period, as of 04/10/2025, revealed, in part, a total of 39 patients; including Patient #1, #2, #3 and #4. Patient #1Review of Patient #1’s Clinical Record revealed she was admitted to the Hospice agency on 04/01/2025 with a terminal diagnosis of Senile Degeneration of the Brain. Further review revealed a current Certification Period of 04/01/2025 through 04/13/2025 and she moved to the contracted IPU on 04/01/2025. Review of Patient #1’s Patient Information Sheet, as of 04/09/2025 at 9:10 a.m., revealed her physical address at the time of her death was 141 Pleasant Drive; Slidell, LA 70460.Review of Patient #1’s POC and Physician’s Orders for the current Certification Period, revealed, in part, the following: Problem: ComfortIntervention: SN to complete medication reconciliation during every visit. Ensure patient has a minimum of 7 day supply of medications. Goal: Patient’s pain is managed at a stated sit score using numeric scale as evidenced by pain level at or below sit of 2.Intervention: Evaluate patient’s pain level against sit score at each visit.Further review revealed, in part, the following active medication orders: 04/01/2025: Acetaminophen 650mg Rectal Suppository – Every 6 hours as needed for fever;04/01/2025: Bisacodyl 10mg Rectal Suppository – Daily as needed for constipation;04/01/2025: Levsin 0.125mg Disintegrating Tablet – Every 4 hours by mouth as needed for terminal secretions;04/01/2025: Lorazepam 2mg/mL Oral Concentrate – 0.25mL every 4 hours as needed for anxiety/agitation;04/01/2025: Morphine Concentrate 20mg/mL – 0.25mL every 2 hours as needed for shortness of breath or pain; 04/01/2025: Oxygen Gas for inhalation – Administer as needed at 2 to 4 liters per minute for shortness of breath; and04/01/2025: Prochlorperazine Maleate 10mg tablet – every 6 hours as needed by mouth for nausea/vomiting.Review of Patient #1’s IDG Composition revealed, in part, RN Case Manager and Assigned SN: S4RN.Review of Patient #1’s signed House Rules for the contracted IPU, revealed, in part, it was signed indicating agreement by Patient #1’s RP on 04/01/2025. Further review revealed, in part, family members were not allowed to administer any type of medications. All medications must be ordered by the Hospice nurse and given by the contracted IPU’s caregivers.Review of Patient #1’s MAR during their time at the contracted IPU was attempted on 04/09/2025 and 04/10/2025 with the contracted IPU not willing to provide the requested documentation for review. An interview was conducted on 04/10/2025 at 11:00 a.m. with S1ED. S1ED confirmed Patient #1 resided at the contracted IPU from 04/01/2025 through 04/06/2025. Patient #2Review of Patient #2’s Clinical Record revealed he was admitted to the Hospice agency on 04/02/2025 with a terminal diagnosis of Senile Degeneration of the Brain. Further review revealed a current Certification Period of 04/02/2025 through 04/09/2025 and he moved to the contracted IPU on 04/02/2025.Review of Patient #2’s Patient Information Sheet, as of 04/09/2025 at 9:10 a.m., revealed his current physical address was 141 Pleasant Drive; Slidell, LA 70460.Review of Patient #2’s POC and Physician’s Orders for the current Certification Period, revealed, in part, the following: Problem: ComfortIntervention: SN to complete medication reconciliation during every visit. Ensure patient has a minimum of 7 day supply of medications. Goal: Patient’s pain is managed at a stated sit score using numeric scale as evidenced by pain level at or below sit of 2.Intervention: Evaluate patient’s pain level against sit score at each visit.Further review revealed, in part, the following active medication orders: 04/01/2025: Bisacodyl 10mg Rectal Suppository – Daily as needed for constipation;04/01/2025: Levsin 0.125mg Disintegrating Tablet – Every 4 hours by mouth as needed for terminal secretions;04/02/2025: Lorazepam 2mg/mL Oral Concentrate – 0.25mL every 4 hours as needed for anxiety/agitation; 04/02/2025: Morphine Concentrate 20mg/mL – 0.25mL every 2 hours as needed for shortness of breath or pain; and 04/01/2025: Oxygen Gas for inhalation – Administer as needed at 2 to 4 liters per minute for shortness of breath.Review of Patient #2’s IDG Composition revealed, in part, RN Case Manager and Assigned SN: S4RN.Review of Patient #2’s signed House Rules for the contracted IPU, revealed, in part, it was signed indicating agreement by Patient #2’s RP on 04/02/2025. Further review revealed, in part, family members were not allowed to administer any type of medications. All medications must be ordered by the Hospice nurse and given by the contracted IPU’s caregivers.Review of Patient #2’s MAR during their time at the contracted IPU was attempted on 04/09/2025 and 04/10/2025 with the contracted IPU not willing to provide the requested documentation for review. An interview was conducted on 04/10/2025 at 11:00 a.m. with S1ED. S1ED confirmed Patient #2 resided at the contracted IPU from 04/02/2025 through 04/09/2025. Patient #3Review of Patient #3’s Clinical Record revealed she was admitted to the Hospice agency on 03/28/2025 with a terminal diagnosis of Malignant Neoplasm of Rectum. Further review revealed a current Certification Period of 03/28/2025 through 06/25/202 and she moved to the contracted IPU on 04/08/2025.Review of Patient #3’s Patient Information Sheet, as of 04/09/2025 at 9:10 a.m., revealed her current physical address was 141 Pleasant Drive; Slidell, LA 70460.Review of Patient #3’s POC and Physician’s Orders for the current Certification Period, revealed, in part, the following: Problem: ComfortIntervention: Evaluate patient’s pain level against sit score at each visit.Intervention: SN to complete medication reconciliation during every visit. Ensure patient has a minimum of 7 day supply of medications. Goal: Patients symptoms will be assessed to determine comfort level and to maintain an acceptable pain threshold as evidenced by pain assessment on each visit. Further review revealed, in part, the following active medication orders: 03/28/2025: Amlodipine 5mg tablet – Administer by mouth daily; 03/28/2025: Aspirin 81mg tablet – Administer by mouth daily; 03/28/2025: Carafate 1gram tablet – Administer by mouth twice daily as needed for reflux; 03/28/2025: Dexamethasone 2mg tablet – Administer by mouth daily;03/28/2025: Famotidine 40mg tablet – Administer by mouth daily;03/28/2025: Ferrous Sulfate 325mg tablet – Administer by mouth daily;03/28/2025: Hydrochlorothiazide 12.5mg tablet – Administer by mouth daily;03/28/2025: Levothyroxine 88mcg tablet – Administer by mouth daily; 03/28/2025: Nystatin 100,000unit/mL Oral Suspension – Administer 4mL by mouth daily;03/28/2025: Ondansetron 4mg Disintegrating Tablet – Administer by mouth every 4 hours as needed for nausea and vomiting;03/28/2025: Oxygen Gas for inhalation – Administer as needed at 2 to 4 liters per minute for shortness of breath;03/28/2025: Pantoprazole 40mg Tablet – Administer by mouth daily; 03/28/2025: Ropinirole 4mg Tablet – Administer at bedtime for restless legs; 03/28/2025: Zyrtec 10mg Capsule – Administer by mouth daily; 03/28/2025: Fentanyl transdermal patch 12mcg/hr – Apply to skin every 72 hours for pain control. Discontinued on 04/03/2025; 04/04/2025: Fentanyl transdermal patch 25mcg/hr – Apply to skin every 72 hours for pain control; 03/28/2025: Ativan 0.5mg - 1 tablet every 4 hours as needed for anxiety/agitation; and03/28/2025: Morphine Concentrate 20mg/mL – 0.25mL every 2 hours as needed for shortness of breath or pain. Review of Patient #3’s IDG Composition revealed, in part, RN Case Manager and Assigned SN: S4RN.Review of Patient #3’s signed House Rules for the contracted IPU, revealed, in part, it was signed indicating agreement by Patient #3’s RP on 04/08/2025. Further review revealed, in part, family members were not allowed to administer any type of medications. All medications must be ordered by the Hospice nurse and given by the contracted IPU’s caregivers.Review of Patient #3’s MAR during their time at the contracted IPU was attempted on 04/09/2025 and 04/10/2025 with the contracted IPU not willing to provide the requested documentation for review. An interview was conducted on 04/10/2025 at 11:00 a.m. with S1ED. S1ED confirmed Patient #3 resided at the contracted IPU from 04/08/2025 through 04/09/2025. Patient #4Review of Patient #4’s Clinical Record revealed she was admitted to the Hospice agency on 02/12/2025 with a terminal diagnosis of Malignant Neoplasm of Pancreas with numerous metastases. Further review revealed a current Certification Period of 02/12/2025 through 05/12/2025 and she moved to the contracted IPU on 02/12/2025.Review of Patient #4’s Patient Information Sheet, as of 04/09/2025 at 9:10 a.m., revealed her current physical address was 141 Pleasant Drive; Slidell, LA 70460.Review of Patient #4’s POC and Physician’s Orders for the current Certification Period, revealed, in part, the following: Problem: ComfortIntervention: Monitor pain level using appropriate pain risk scale. Intervention: SN to monitor anxiety using the appropriate level of anxiety scale. Intervention: SN to complete medication reconciliation during every visit. Ensure patient has a minimum of 7 day supply of medications. Further review revealed, in part, the following active medication orders: 02/12/2025: Bisacodyl 10mg Rectal Suppository – Daily as needed for constipation;02/12/2025: Levsin 0.125mg Disintegrating Tablet – Every 4 hours by mouth as needed for terminal secretions;02/12/2025: Lomotil 2.5mg-0.025mg Tablet – Administer 3 times daily as needed by mouth for diarrhea;02/12/2025: Simethicone 80mg Chewable Tablet – Administer every 6 hours as needed by mouth for gas control;02/12/2025: Oxygen Gas for inhalation – Administer as needed at 2 to 4 liters per minute for shortness of breath; 02/12/2025: Ativan 0.5mg - 1 tablet every 4 hours as needed for anxiety/agitation; 02/12/2025: Morphine Concentrate 20mg/mL – 0.25mL every 2 hours as needed for shortness of breath or pain. Review of Patient #4’s IDG Composition revealed, in part, RN Case Manager and Assigned SN: S4RN.Review of Patient #4’s signed House Rules for the contracted IPU, revealed, in part, it was signed indicating agreement by Patient #4’s RP on 02/11/2025. Further review revealed, in part, family members were not allowed to administer any type of medications. All medications must be ordered by the Hospice nurse and given by the contracted IPU’s caregivers.Review of Patient #4’s MAR during their time at the contracted IPU was attempted on 04/09/2025 and 04/10/2025 with the contracted IPU not willing to provide the requested documentation for review. An interview was conducted on 04/10/2025 at 11:00 a.m. with S1ED. S1ED confirmed Patient #4 resided at the contracted IPU from 02/11/2025 through 04/09/2025 at 10:08 p.m. when she was moved to her daughter’s home.An interview was conducted on 04/09/2025 at 12:05 p.m. with the Assistant Director of the contracted IPU while onsite at the home. She confirmed the IPU had a current contract in place for the Hospice agency to send patients to them. She confirmed Patients #1, #2, and #3 were currently living in the IPU and were patients of the Hospice agency. She confirmed the IPU “contracted caregivers, who were sometimes CNAs,” through an outside staffing agency. She confirmed the IPU did not contract or have a nurse on staff in the home 24/7. She confirmed the Hospice agency nurse was responsible for performing nurse duties for patients in the home when they performed their routine and/or PRN SN visits. An interview was conducted on 04/09/2025 at 12:11 p.m. with the agency CNA currently providing patient care for the contracted IPU. She confirmed she was a CNA and worked at the IPU for the past year. She confirmed the IPU did not have a nurse onsite or contracted to perform medication administration for patients. She confirmed she was responsible for the administration of all routine and PRN medications, including Morphine and Ativan, for all patients in the home. She confirmed she did not work under the supervision of a licensed nurse when she assessed the need for and/or performed medication administration. She confirmed when she began working at the IPU, the Hospice agency nurse informed her PRN medications could be given every 2 hours if the patient “moaned, groaned, or became restless”. She confirmed she administered patient medications from the IPU’s locked medication closet which she maintained sole possession of the key throughout her shift. She confirmed she administered PRN Morphine and Ativan from syringes which were pre-filled by the Hospice agency’s nurse during their visits and stored in the medication closet until the CNA administered them. She confirmed the Hospice agency nurse pre-filled around 10 syringes with the ordered amount of Morphine and Ativan then placed them into plastic sandwich bags with the patient’s name and medication name written on the bag. She confirmed she documented the administration of patient medications on each patient’s MAR located inside their patient binder and kept inside the locked medication closet. She confirmed when the IPU was running low on pre-filled syringes, they contacted the Hospice agency nurse who would come immediately to fill more. An observation conducted on 04/09/2025 at 12:20 p.m. of the IPU’s medication storage closet by this surveyor confirmed all of the aforementioned information. An interview was conducted on 04/09/2025 at 4:19 p.m. with S2DCS. S2DCS confirmed the Hospice agency had a current, valid contract in place with the IPU. S2DCS confirmed the Hospice agency had 3 patients residing in the home at the start of this survey and had 39 patients who resided in the home over the past 12 months. S2DCS confirmed the IPU was a 501c3 nonprofit agency which provided residential housing for active Hospice agency patients for up to 90 days during end of life, typically during the active dying stage. S2DCS confirmed the IPU utilized a 3rd party staffing agency for CNAs/sitters to provide patient care. S2DCS confirmed the Hospice agency provided the IPU with a current medication list with up to date orders the IPU’s CNAs/sitters used to administer all patient medications. S2DCS confirmed she was unaware if the IPU’s caregivers were actual certified nursing assistants or untrained sitters. S2DCS confirmed the IPU did not have nurses on staff nor did nurses oversee or perform medication administration which was why the Hospice agency nurse prefilled pill organizers for each patient and pre-filled syringes with the proper doses of medications for each patient. S2DCS confirmed the agreement the Hospice agency made with the IPU ensured sitters were not allowed to administer medications to patients unless they were pre-filled and/or pre-drawn by the Hospice agency nurse. S2DCS confirmed Hospice agency nurses filled routine pill medications in daily pill organizers which could include nonnarcotic and narcotic medications. S2DCS confirmed the assessments patients received from a nurse were performed by the Hospice agency’s nurses when they were present in the home for routine and/or PRN visits. S2DCS confirmed each of the IPU patients had a binder which included a scheduled and PRN MAR where the CNA/sitter documented what medication was administered and when. S2DCS confirmed the Hospice nurse reviewed the MARs during their visits to determine if additional doses should be pre-filled and left for the patient due to increased need for administration. S2DCS confirmed all Hospice patients in the IPU would always have medications on-hand to treat signs and symptoms associated with the dying process, which would always include narcotic and nonnarcotic medications. An interview was conducted on 04/10/2025 at 11:00 a.m. with S1ED. S1ED confirmed she signed the Hospice agency’s current contract with the IPU and it was valid at this time. S1ED confirmed S4RN was the Hospice agency nurse who would be assigned to patients in the contracted IPU. S1ED confirmed the Hospice agency had 3 patients residing in the home at the start of this survey and had 39 patients who resided in the home over the past 12 months. S1ED confirmed the IPU was a 501c3 nonprofit agency which provided residential housing for active Hospice agency patients for up to 90 days during end of life, typically during the active dying stage. S1ED confirmed the IPU utilized a 3rd party staffing agency for CNAs/sitters to provide patient care. S1ED confirmed the Hospice agency provided the IPU with a current medication list with up to date orders the IPU’s CNAs/sitters used to administer all patient medications. S1ED confirmed she was unaware if the IPU’s caregivers were actual certified nursing assistants or untrained sitters. S1ED confirmed the IPU did not have nurses on staff nor did nurses oversee or perform medication administration which was why the Hospice agency nurse prefilled pill organizers for each patient and pre-filled syringes with the proper doses of medications for each patient. S1ED confirmed the agreement the Hospice agency made with the IPU ensured sitters were not allowed to administer medications to patients unless they were pre-filled and/or pre-drawn by the Hospice agency nurse. S1ED confirmed Hospice agency nurses filled routine pill medications in daily pill organizers which could include nonnarcotic and narcotic medications. S1ED confirmed the assessments patients received from a nurse were performed by the Hospice agency’s nurses when they were present in the home for routine and/or PRN visits. S1ED confirmed each of the IPU patients had a binder which included a scheduled and PRN MAR where the CNA/sitter documented what medication was administered and when. S1ED confirmed the Hospice nurse reviewed the MARs during their visits to determine if additional doses should be pre-filled and left for the patient due to increased need for administration. S1ED confirmed all Hospice patients in the IPU would always have medications on-hand to treat signs and symptoms associated with the dying process, which would always include narcotic and nonnarcotic medications. S1ED confirmed the Hospice agency did not maintain copies of the signed MARs from the IPU at the Hospice agency. S1ED stated if there were questions or a need, they would contact the IPU to request the MAR be sent over to the Hospice agency. S1ED confirmed the Hospice agency had been reaching out to the Administration team of the IPU to request the MARs for Patient #1, #2, #3 and #4 and had not received them.”