Concerned Care Hospice

“Based on interviews and record reviews, the Hospice agency failed to meet the Condition of Participation (COP) for the Organization and Administration of Services. This deficient practice was evidenced by failure to have a system in place to ensure the Hospice agency: 1. Met the COP for Patient Rights in regards to the 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 5 (#1, #2, #3, #4, and #13) of 6 (#1, #2, #3, #4, #6 and #13) patients reviewed for Revocations. (See Findings in L505); 2. Met the COP for the Organization and Administration of Services in regards to the provision of wound care; provision of timely medication delivery, provision of controlled substances; provision of inpatient services; the provision of Medical Social Work Services; and improper Revocations for 13 (#1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) of 14 (#1 through #14) patients in the sample. (See findings in L505, L523, L524, L531, L539, L545, L549, L552, L591, L594, L652, L683, L686, L694, and L706); 3. Met the COP for Drugs and Biologicals in regards to the provision of medications as ordered and the provision, management and destruction of controlled substances for 9 (#3, #5, #6, #8, #9, #10, #11, #12, and #13) of 10 (#1 through #14) patients in the sample. (See findings in L652, L686, and L694).This deficient practice had the potential to affect any of the 39 admissions during the past 12 months, a current census of 18 patients, any future admissions to the agency, along with any of the 36 patients who revoked Hospice benefits during the past 12 months. See Findings in L505, L523, L524, L531, L539, L545, L549, L552, L591, L594, L652, L683, L686, L694, and L706. See Findings in L505, L523, L524, L531, L539, L545, L549, L552, L591, L594, L652, L683, L686, L694, and L706.”

“Based on observations, interviews and record review, the Hospice agency failed to meet the Condition of Participation for Drugs and Biologicals. This deficient practice was evidenced by failure to have a system in place to ensure the safe use, management and/or destruction of all controlled substances provided by the Hospice agency to the patient. The Hospice agency failed to:1. Establish a written policy and procedure to ensure the safe disposal of unused controlled substances by the Hospice nurse immediately following a patient’s death (See Findings: L694);2. Ensure immediately upon a patient’s death, the Hospice nurse, in the presence of a witness, documented the name and remaining counts of all controlled substances for 1 (#3) of 2 (#3 and #4) death records reviewed for controlled substances upon death (See Findings: L694); 3. Ensure immediately upon a patient’s death, the Hospice nurse, in the presence of a witness, performed the disposal of all controlled substances with documentation of the witness’ signature for 1 (#3) of 2 (#3 and #4) death records reviewed for controlled substances upon death (See Findings: L694); 4. Establish a written policy and procedure to maintain current and accurate records of the disposition of all controlled substances provided by the Hospice agency to the patient (See Findings: L694); and 5. Ensure current and accurate records were maintained of the disposition of all controlled substances provided by the Hospice agency to the patient for 8 of 8 (#5, #6, #8, #9, #10, #11, #12, and #13) patients reviewed for safe use and disposition of controlled substances (See Findings: L694). This deficient practice had the potential to affect any of the 102 patients admitted during the past 12 months, a current census of 28 patients and any future admissions to the agency. See Findings: L694. See Findings: 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 5 (#1, #2, #3, #4, and #13) of 6 (#1, #2, #3, #4, #6 and #13) patients reviewed for Revocations.This deficient practice had the potential to affect any of the 39 admissions during the past 12 months, a current census of 18 patients, any future admissions to the agency, along with any of the 36 patients who revoked Hospice benefits during the past 12 months. Cross Reference: L648. Review of the Hospice agency’s policy # 1-024 titled “Revocation of Hospice Benefit”, last revised 11/2020, revealed, in part, the following: Procedure: 1. The patient will choose to revoke his/her Election of Hospice Benefit (EOB) when he/she: A. Elects active treatment, inconsistent with the role of palliative care.Patient #1Review of Patient #1’s Clinical Record for her Initial Admission revealed she was admitted to the Hospice agency on 03/06/2025 with a terminal diagnosis of Senile Degeneration of the Brain and an Initial Certification Period of 03/06/2025 through 03/25/2025. Review of Patient #1’s Revocation of Hospice Benefits revealed, in part, the form was signed by her daughter on 03/25/2025 when her family opted for Emergency Department (ED) Evaluation following a fall which resulted in a fractured humerus. Review of Patient #1’s Nurse Revocation Statement, written by S2DON on 03/25/2025, revealed in part, the following: Patient#1 fell resulting in complaints of uncontrolled pain. Portable XRay performed at Patient #1’s home revealed an acute non-displaced fracture of the right humerus. Patient #1’s family wanted her transferred to ED to evaluate the fracture. Revocation signed. Review of Patient #1’s Registered Nurse (RN) RN Initial Assessment, dated 03/26/2025, revealed, in part, patient was previously on Hospice service and discharged after having a fall which resulted in a fracture to her right arm. Patient now back from the ED with an immobilizer in place to the right arm and resuming Hospice services. Review of Patient #1’s Clinical Record for her Second Admission revealed she was re-admitted to the Hospice agency on 03/26/2025 for a Certification Period of 03/26/2025 through 04/18/2025 after her aforementioned Revocation of Hospice Benefits on 03/25/2025. An interview was conducted on 06/26/2025 at 12:30 p.m. with S2DON. S2DON confirmed Patient #1’s family revoked services on 03/25/2025 to have her evaluated in the ED after a fall which resulted in increased pain due to a fractured right humerus. S2DON confirmed Patient #1 was re-admitted to Hospice services once she returned home from the ED with an immobilizer brace for her comfort.Patient #2Review of Patient #2’s Clinical Record revealed he was admitted to the Hospice agency on 11/13/2024 with a Certification Period of 11/13/2024 through 02/10/2025 and a terminal diagnosis of Senile Degeneration of the Brain. Further review revealed he was admitted with a PEG tube in place. Review of Patient #2’s Revocation of Hospice Benefits revealed, in part, the form was signed on 11/24/2024 when the patient’s PEG tube became displaced resulting in an ED visit to have it replaced. Review of Patient #2’s Nurse Revocation Statement, written by S3LPN on 11/24/2024, revealed in part, patient pulled out his PEG tube so his family wanted him to go to ED. An interview was conducted on 06/23/2025 at 1:00 p.m. with S2DON. S2DON confirmed the Hospice agency’s nurses did not replace PEG tubes. S2DON confirmed because the agency’s nurses did not replace PEG tubes, his family wanted him sent to the local ED to have it replaced which meant the Hospice agency required them to revoke Patient #2’s Hospice benefits to seek this level of care. Patient #3Review of Patient #3’s Clinical Record revealed she was admitted to the Hospice agency on 04/27/2021 with a current Certification Period of 10/01/2024 through 11/05/2024 and a terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD).Review of Patient #3’s Revocation of Hospice Benefits revealed, in part, the form was signed on 11/05/2024 when her family opted for ED Evaluation after the patient began experiencing uncontrolled vomiting following an unwitnessed fall with possible head injury. Review of Patient #3’s Nurse Revocation Statement, written by S3LPN on 11/05/2024 revealed, in part, patient’s daughter revoked services due to patient vomiting non-stop after an unwitnessed fall.Review of Patient #3’s Registered Nurse (RN) RN Initial Assessment, dated 11/07/2024, revealed, in part, patient now back from the ED and resuming Hospice services. Review of Patient #3’s Clinical Record for her Second Admission revealed she was re-admitted to the Hospice agency on 11/07/2024 for a Certification Period of 11/07/2024 through 11/11/2024 after her aforementioned Revocation of Hospice Benefits on 11/05/2024. An interview was conducted on 06/26/2025 at 12:30 p.m. with S2DON. S2DON confirmed Patient #3’s family revoked services on 11/05/2024 to have her evaluated in the ED after an unwitnessed fall with concerns she may have hit her head followed by uncontrolled vomiting. S2DON confirmed Patient #3 was re-admitted to Hospice services once she returned home from the ED.Patient #4Review of Patient #4’s Clinical Record revealed she was admitted to the Hospice agency on 04/11/2024 with a current Certification Period of 04/11/2024 through 05/20/2024 and a terminal diagnosis of Malignant Neoplasm of the Pancreas. Review of Patient #4’s Communication Note, dated 05/19/2024, revealed, in part, On-call nurse received a call from patient’s son at 2:38 p.m. stating his mother was experiencing increased abdominal swelling which caused increased pain. Patient’s son reported her current medications were not relieving the pain. Review of Patient #4’s Revocation of Hospice Benefits revealed, in part, the form was signed on 05/20/2024 when in effort to better manage the patient’s persistent, uncontrolled pain, which began on 05/19/2024 and remained uncontrolled until 05/20/2024, when her family opted for ED Evaluation due to the Hospice agency not having an inpatient unit available. Review of Patient #4’s Nurse Revocation Statement, written by S7LPN on 05/20/2024, revealed, in part, patient complained of increased shortness of breath and stated “please help me I feel terrible”. Noted +4 edema to bilateral lower extremities. Increased ascites present to the abdomen with consistent increased pain levels of 10 out of 10. Patient’s son stated he wanted her to go to the ED for pain management because he could not watch her suffer. Review of Patient #4’s Clinical Record for her Second Admission revealed she was re-admitted to the Hospice agency on 05/22/2024 for a Certification Period of 05/22/2024 through 05/27/2024 after her aforementioned Revocation of Hospice Benefits on 05/20/2024. An interview was conducted on 06/26/2024 at 3:45 p.m. with S2DON. S2DON confirmed the Hospice agency did not have an inpatient unit contract in place to send their patients with uncontrolled pain and symptoms. S2DON confirmed if the agency had an inpatient unit available, Patient #4 would not have had to be treated in the ED. S2DON confirmed if Patient #4’s family wanted her to be seen in the ED for pain and symptoms currently uncontrolled by the Hospice agency, it meant they had to revoke her Hospice benefits in order to do so. S2DON reviewed Patient #4’s record and confirmed once her pain and symptoms were controlled, she was discharged from the hospital and re-admitted to Hospice services. Patient #13Review of Patient #13’s Clinical Record revealed he was admitted to the Hospice agency on 11/22/2024 with a Certification Period of 02/20/2025 through 03/01/2025 and a terminal diagnosis of COPD. Review of Patient #13’s Communication Note, dated 03/01/2025, revealed, in part, S2DON received a call at 4:30 p.m. from Patient #13’s spouse indicating he was experiencing uncontrolled pain, swelling and redness to bilateral lower extremities so they were taking him to the ED. Review of Patient #13’s Revocation of Hospice Benefits revealed, in part, the form was signed on 03/01/2025 when in effort to better manage the patient’s uncontrolled pain and symptoms his family opted for ED Evaluation due to the Hospice agency not having an inpatient unit available. Review of Patient #13’s Nurse Revocation Statement, written by S2DON on 03/01/2025, revealed, in part, patient’s family took him to the ED due to swelling in bilateral lower extremities. The Hospice agency was notified after he arrived to the ED. Review of Patient #13’s Clinical Record for his Second Admission revealed he was re-admitted to the Hospice agency on 03/05/2025 for a Certification Period of 03/05/2025 through 05/03/2025 after his aforementioned Revocation of Hospice Benefits on 03/01/2025. An interview was conducted on 06/30/2025 at 11:00 a.m. with S2DON. S2DON confirmed she received a call from Patient #13’s son stating they took him to the ED due to uncontrolled pain and symptoms indicative of a possible deep vein thrombosis. S2DON confirmed once he was evaluated and his pain and symptoms were controlled, he was discharged from the hospital and re-admitted to Hospice services. An interview was conducted on 06/25/2025 at 10:25 a.m. with S3LPN. S3LPN confirmed she was responsible for processing Revocations of Hospice Benefits and ensuring they were completed when necessary. S3LPN confirmed the Hospice agency required the patient/family to revoke their Hospice benefits if they wanted their family members seen in the ED for any reason. S3LPN confirmed this included a fall with injury, a PEG tube being inadvertently removed, an injury which required treatment such as a splint or sutures, uncontrolled pain and symptoms, etc. S3LPN confirmed the Hospice agency did not have an Inpatient Unit to admit their patients to in order to resolve uncontrolled pain and symptoms. S3LPN confirmed the agency required a patient/family to sign a Revocation of Hospice Benefits if a patient was transported to the ED for treatment of things the Hospice was responsible for managing. S3LPN stated they let the patient/family know during admission to inform the agency before transporting to the ED so the Revocation of Hospice Benefits could be signed before transport but if they failed to do so, the Hospice agency would send the nurse to the hospital to have it signed immediately. S3LPN confirmed the reason the patient/family was required to revoke Hospice benefits prior to transport and/or evaluation in the ED was due to payment issues to prevent the Hospice agency from being responsible for payment of the services. An interview was conducted on 06/26/2025 at 12:30 p.m. with S2DON. S2DON confirmed any time a patient/family opted to go to the hospital, the Hospice agency had them sign a Revocation of Hospice Benefits due to payment reasons to avoid the agency being charged for transport, assessment, treatment, etc. S2DON confirmed after reviewing the guidelines for Revocation of Hospice Benefits, PEG Tube displacement, a fall with head injury, other suspected injuries, concerns for possible displacement of chest tube, and/or uncontrolled pain and symptoms were not reasons to have a patient revoke their hospice benefits. An interview was conducted on 06/30/2025 at 3:45 p.m. with S1ADM. S1ADM confirmed just because a patient/family opted to have a patient evaluated in the ED it did not automatically mean they were revoking their Hospice services. S1ADM confirmed things that would allow a patient to be transported and receive treatment in the ED could include a fall with injury, a PEG tube being inadvertently removed, an injury which required treatment such as a splint or sutures, uncontrolled pain and symptoms, etc. because treatment of those would be considered for comfort and not curative.”

“Based on interviews and record review, the Hospice agency failed to have a system in place to ensure a patient’s Comprehensive Assessment was completed by all members of the Interdisciplinary Group (IDG) no later than 5 days from the Election of Hospice Benefits (EOB). This deficient practice was evidenced by failure to ensure the Comprehensive Assessment was performed no later than 5 days from the patient’s EOB by the: 1. Medical Social Worker (MSW) for 4 (#5, #6, #13, and #14) of 14 (#1 through #14) patients in the sample; 2. MSW and Chaplain for 1 of 1 (#3) admissions of actively dying patients in the sample. This deficient practice had the potential to affect any of the 102 admissions during the past 12 months, a current census of 28 patients and any future admissions to the agency. 1. MSW.Patient #5Review of Patient #5’s Clinical Record revealed she was admitted to the Hospice agency on 03/19/2025 with her EOB signed on 03/19/2025. Review of Patient #5’s MSW Comprehensive Assessment, dated 03/19/2025 through 03/23/2025, was attempted throughout the course of the survey with no documented evidence available for review. An interview was conducted on 06/26/2025 at 10:26 a.m. with S2DON. S2DON confirmed all members of the IDG must perform their Comprehensive Assessment within 5 days of a patient’s EOB being signed; which included the MSW and Chaplain. S2DON confirmed Patient #5 did not receive a Comprehensive Assessment from the MSW within the required 5 day window and should have.Patient #6Review of Patient #6’s Clinical Record revealed she was admitted to the Hospice agency on 05/03/2025 with her EOB signed on 05/03/2025. Review of Patient #6’s MSW Comprehensive Assessment, dated 05/03/2025 through 05/07/2025 was attempted throughout the course of the survey with no documented evidence available for review.An interview was conducted on 06/26/2025 at 10:26 a.m. with S2DON. S2DON confirmed Patient #6 did not receive a Comprehensive Assessment from the MSW within the required 5 day window and should have.Patient #13Review of Patient #13’s Clinical Record revealed he was admitted to the Hospice agency on 03/05/2025Review of Patient #13’s MSW Comprehensive Assessment, dated 03/05/2025 through 05/09/2025, was attempted throughout the course of the survey with no documented evidence available for review.An interview was conducted on 06/26/2025 at 10:26 a.m. with S2DON. S2DON confirmed Patient #13 did not receive a Comprehensive Assessment from the MSW within the required 5 day window and should have.Patient #14Review of Patient #14’s Clinical Record revealed he was admitted to the Hospice agency on 04/29/2025 with his EOB signed on 04/29/2025. Review of Patient #14’s MSW Comprehensive Assessment, dated 04/29/2025 through 05/03/2025 was attempted throughout the course of the survey with no documented evidence available for review.An interview was conducted on 06/26/2025 at 10:26 a.m. with S2DON. S2DON confirmed Patient #14 did not receive a Comprehensive Assessment from the MSW within the required 5 day window and should have.2. MSW and Chaplain for an Actively Dying patient. Patient #3Review of Patient #3’s Clinical Record revealed she was admitted to the Hospice agency on 11/07/2024 with her EOB signed on 11/07/2024. Further review revealed she expired at home with family on 11/11/2024.Review of Patient #3’s MSW and/or Chaplain Assessments, dated 11/07/2024 through 11/11/2024, was attempted throughout the course of the survey with no documented evidence available for review. Review of Patient #3’s Initial Registered Nurse (RN) Assessment, performed on 11/07/2024 revealed, in part, the RN identified signs and symptoms indicative of Patient #3 being in the active dying phase during this assessment. Review of Patient #3’s Nurse Practitioner (NP) Assessment, performed on 11/09/2024 revealed, in part, patient being seen for hospice readmission and upon entering room, patient noted to be moribund appearing with death likely in the next 24 to 72 hours. Review of the definition of “Moribund” according to Webster’s Dictionary revealed, in part, in the process of dying, or at the point of death.An interview was conducted on 06/30/2025 at 2:30 p.m. with S2DON. S2DON confirmed when signs and symptoms indicative of a patient in the active dying phase were identified during Patient #3’s Initial RN Assessment and NP Assessment, this should have triggered the prompt completion of her Comprehensive Assessment by all members of the IDG in order to ensure patient and/or family needs were met during her final days. S2DON confirmed Patient #3 and/or her family did not receive a Comprehensive Assessment from the MSW and/or Chaplain during her final Certification Period prior to her passing and should have. An interview was conducted on 06/30/2025 at 3:55 p.m. with S1ADM. S1ADM confirmed when a patient was admitted in the active dying phase, they should receive a Comprehensive Assessment from all members of the IDG promptly in order to ensure patient and/or family needs were met during their final days and it was not for Patient #3.”

“Based on interviews and record review, the Hospice agency failed to have a system in place to ensure the timely completion of all required components of the Comprehensive Assessment. This deficient practice was evidenced by failure to:1. Complete the Psychosocial Assessment within 5 days of the patient’s Election of Hospice Benefits (EOB) for 4 (#5, #6, #13, and #14) of 14 (#1 through #14) patients in the sample; and2. Complete the Initial Psychosocial and Spiritual Assessments following the admission of an actively dying patient for 1 of 1 (#3) admissions of actively dying patients in the sample. This deficient practice had the potential to affect any of the 102 admissions during the past 12 months, a current census of 28 patients and any future admissions to the agency. 1. Initial Psychosocial AssessmentPatient #5Review of Patient #5’s Clinical Record revealed she was admitted to the Hospice agency on 03/19/2025 with her EOB signed on 03/19/2025. Review of Patient #5’s Initial Psychosocial Assessment, dated 03/19/2025 through 03/23/2025, was attempted throughout the course of the survey with no documented evidence available for review. Review of Patient #5’s Initial Registered Nurse (RN) Assessment revealed, in part, no documented evidence of an Initial Psychosocial Assessment performed during this visit. An interview was conducted on 06/26/2025 at 10:26 a.m. with S2DON. S2DON confirmed all required components of the Comprehensive Assessment must be completed within 5 days of a patient’s EOB being signed; which included their Initial Psychosocial and Spiritual Assessments. S2DON confirmed Patient #5 did not receive an Initial Psychosocial Assessment within the required 5 day window and should have.Patient #6Review of Patient #6’s Clinical Record revealed she was admitted to the Hospice agency on 05/03/2025 with her EOB signed on 05/03/2025. Review of Patient #6’s Initial Psychosocial Assessment, dated 05/03/2025 through 05/07/2025 was attempted throughout the course of the survey with no documented evidence available for review.Review of Patient #6’s Initial RN Assessment revealed, in part, no documented evidence of an Initial Psychosocial Assessment performed during this visit. An interview was conducted on 06/26/2025 at 10:26 a.m. with S2DON. S2DON confirmed Patient #6 did not receive an Initial Psychosocial Assessment within the required 5 day window and should have.Patient #13Review of Patient #13’s Clinical Record revealed he was admitted to the Hospice agency on 03/05/2025Review of Patient #13’s Initial Psychosocial Assessment, dated 03/05/2025 through 05/09/2025, was attempted throughout the course of the survey with no documented evidence available for review.Review of Patient #13’s Initial RN Assessment revealed, in part, no documented evidence of an Initial Psychosocial Assessment performed during this visit. An interview was conducted on 06/26/2025 at 10:26 a.m. with S2DON. S2DON confirmed Patient #13 did not receive an Initial Psychosocial Assessment within the required 5 day window and should have.Patient #14Review of Patient #14’s Clinical Record revealed he was admitted to the Hospice agency on 04/29/2025 with his EOB signed on 04/29/2025. Review of Patient #14’s Initial Psychosocial Assessment, dated 04/29/2025 through 05/03/2025, was attempted throughout the course of the survey with no documented evidence available for review.Review of Patient #14’s Initial RN Assessment revealed, in part, no documented evidence of an Initial Psychosocial Assessment performed during this visit. An interview was conducted on 06/26/2025 at 10:26 a.m. with S2DON. S2DON confirmed Patient #14 did not receive an Initial Psychosocial Assessment within the required 5 day window and should have.2. Initial Psychosocial and Spiritual Assessments for actively dying patient.Patient #3Review of Patient #3’s Clinical Record revealed she was admitted to the Hospice agency on 11/07/2024 with her EOB signed on 11/07/2024. Further review revealed she expired at home with family on 11/11/2024.Review of Patient #3’s Initial Psychosocial and/or Spiritual Assessment, dated 11/07/2024 through 11/11/2024, was attempted throughout the course of the survey with no documented evidence available for review. Review of Patient #3’s Initial RN Assessment, performed on 11/07/2024 revealed, in part, no documented evidence of an Initial Psychosocial and/or Spiritual Assessment performed during this visit. Further review revealed the RN identified signs and symptoms indicative of Patient #3 being in the active dying phase during this assessment. Review of Patient #3’s Nurse Practitioner (NP) Assessment, performed on 11/09/2024 revealed, in part, patient being seen for hospice readmission and upon entering room, patient noted to be moribund appearing with death likely in the next 24 to 72 hours. Review of the definition of “Moribund” according to Webster’s Dictionary revealed, in part, in the process of dying, or at the point of death.An interview was conducted on 06/30/2025 at 2:30 p.m. with S2DON. S2DON confirmed when signs and symptoms indicative of a patient in the active dying phase were identified during Patient #3’s Initial RN Assessment and NP Assessment, this should have triggered the prompt completion of all required components of the Initial Assessment in order to ensure patient and/or family needs were met during her final days. S2DON confirmed Patient #3 and/or her family did not receive an Initial Psychosocial and/or Spiritual Assessment during her final Certification Period prior to her passing and should have. An interview was conducted on 06/30/2025 at 3:55 p.m. with S1ADM. S1ADM confirmed when a patient was admitted in the active dying phase, their Initial Psychosocial and/or Spiritual Assessments should be completed promptly in order to ensure patient and/or family needs were met during their final days and it was not for Patient #3.”

“Based on interviews and record review, the Hospice agency failed to have a system in place to ensure the completion of an Initial Bereavement Assessment following the admission of an actively dying patient for 1 of 1 (#3) admissions of actively dying patients in the sample. This deficient practice had the potential to affect any of the 102 admissions during the past 12 months, a current census of 28 patients and any future admissions to the agency. Review of the Hospice agency’s policy #9-023 titled “Bereavement Services”, last revised November 2020, revealed, in part, the following:Policy: The Bereavement Services program will provide services to the families/caregivers of Hospice patients both before and after the patient’s death. Procedure: 1. A Bereavement Assessment will be completed at the time of admission to Hospice. 3. Depending on the needs identified in the Bereavement Assessment, Bereavement Counselors may need to contact and/or visit the patient and family/caregiver prior to death.Review of Patient #3’s Clinical Record revealed she was admitted to the Hospice agency on 11/07/2024 and her most recent Certification Period was 11/07/2024 through 11/11/2024. Further review revealed she expired at home with family on 11/11/2024.Review of Patient #3’s Initial Bereavement Assessment for the Certification Period of 11/07/2024 through 11/11/2024 was attempted on 06/23/2025 at 2:30 p.m. with no documented evidence available for review. Review of Patient #3’s Initial Registered Nurse (RN) Assessment, performed on 11/07/2024, as of 06/23/2025 at 2:30 p.m., revealed, in part, no documented evidence of an Initial Bereavement Assessment performed during this visit. Further review revealed the RN identified signs and symptoms indicative of Patient #3 being in the active dying phase during this assessment. Review of Patient #3’s Nurse Practitioner (NP) Assessment, performed on 11/09/2024 revealed, in part, patient being seen for hospice readmission and upon entering room, patient noted to be moribund appearing with death likely in the next 24 to 72 hours. Review of the definition of “Moribund” according to Webster’s Dictionary revealed, in part, in the process of dying, or at the point of death.An interview was conducted on 06/30/2025 at 2:30 p.m. with S2DON. S2DON confirmed when signs and symptoms indicative of a patient in the active dying phase were identified during Patient #3’s Initial RN Assessment, this should have triggered the prompt completion of the Initial Bereavement Assessment in order to ensure patient and/or family needs were met during her final days. S2DON confirmed Patient #3 and/or her family did not receive an Initial Bereavement Assessment during her final Certification Period prior to her passing and should have. An interview was conducted on 06/30/2025 at 3:55 p.m. with S1ADM. S1ADM confirmed when a patient was admitted in the active dying phase, their Initial Bereavement Assessment should be completed promptly in order to ensure patient and/or family needs were met during their final days and it was not for Patient #3.”

“Based on interviews and record review, the Hospice agency failed to have a system in place to ensure the Interdisciplinary Group (IDG) maintained a system of communication, coordination, and integration of services. This deficient practice was evidenced by failure to inform and involve the patient’s prescribing physician and other members of the IDG when: 1. The Social Worker (MSW) identified psychosocial concerns for 3 (#9, #13, and #14) of 10 (#5 through #14) live patients reviewed; and 2. The Registered Nurse (RN) identified a newly admitted patient was actively dying in order to ensure the timely completion of all required Initial Assessments prior to the patient’s passing for 1 of 1 (#3) actively dying patients reviewed. This deficient practice had the potential to affect any of the 102 patients admitted during the past 12 months, a current census of 28 patients and any future admissions to the agency. 1. MSW identified new Psychosocial Concerns. Review of the National Association of Social Workers (NASW) “Standards for Palliative and End of Life Care”, from the NASW Code of Ethics-2000, revealed, in part, the following: Standard 3. Assessment The MSW shall assess clients and include comprehensive information to develop interventions and treatment planning. Standard 4. Intervention/Treatment Planning MSWs shall incorporate assessments in developing and implementing intervention plans that enhance the clients’ abilities and decisions in palliative and end of life care. Standard 6. Empowerment and Advocacy The MSW shall advocate for the needs, decisions, and rights of clients in palliative and end of life care. The MSW shall engage in social and political action that seeks to ensure that people have equal access to resources to meet their biopsychosocial needs in palliative and end of life care. Standard 7. Documentation MSWs shall document all practice with clients in either the client record.Standard 8. Interdisciplinary Teamwork The MSW should be part of an interdisciplinary effort for the comprehensive delivery of palliative and end of life services. MSWs shall strive to collaborate with team members and advocate for clients’ needs.Patient #9Review of Patient #9’s Clinical Record revealed she was admitted to the Hospice agency on 05/22/2025 with a terminal diagnosis of Malignant Neoplasm of Unspecified Part of Bronchus or Lung and co-morbidities including Secondary Malignant Neoplasm of Unspecified Lung and Chronic Obstructive Pulmonary Disease (COPD) and in a current Certification Period of 05/22/2025 through 08/19/2025. Further review revealed Patient #9 lived at home with family. Review of Patient #9’s Initial MSW Assessment, performed by S5MSW on 05/28/20025, revealed, in part, the following:Effect of Illness on Everyday Activities: Patient #9 requested help in acquiring a forehead (temporal) thermometer and an oxygen meter (pulse oximeter). She is open to transportation benefits and assistance with obtaining “priority reconnection” status with her electric company. Review of Patient #9’s Plan of Care (POC) for the current Certification Period revealed, in part, no documented evidence of any of Patient #9’s needs identified by the MSW on 05/28/2025 being discussed and/or addressed by the IDG. Review of Patient #9’s MSW Visits, dated 05/29/2025 through 06/30/2025, revealed, in part, no documented evidence of any needs identified by the MSW on 05/28/2025 being discussed and/or addressed by the IDG. Review of Patient #9’s IDG Meeting Notes, dated 05/28/2025 through 06/30/2025, revealed, in part, no documented evidence of any needs identified by the MSW on 05/28/2025 being discussed and/or addressed with the members of the IDG.Review of Patient #9’s Communication Notes, dated 05/28/2025 through 06/30/2025, revealed, in part, no documented evidence of any needs identified by the MSW on 05/28/2025 being discussed and/or addressed by the IDG. Review of Patient #9’s Physician’s Orders for Durable Medical Equipment (DME) and Supplies, dated 05/28/2025 through 06/30/2025, revealed, in part, no documented evidence of an order written for a temporal thermometer or pulse oximeter. An interview was conducted on 06/30/2025 at 12:00 p.m. with S2DON. S2DON confirmed any needs/concerns identified by any discipline during a patient assessment should be communicated and documented immediately to the relevant members of the IDG then discussed and documented during the next IDG Meeting. S2DON confirmed the conversation should continue during IDG to ensure status updates were discussed and documented in order to ensure needs were being met. S2DON confirmed there was no documented evidence the aforementioned process was followed by S5MSW for Patient #9 and should have been. Patient #13Review of Patient #13’s Clinical Record revealed he was admitted to the Hospice agency on 03/05/2025 with a terminal diagnosis of COPD and a co-morbidity of Congestive Heart Failure. Further review revealed he was in a current Certification Period of 05/04/2025 through 07/02/2025 and lived at home with family. Review of Patient #13’s Initial MSW Assessment, performed by S5MSW on 05/15/2025, revealed, in part, the following:Psychosocial Assessment Notes: Patient endorsed periods of sadness/light depression. His condition worsened suddenly and it has been difficult for the patient and his spouse to adjust. Patient/Spouse asked for help applying for services through a local non-profit organization for meal delivery assistance and possible sitter services. Patient/Spouse requested assistance with acquiring a portable oxygen concentrator and a blood glucose monitor.Visit Comments: Identified multiple social needs to be addressed for Patient/Spouse: Applying for services through a local non-profit organization will help with meals on wheels and possibly providing a sitter/aide to assist with activities of daily living (ADL). In need of a portable oxygen concentrator and blood a glucose monitor. Review of Patient #13’s MSW Visits, dated 05/16/2025 through 06/30/2025, revealed, in part, the following:06/05/2025 by S5MSWPsychosocial Assessment Notes: Patient endorsed periods of sadness/light depression. His condition worsened suddenly and it has been difficult for the patient and his spouse to adjust. Patient/Spouse asked for help applying for services through a local non-profit organization for meal delivery assistance and possible sitter services. Patient/Spouse requested assistance with acquiring a portable oxygen concentrator and a blood glucose monitor.Visit Comments:Patient/Spouse had questions regarding a possible move to palliative care, what the Program of All-Inclusive Care for the Elderly (PACE) was and if Hospice care was the right fit for them at this time. S5MSW notified Patient/Spouse he would look into PACE for them and ensure palliative care contacted them soon. Patient/Spouse also asked about the status of applying for services through a local non-profit organization will help with meals on wheels and possibly providing a sitter/aide to assist with ADLs. S5MSW informed them he had no answers for them at this time. Further review, revealed, in part, no documented evidence of any needs identified by the MSW on 05/15/2025 and/or 06/05/2025 being discussed and/or addressed by the IDG. Review of Patient #13’s POC, dated 05/16/2025 through 06/30/2025, revealed, in part, no documented evidence of any needs identified by the MSW on 05/15/2025 and/or 06/05/2025 being discussed and/or addressed by the IDG. Review of Patient #13’s MSW Visits, dated 05/16/2025 through 06/30/2025, revealed, in part, no documented evidence of any needs identified by the MSW on 05/15/2025 being discussed and/or addressed by the IDG. Review of Patient #13’s IDG Meeting Notes, dated 05/15/2025 through 06/30/2025, revealed, in part, no documented evidence of any needs identified by the MSW on 05/15/2025 being discussed and/or addressed with the members of the IDG.Review of Patient #13’s Communication Notes, dated 05/15/2025 through 06/30/2025, revealed, in part, no documented evidence of any needs identified by the MSW on 05/15/2025 being discussed and/or addressed by the IDG. Review of Patient #13’s Physician’s Orders for DME and Supplies, dated 05/15/2025 through 06/30/2025, revealed, in part, no documented evidence of an order written for a portable oxygen concentrator or blood glucose monitor. An interview was conducted on 06/30/2025 at 12:00 p.m. with S2DON. S2DON confirmed there was no documented evidence the aforementioned process was followed by S5MSW for Patient #13 and should have been. Patient #14Review of Patient #14’s Clinical Record revealed he was admitted to the Hospice agency on 04/29/2025 with a terminal diagnosis of Congestive Heart Failure and a co-morbidity of COPD. Further review revealed he was in a current Certification Period of 04/29/2025 through 07/27/2025 and lived at home with family. Review of Patient #14’s Initial MSW Assessment, performed by S5MSW on 05/04/2025, revealed, in part, the following:Visit Comments:Patient remains active and social despite his condition. His only concern is the loss of his portable oxygen concentrator, which will put a damper on his ability to attend meetings and Bingo at the local gathering space for veterans. Patient would like assistance to obtain another portable oxygen concentrator, possibly through his benefits with Veterans Affairs (VA). He would like MSW visit once a month.Review of Patient #14’s MSW Visits, dated 05/04/2025 through 06/30/2025, revealed, in part a MSW Visit was scheduled for S5MSW on 06/09/2025 with no documented evidence the visit was conducted and/or no documented evidence of why the visit was missed and if the missed visit was approved. Further review revealed no documented evidence of any needs identified by the MSW on 05/04/2025 being discussed and/or addressed by the IDG. Review of Patient #14’s POC, dated 05/04/2025 through 06/30/2025, revealed, in part, no documented evidence of any needs identified by the MSW on 05/04/2025 being discussed and/or addressed by the IDG. Review of Patient #14’s IDG Meeting Notes, dated 05/04/2025 through 06/30/2025, revealed, in part, no documented evidence of any needs identified by the MSW on 05/04/2025 being discussed and/or addressed by the IDG. Further review revealed no documented evidence of the MSW Visit on 06/09/2025 being conducted, missed, discussed and/or approved as a Missed Visit by the IDG. Review of Patient #14’s Communication Notes, dated 05/04/2025 through 06/30/2025, revealed, in part, no documented evidence of any needs identified by the MSW on 05/04/2025 being discussed and/or addressed by the IDG. Further review revealed no documented evidence of the MSW Visit on 06/09/2025 being conducted, missed, discussed and/or approved as a Missed Visit by the IDG. Review of Patient #14’s Physician’s Orders for DME and Supplies, dated 05/04/2025 through 06/30/2025, revealed, in part, no documented evidence of an order written for a portable oxygen concentrator. An interview was conducted on 06/30/2025 at 12:00 p.m. with S2DON. S2DON confirmed there was no documented evidence the aforementioned process was followed by S5MSW for Patient #14 and should have been. An interview was conducted on 06/30/2025 at 2:30 p.m. with S1ADM. S1ADM confirmed any needs/concerns identified by any discipline during a patient assessment should be discussed and documented immediately with the relevant members of the IDG then discussed and documented with the entire IDG during the next IDG Meeting. S1ADM confirmed the conversation should continue during subsequent IDG Meetings to ensure status updates were discussed and documented in order to ensure needs were being met. 2. Admission of Actively Dying Patient. Review of the National Library of Medicine and National Institute of Health’s Journal of Palliative and Hospice Care article titled “End of Life Assessments and Communication for Dying Patients and their Families”, published 09/01/2021, revealed, in part, the following: End-of-life assessments aim to help dying patients and their families plan clinical interventions in advance and prepare them for a peaceful end of life, in which the patient accepts life and death, and the family accepts the patient’s departure. It is important to assess whether death is imminent within a few days, because critical Hospice care is provided intensively during that period. The end of life refers to the period in which death is anticipated within a few days or during hospitalization for acute deterioration of cancer, chronic diseases, or chronic organ failure after an accident, without the possibility of recovery or improvement despite treatment; it also encompasses the slowly-progressing dying process associated with aging or dementia. Since discharge is equated with death for most patients admitted to Hospice, it is necessary to identify end-of-life patients at the time of admission, immediately determine the phase of the end-of-life process, and develop an appropriate care plan.The purpose of end-of-life assessments is for the Hospice medical staff to plan clinical interventions in advance and help prepare for a peaceful end of life, in which patients can reflect on their lives and accept death, while families deal with the imminent departure of their loved ones.Patient #3Review of Patient #3’s Clinical Record revealed she was admitted to the Hospice agency on 11/07/2024 and expired at home with family on 11/11/2024.Review of Patient #3’s Initial Registered Nurse (RN) Assessment, performed on 11/07/2024 revealed, in part, the RN identified signs and symptoms indicative of Patient #3 being in the active dying phase during this assessment. Further review revealed no documented evidence Patient #3’s status was communicated to all members of the IDG to ensure the timely completion of all required Initial Assessments so patient/family needs could be met prior to the patient’s passing.Review of Patient #3’s Nurse Practitioner (NP) Assessment, performed on 11/09/2024 revealed, in part, patient being seen for Hospice readmission and upon entering room, patient noted to be moribund appearing with death likely in the next 24 to 72 hours. Further review revealed no documented evidence Patient #3’s status was communicated to all members of the IDG to ensure the timely completion of all required Initial Assessments so patient/family needs could be met prior to the patient’s passing.Review of the definition of “Moribund” according to Webster’s Dictionary revealed, in part, “in the process of dying” or “at the point of death”.Review of Patient #3’s Communication Notes, dated 11/07/2024 through 11/11/2024, revealed, in part, no documented evidence Patient #3’s status was communicated to all members of the IDG to ensure the timely completion of all required Initial Assessments so patient/family needs could be met prior to the patient’s passing.Review of Patient #3’s Visit Calendar for all Disciplines, dated 11/07/2024 through 11/11/2024, revealed, in part, the only visits conducted for the patient/family from the time she was admitted until after she expired were as follows: 11/07/2024 – RN Initial Assessment Visit; 11/09/2024 – NP Face to Face Assessment; and 11/11/2024 – RN Death Visit.Further review revealed, in part, no MSW and/or Chaplain Services were attempted or provided for Patient #3 and/or her family from the time she was admitted until after she expired. An interview was conducted on 06/30/2025 at 2:30 p.m. with S2DON. S2DON confirmed a newly admitted patient in the active dying phase should trigger the prompt completion of all Initial Comprehensive Assessments by all members of the IDG followed by communication within the IDG of any identified needs in order to ensure all patient and/or family needs were met during their final days. S2DON confirmed when signs and symptoms indicative of a patient in the active dying phase were identified for Patient #3, there should be documented evidence her status was immediately communicated to all members of the IDG to ensure the timely completion of all required Initial Assessments so patient/family needs could be met prior to the patient’s passing and there was not. An interview was conducted on 06/30/2025 at 3:55 p.m. with S1ADM. S1ADM confirmed a newly admitted patient in the active dying phase should trigger the prompt completion of all Initial Comprehensive Assessments by all members of the IDG followed by communication within the IDG of any identified needs in order to ensure all patient and/or family needs were met during their final days.”

“Based on interviews and record reviews, the Hospice agency failed to develop an individualized, written Plan of Care (POC) reflective of patient/family goals and interventions, as well as, problems identified during assessment. This deficient practice was evidenced by failure to develop a POC, which accurately reflected the patient’s status for 5 (#6, #9, #10, #13, and #14) of 10 (#5 through #14) live patients in the sample.This deficient practice had the potential to affect any of the 102 patients admitted during the past 12 months, a current census of 28 patients and any future admissions to the agency. Patient #6Review of Patient #6’s Clinical Record revealed she was admitted to the Hospice agency on 05/03/2025 with a current Certification Period of 05/03/2025 through 07/01/2025. Further review revealed she lived at home with her disabled son who served as her sole caregiver. Review of Patient #6’s Medical Social Worker (MSW) Visits, dated 05/03/2025 through 06/30/2025, revealed, in part, the following: 05/10/2025 by S5MSWPatient/son received the patient’s social security check, the son’s disability and the patient has some stocks. Patient/son requested help applying for food stamp benefits and services through a local non-profit organization for meal delivery assistance. Also requested assistance with obtaining a new wheelchair for the patient and a life alert bracelet. Please describe any financial assistance required: Food stamp benefits.Caregiver Communication Skills: Patient’s son requires assistance with completing forms due to disability.05/24/2025 by S5MSWPlease describe any additional financial assistance required: Food Stamp benefits and services through a local non-profit organization for meal delivery assistance. Risks: No risks identified.Notes: Met with Patient to discuss her options through a local non-profit organization for meal delivery assistance and if she would like to sign up for food stamp benefits. Patient’s son asked for assistance in helping his mother prepare a Living Will. 06/13/2025 by S6MSWPatient/son requested help in applying for Food Stamp benefits and services through a local non-profit organization for meal delivery assistance. Also requested assistance with obtaining a new wheelchair for the patient and a life alert bracelet. There was no change to any of this information during my most recent visit.Please describe any additional financial assistance required: Food Stamp benefits and services through a local non-profit organization for meal delivery assistance. Review of Patient #6’s POC, dated 05/03/2025 through 06/30/2025 revealed, in part, no documented evidence of the identification of and addition of interventions for the aforementioned issues/concerns identified during MSW assessments.An interview was conducted on 06/30/2025 at 1:30 p.m. with S2DON. S2DON confirmed any needs/concerns identified by any discipline during a patient assessment should be clearly documented in their POC to ensure needs were being met. S2DON confirmed Patient #6’s POC should reflect the presence of and identification of necessary interventions for all needs/concerns identified during her MSW assessments and it did not. Patient #9Review of Patient #9’s Clinical Record revealed she was admitted to the Hospice agency on 05/22/2025 with a current Certification Period of 05/22/2025 through 08/19/2025. Further review revealed Patient #9 lived at home with family. Review of Patient #9’s Initial MSW Assessment, performed by S5MSW on 05/28/20025, revealed, in part, the following:Effect of Illness on Everyday Activities: Patient #9 requested help in acquiring a forehead (temporal) thermometer and an oxygen meter (pulse oximeter). She is open to transportation benefits and assistance with obtaining “priority reconnection” status with her electric company. Review of Patient #9’s POC for the current Certification Period revealed, in part, no documented evidence of the identification of and addition of interventions for the aforementioned issues/concerns identified during MSW assessments.An interview was conducted on 06/30/2025 at 12:00 p.m. with S2DON. S2DON confirmed Patient #9’s POC should reflect the presence of and identification of necessary interventions for all needs/concerns identified during her MSW assessments and it did not. Patient #10Review of Patient #10’s Clinical Record revealed she was admitted to the Hospice agency on 01/25/2022 with a current Certification Period of 06/10/2025 through 08/08/2025. Further review revealed she had an active Stage 3 Pressure Ulcer to the Left Heel identified on 03/18/2024. Review of Patient #10’s POC for the Certification Periods of 04/11/2025 through 06/09/2025 and 06/10/2025 through 08/08/2025, revealed, in part, no documented evidence of the presence of and addition of interventions for the aforementioned Pressure Ulcer.An interview was conducted on 06/30/2025 at 12:00 p.m. with S2DON. S2DON confirmed Patient #10’s POC should reflect the presence of and identification of necessary interventions for the care of her Pressure Ulcer and it did not. Patient #13Review of Patient #13’s Clinical Record revealed he was admitted to the Hospice agency on 03/05/2025 with a current Certification Period of 05/04/2025 through 07/02/2025. Further review revealed he lived at home with his spouse/primary caregiver. Review of Patient #13’s Initial MSW Assessment, performed by S5MSW on 05/15/2025, revealed, in part, the following:Psychosocial Assessment Notes: Patient endorsed periods of sadness/light Depression. His condition worsened suddenly and it has been difficult for the patient and his spouse to adjust. Patient/Spouse asked for help applying for services through a local non-profit organization for meal delivery assistance and possible sitter services. Patient/Spouse requested assistance with acquiring a portable oxygen concentrator and a blood glucose monitor.Visit Comments: Identified multiple social needs to be addressed for Patient/Spouse: Applying for services through a local non-profit organization will help with meals on wheels and possibly providing a sitter/aide to assist with activities of daily living (ADL). In need of a portable oxygen concentrator and blood a glucose monitor. Review of Patient #13’s MSW Visits, dated 05/16/2025 through 06/30/2025, revealed, in part, the following:06/05/2025 by S5MSWPsychosocial Assessment Notes: Patient endorsed periods of sadness/light Depression. His condition worsened suddenly and it has been difficult for the patient and his spouse to adjust. Patient/Spouse asked for help applying for services through a local non-profit organization for meal delivery assistance and possible sitter services. Patient/Spouse requested assistance with acquiring a portable oxygen concentrator and a blood glucose monitor.Visit Comments:Patient/Spouse had questions regarding a possible move to palliative care, what the Program of All-Inclusive Care for the Elderly (PACE) was and if Hospice care was the right fit for them at this time. S5MSW notified Patient/Spouse he would look into PACE for them and ensure palliative care contacted them soon. Patient/Spouse also asked about the status of applying for services through a local non-profit organization will help with meals on wheels and possibly providing a sitter/aide to assist with ADLs. S5MSW informed them he had no answers for them at this time. Further review revealed no additional MSW Visits were conducted from 06/05/2025 through 06/30/2025.Review of Patient #13’s POC, dated 05/16/2025 through 06/30/2025, revealed, in part, no documented evidence of the identification of and addition of interventions for the aforementioned issues/concerns identified during MSW assessments.An interview was conducted on 06/30/2025 at 12:00 p.m. with S2DON. S2DON confirmed Patient #13’s POC should reflect the presence of and identification of necessary interventions for all needs/concerns identified during her MSW assessments and it did not. Patient #14Review of Patient #14’s Clinical Record revealed he was admitted to the Hospice agency on 04/29/2025 with a terminal diagnosis of Congestive Heart Failure and a co-morbidity of Chronic Obstructive Pulmonary Disease (COPD). Further review revealed he was in a current Certification Period of 04/29/2025 through 07/27/2025 and lived at home with family. Review of Patient #14’s Initial MSW Assessment, performed by S5MSW on 05/04/2025, revealed, in part, the following:Visit Comments:Patient remains active and social despite his condition. His only concern is the loss of his portable oxygen concentrator, which will put a damper on his ability to attend meetings and Bingo at the local gathering space for veterans. Patient would like assistance to obtain another portable oxygen concentrator, possibly through his benefits with Veterans Affairs (VA). He would like MSW visit once a month.Review of Patient #14’s POC, dated 05/04/2025 through 06/30/2025, revealed, in part, no documented evidence of the identification of and addition of interventions for the aforementioned issues/concerns identified during MSW assessments.An interview was conducted on 06/30/2025 at 12:00 p.m. with S2DON. S2DON confirmed Patient #14’s POC should reflect the presence of and identification of necessary interventions for all needs/concerns identified during her MSW assessments and it did not. An interview was conducted on 06/30/2025 at 2:30 p.m. with S1ADM. S1ADM confirmed any needs/concerns identified by any discipline during a patient assessment should be clearly documented in the patient’s POC in order to ensure all of their needs were met.”

“Based on observations, interviews and record review, the Hospice agency failed to have a system in place to ensure the patient’s individualized Plan of Care (POC) reflected accurate orders for drugs necessary to manage the terminal illness and related conditions for 1 (#5) of 3 (#5, #6, and #7) home visits conducted. This deficient practice had the potential to affect any of the 102 admissions during the past 12 months, a current census of 28 patients and any future admissions to the agency. Review of Patient #5’s Clinical Record revealed she was admitted to the Hospice agency on 03/19/2025 and in a current Certification Period of 06/17/2025 through 09/14/2025. Review of Patient #5’s POC, as of 06/23/2025, revealed, in part, the following active Physician’s Orders: Tujeo Insulin Glargine Injection - 300 units/milliliter (mL). Give 64 units subcutaneously every night. (Start Date: 03/19/2025); Lantus Solution - 100 units/mL. Give 35 units subcutaneously every night. (Start Date: 03/19/2025); and Novolog Flex Pen - 100 units/mL. Give 8 units subcutaneously three times daily with meals. (Start Date: 03/19/2025). An observation was conducted on 06/24/2025 at 10:40 a.m. during a Home Visit for Patient #5. Upon conclusion of all required care, S2DON was observed asking Patient #5’s daughter if any medication refills were needed. Patient #5’s daughter responded “I only need the Tujeo and the Novolog” then S2DON exited the home. Throughout the course of the Home Visit, S2DON did not visualize any of Patient #5’s medications or review what medications and/or dosages her caregiver currently administered to the patient against her POC. An observation and interview was conducted on 06/24/2025 at 10:45 a.m. with Patient #5’s daughter and primary caregiver during her Home Visit. Upon conclusion of S2DON’s Home Visit, once she left the home, Patient #5’s daughter was observed to pull all of the medications she currently administered to her mother and assisted the surveyors to check each medication off against the current medication orders present in her current POC. Patient #5’s daughter confirmed Lantus was not an active medication her mother received at any time since being admitted to Hospice. She then reviewed the ordered doses for Tujeo and Novolog and confirmed the aforementioned doses were inaccurate.An interview was conducted on 06/24/2025 at 2:00 p.m. with S2DON. S2DON confirmed since Patient #5 was admitted to the agency, she had not performed a review of the medications present on Patient #5’s POC against the actual medications and dosages she currently received in her home and should have. S2DON confirmed Patient #5’s medication orders present in her POC should accurately reflect the medications she was being administered by her caregiver at home.”

“Based on interview and record review, the Hospice agency failed to have a system in place to ensure the Interdisciplinary Group (IDG) reviewed, revised and documented updates to a patient’s individualized Plan of Care (POC) as frequently as required and no less frequently than every 15 calendar days. This deficient practice was evidenced by failure to update the patient’s POC to reflect the progress of all identified problems, needs and/or the current status of interventions for 5 (#6, #9, #10, #13, and #14) of 10 (#5 through #14) live patients in the sample.This deficient practice had the potential to affect any of the 102 patients admitted during the past 12 months, a current census of 28 patients and any future admissions to the agency. Patient #6Review of Patient #6’s Clinical Record revealed she was admitted to the Hospice agency on 05/03/2025 with a current Certification Period of 05/03/2025 through 07/01/2025. Further review revealed she lived at home with her disabled son who served as her sole caregiver. Review of Patient #6’s MSW Visits, dated 05/03/2025 through 06/30/2025, revealed, in part, the following: 05/10/2025 by S5MSWPatient/son receive the patient’s social security check, the son’s disability and the patient has some stocks. Patient/son requested help applying for food stamp benefits and services through a local non-profit organization for meal delivery assistance. Also requested assistance with obtaining a new wheelchair for the patient and a life alert bracelet. Please describe any financial assistance required: Food stamp benefits.Caregiver Communication Skills: Patient’s son requires assistance with completing forms due to disability.05/24/2025 by S5MSWPlease describe any additional financial assistance required: Food Stamp benefits and services through a local non-profit organization for meal delivery assistance. Risks: No risks identified.Notes: Met with Patient to discuss her options through a local non-profit organization for meal delivery assistance and if she would like to sign up for food stamp benefits. Patient’s son asked for assistance in helping his mother prepare a Living Will. 06/13/2025 by S6MSWPatient/son requested help in applying for Food Stamp benefits and services through a local non-profit organization for meal delivery assistance. Also requested assistance with obtaining a new wheelchair for the patient and a life alert bracelet. There was no change to any of this information during my most recent visit.Please describe any additional financial assistance required: Food Stamp benefits and services through a local non-profit organization for meal delivery assistance. Review of Patient #6’s POC, dated 05/03/2025 through 06/30/2025 revealed, in part, no documented evidence of the progress of the aforementioned identified needs/concerns and/or the status of implemented interventions. An interview was conducted on 06/30/2025 at 1:30 p.m. with S2DON. S2DON confirmed any needs/concerns identified by any discipline during a patient assessment should be clearly documented in their POC with updates documented as frequently as necessary and no less than every 15 days to ensure their care was appropriately reflected and their needs were being met. S2DON confirmed Patient #6’s POC should reflect the progress of all identified needs/concerns and the status of all implemented interventions and it did not. Patient #9Review of Patient #9’s Clinical Record revealed she was admitted to the Hospice agency on 05/22/2025 with a current Certification Period of 05/22/2025 through 08/19/2025. Further review revealed Patient #9 lived at home with family. Review of Patient #9’s Initial MSW Assessment, performed by S5MSW on 05/28/20025, revealed, in part, the following:Effect of Illness on Everyday Activities: Patient #9 requested help in acquiring a forehead (temporal) thermometer and an oxygen meter (pulse oximeter). She is open to transportation benefits and assistance with obtaining “priority reconnection” status with her electric company. Review of Patient #9’s POC for the current Certification Period revealed, in part, no documented evidence of the progress of the aforementioned identified needs/concerns and/or the status of implemented interventions.An interview was conducted on 06/30/2025 at 12:00 p.m. with S2DON. S2DON confirmed Patient #9’s POC should reflect the progress of all identified needs/concerns and the status of all implemented interventions and it did not. Patient #10Review of Patient #10’s Clinical Record revealed she was admitted to the Hospice agency on 01/25/2022 with a current Certification Period of 06/10/2025 through 08/08/2025. Further review revealed she had an active Stage 3 Pressure Ulcer to the Left Heel identified on 03/18/2024. Review of Patient #10’s POC for the Certification Periods of 04/11/2025 through 06/09/2025 and 06/10/2025 through 08/08/2025, revealed, in part, no documented evidence of the progress of her pressure ulcer and/or the status of implemented interventions to treat it.An interview was conducted on 06/30/2025 at 12:00 p.m. with S2DON. S2DON confirmed Patient #10’s POC should reflect the progress of all identified needs/concerns and the status of all implemented interventions and it did not. Patient #13Review of Patient #13’s Clinical Record revealed he was admitted to the Hospice agency on 03/05/2025 with a current Certification Period of 05/04/2025 through 07/02/2025. Further review revealed he lived at home with his spouse/primary caregiver. Review of Patient #13’s Initial MSW Assessment, performed by S5MSW on 05/15/20025, revealed, in part, the following:Psychosocial Assessment Notes: Patient endorsed periods of sadness/light depression. His condition worsened suddenly and it has been difficult for the patient and his spouse to adjust. Patient/Spouse asked for help applying for services through a local non-profit organization for meal delivery assistance and possible sitter services. Patient/Spouse requested assistance with acquiring a portable oxygen concentrator and a blood glucose monitor.Visit Comments: Identified multiple social needs to be addressed for Patient/Spouse: Applying for services through a local non-profit organization will help with meals on wheels and possibly providing a sitter/aide to assist with activities of daily living (ADL). In need of a portable oxygen concentrator and blood a glucose monitor. Review of Patient #13’s MSW Visits, dated 05/16/2025 through 06/30/2025, revealed, in part, the following:06/05/2025 by S5MSWPsychosocial Assessment Notes: Patient endorsed periods of sadness/light depression. His condition worsened suddenly and it has been difficult for the patient and his spouse to adjust. Patient/Spouse asked for help applying for services through a local non-profit organization for meal delivery assistance and possible sitter services. Patient/Spouse requested assistance with acquiring a portable oxygen concentrator and a blood glucose monitor.Visit Comments:Patient/Spouse had questions regarding a possible move to palliative care, what the Program of All-Inclusive Care for the Elderly (PACE) was and if Hospice care was the right fit for them at this time. S5MSW notified Patient/Spouse he would look into PACE for them and ensure palliative care contacted them soon. Patient/Spouse also asked about the status of applying for services through a local non-profit organization will help with meals on wheels and possibly providing a sitter/aide to assist with ADLs. S5MSW informed them he had no answers for them at this time. Further review revealed no additional MSW Visits were conducted from 06/05/2025 through 06/30/2025.Review of Patient #13’s POC, dated 05/16/2025 through 06/30/2025, revealed, in part, no documented evidence of the progress of the aforementioned identified needs/concerns and/or the status of implemented interventions.An interview was conducted on 06/30/2025 at 12:00 p.m. with S2DON. S2DON confirmed Patient #13’s POC should reflect the progress of all identified needs/concerns and the status of all implemented interventions and it did not. Patient #14Review of Patient #14’s Clinical Record revealed he was admitted to the Hospice agency on 04/29/2025 with a terminal diagnosis of Congestive Heart Failure and a co-morbidity of COPD. Further review revealed he was in a current Certification Period of 04/29/2025 through 07/27/2025 and lived at home with family. Review of Patient #14’s Initial MSW Assessment, performed by S5MSW on 05/04/2025, revealed, in part, the following:Visit Comments:Patient remains active and social despite his condition. His only concern is the loss of his portable oxygen concentrator, which will put a damper on his ability to attend meetings and Bingo at the local gathering space for veterans. Patient would like assistance to obtain another portable oxygen concentrator, possibly through his benefits with Veterans Affairs (VA). He would like MSW visit once a month.Review of Patient #14’s POC, dated 05/04/2025 through 06/30/2025, revealed, in part, no documented evidence of the progress of the aforementioned identified needs/concerns and/or the status of implemented interventions.An interview was conducted on 06/30/2025 at 12:00 p.m. with S2DON. S2DON confirmed Patient #14’s POC should reflect the progress of all identified needs/concerns and the status of all implemented interventions and it did not. An interview was conducted on 06/30/2025 at 2:30 p.m. with S1ADM. S1ADM confirmed every need/concern identified by any discipline during a patient assessment should be clearly documented in their POC with updates documented as frequently as necessary and no less than every 15 days to ensure their care was appropriately reflected and their needs were being met.”

“Based on interviews and record reviews, the Hospice agency failed to have a system in place to ensure nursing care and services were provided under the supervision of a Registered Nurse (RN) in order to meet all of the patient’s needs. This deficient practice was evidenced by failure to ensure the RN assessed and documented wound measurements and wound descriptions every 7 days for 2 (#1 and #10) of 3 (#1, #5, and #10) patients reviewed for wounds.This deficient practice had the potential to affect any of the 102 patients admitted during the past 12 months, a current census of 28 patients and any future admissions to the agency. Review of the Louisiana State Board of Nursing Declaratory Statement Scope of Practice for a RN - Wound Care Management, adapted 02/1999, revealed, in part, the following: RNs 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. RN 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 RN in the practice setting. The RN 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 RN 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 re-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.Patient #1Review of Patient #1’s Clinical Record revealed she was initially admitted to the Hospice agency on 03/06/2025 and readmitted on 03/26/2025 following revocation of benefits on 03/25/2025 with a terminal diagnosis of Senile Degeneration of the Brain. Further review revealed she had an active Stage 3 Pressure Ulcer to the Sacrum (#1) and a Stage 3 Pressure Ulcer to the Right Hip (#2) which were present upon her initial admission and both unrelated to her terminal diagnosis.Review of Patient #1’s Plan of Care (POC) during Patient #1’s time with the Hospice agency revealed, in part, she was to receive a Skilled Nurse Visit (SNV) frequency of twice weekly.Review of Patient #1’s Physician’s Orders for Wound Care during Patient #1’s time with the Hospice agency revealed, in part, the following order for the treatment of Wounds #1 and #2, both unrelated to terminal prognosis, to be performed daily and as needed. Cleanse with wound cleanser. Pat dry. Apply Medihoney to necrotic tissue and apply Silver Collagen sheet to granulated wound bed. Cover with dry dressing.Review of Patient #1’s Visit Calendar revealed, in part, the following Nurse Visits were conducted during Patient #1’s time with the Hospice agency:03/07/2025 – RN Visit;03/10/2025 – Licensed Practical Nurse (LPN) Visit, 03/14/2025 – LPN Visit, 03/20/2025 – LPN Visit, 03/21/2025 – RN Visit; 03/24/2025 – LPN Visit, 03/25/2025 – LPN Visit, 03/26/2025 – LPN Visit, 03/28/2025 – RN Visit;03/31/2025 – RN Missed Visit, 04/02/2025 – LPN Visit,04/04/2025 – LPN Visit, 04/08/2025 – LPN Visit, 04/09/2025 – RN Visit; 04/11/2025 – LPN Visit, 04/14/2025 – LPN Visit, 04/16/2025 – LPN Visit, and 04/18/2025 – LPN Visit.Review of Patient #1’s RN Assessments revealed, in part, 3 missed opportunities for wound measurements by the RN on the following dates: 03/14/2025 – No wound measurements or description documented by RN; 04/04/2025 – No wound measurements or description documented by RN; and04/16/2025 – No wound measurements or description documented by RN.Review of Email Communication between Patient #1’s Daughter/Responsible Party and the Hospice agency in order to Revoke Patient #1’s Hospice Benefits revealed, in part, the following: Date/Time Email Received by Hospice agency: 04/18/2025 at 1:08 p.m.Email Written/Signed by Patient #1’s Daughter/Responsible Party.This letter serves as formal notification that our family is revoking Hospice services for our mother effective immediately today, 04/18/2025. After careful consideration, we have decided to admit our mother to the hospital for a thorough evaluation of her bedsores. We believe her condition was not sufficiently addressed under Hospice care. The lack of direct physician involvement contributed to insufficient symptom management and a reduced quality of care, given the progression and severity of our mother’s wounds. An interview was conducted on 06/30/2025 at 1:30 p.m. with S2DON. S2DON confirmed wounds should be measured and documented by a RN every 7 days at a minimum. S2DON confirmed wound measurements should be documented in the patient’s RN Assessment and nowhere else within their chart. S2DON reviewed Patient #1’s record and confirmed there was no documented evidence of wound measurements being performed for her every 7 days and should have been. Patient #10Review of Patient #10’s Clinical Record revealed she was admitted to the Hospice agency on 01/25/2022 and in a current Certification Period of 06/10/2025 through 08/08/2025 with a terminal diagnosis of Senile Degeneration of the Brain. Further review revealed she had an active Stage 3 Pressure Ulcer to the Left Heel (#1) identified on 03/18/2024, which was unrelated to her terminal diagnosis.Review of Patient #10’s POC for the Certification Periods of 04/11/2025 through 06/09/2025 and 06/10/2025 through 08/08/2025, revealed, in part, she was to receive a SNV frequency of twice weekly.Review of Patient #10’s Physician’s Orders for Wound Care for the Certification Periods of 04/11/2025 through 06/09/2025 and 06/10/2025 through 08/08/2025, revealed, in part, the following order for the treatment of Wound #1, unrelated to terminal prognosis, to be performed daily and as needed. Cleanse with Wound Cleanser. Pat Dry. Apply moistened Collagen Sheet to wound bed. Cover with bordered dressing. Review of Patient #10’s Visit Calendar for the Certification Periods of 04/11/2025 through 06/09/2025 and 06/10/2025 through 08/08/2025 revealed, in part, the following Nurse Visits were conducted:04/12/2025 – LPN Visit; 04/16/2025 – RN Visit; 04/18/2025 – LPN Visit; 04/24/2025 – LPN Visit; 04/26/2025 – LPN Visit; 04/29/2025 – RN Visit;05/01/2025 – LPN Visit; 05/05/2025 – RN Visit;05/09/2025 – LPN Visit; 05/12/2025 – LPN Visit; 05/15/2025 – LPN Visit; 05/19/2025 – RN Visit;05/24/2025 – LPN Visit; 05/27/2025 – LPN Visit; 05/31/2025 – LPN Visit; 06/02/2025 – RN Visit;06/06/2025 – RN Visit;06/09/2025 – LPN Visit; 06/13/2025 – LPN Visit; 06/16/2025 – RN Visit;06/21/2025 – LPN Visit; 06/23/2025 – LPN Visit; and06/25/2025 – LPN Visit; Review of Patient #10’s RN Assessments for the Certification Periods of 04/11/2025 through 06/09/2025 and 06/10/2025 through 08/08/2025 revealed, in part, 6 missed opportunities for wound measurements by the RN on the following dates: 04/18/2025 – No wound measurements or description documented by RN;04/25/2025 – No wound measurements or description documented by RN;05/12/2025 – No wound measurements or description documented by RN;05/26/2025 – No wound measurements or description documented by RN;06/13/2025 – No wound measurements or description documented by RN; and 06/23/2025 – No wound measurements or description documented by RN.An interview was conducted on 06/30/2025 at 1:30 p.m. with S2DON. S2DON reviewed Patient #10’s record and confirmed there was no documented evidence of wound measurements being performed for her every 7 days and should have been.”

“Based on interview and record review, the Hospice agency failed to have a system in place to ensure Medical Social Work (MSW) Services were provided to meet all needs identified by the MSW during the patient’s and/or family’s Psychosocial Assessment(s) for 3 (#9, #13, and #14) of 10 (#5, #6, #7, #8, #9, #10, #11, #12, #13 and #14) patients reviewed for MSW services. This deficient practice had the potential to affect any of the 102 patients admitted during the past 12 months, a current census of 28 patients and any future admissions to the agency. Review of the National Association of Social Workers (NASW) “Standards for Palliative and End of Life Care”, from the NASW Code of Ethics-2000, revealed, in part, the following: Standard 3. Assessment The MSW shall assess clients and include comprehensive information to develop interventions and treatment planning. Standard 4. Intervention/Treatment Planning MSWs shall incorporate assessments in developing and implementing intervention plans that enhance the clients’ abilities and decisions in palliative and end of life care. Standard 6. Empowerment and Advocacy The MSW shall advocate for the needs, decisions, and rights of clients in palliative and end of life care. The MSW shall engage in social and political action that seeks to ensure that people have equal access to resources to meet their biopsychosocial needs in palliative and end of life care. Standard 7. Documentation MSWs shall document all practice with clients in either the client record.Standard 8. Interdisciplinary Teamwork The MSW should be part of an interdisciplinary effort for the comprehensive delivery of palliative and end of life services. MSWs shall strive to collaborate with team members and advocate for clients’ needs.Patient #9Review of Patient #9’s Clinical Record revealed she was admitted to the Hospice agency on 05/22/2025 with a terminal diagnosis of Malignant Neoplasm of Unspecified Part of Bronchus or Lung and co-morbidities including Secondary Malignant Neoplasm of Unspecified Lung and Chronic Obstructive Pulmonary Disease (COPD) and in a current Certification Period of 05/22/2025 through 08/19/2025. Further review revealed Patient #9 lived at home with family. Review of Patient #9’s MSW Visit Frequency for the current Certification Period revealed, in part, an ordered MSW Visit frequency of one visit monthly. Review of Patient #9’s Initial MSW Assessment, performed by S5MSW on 05/28/20025, revealed, in part, the following:Effect of Illness on Everyday Activities: Patient #9 requested help in acquiring a forehead (temporal) thermometer and an oxygen meter (pulse oximeter). She is open to transportation benefits and assistance with obtaining “priority reconnection” status with her electric company. Review of Patient #9’s Plan of Care (POC) for the current Certification Period revealed, in part, the following:05/28/2025 - POC UpdateProblem: Psychosocial SupportDescription: Limited Support SystemProgress: 0%Intervention: 1. Evaluate current financial resources and needs.Activities performed related to Intervention 1: 05/28/2025 - Patient endorses no financial or community resource needs, only minor Durable Medical Equipment (DME) needs. 2. Assess the need for additional patient/caregiver resources.Activities performed related to Intervention 2: BLANK. DME and Supplies:No documented evidence of a forehead (temporal) thermometer and an oxygen meter (pulse oximeter) being ordered/provided.Further review of all POC updates, dated 05/28/2025 through 06/30/2025, revealed, in part, no documented evidence of any of Patient #9’s needs identified by the MSW on 05/28/2025 being met and/or updated.Review of Patient #9’s MSW Visits, dated 05/29/2025 through 06/30/2025, revealed, in part, no documented evidence of any needs identified by the MSW on 05/28/2025 being discussed, met and/or updated.Review of Patient #9’s Interdisciplinary Group (IDG) Meeting Notes, dated 05/28/2025 through 06/30/2025, revealed, in part, no documented evidence of any needs identified by the MSW on 05/28/2025 being discussed, met and/or updated with the members of the IDG.Review of Patient #9’s Communication Notes, dated 05/28/2025 through 06/30/2025, revealed, in part, no documented evidence of any needs identified by the MSW on 05/28/2025 being discussed, met and/or updated. Review of Patient #9’s Physician’s Orders for DME and Supplies, dated 05/28/2025 through 06/30/2025, revealed, in part, no documented evidence of an order written for a temporal thermometer or pulse oximeter. An interview was conducted on 06/30/2025 at 12:00 p.m. with S2DON. S2DON confirmed any needs/concerns identified by any discipline during a patient assessment should be communicated immediately to the relevant members of the IDG then discussed and documented during the next IDG Meeting an should be reflected in the patient’s POC with all status updates documented to ensure needs were being met. S2DON confirmed there was no documented evidence the aforementioned process was followed by S5MSW for Patient #9 and should have been. Patient #13Review of Patient #13’s Clinical Record revealed he was admitted to the Hospice agency on 03/05/2025 with a terminal diagnosis of COPD and a co-morbidity of Congestive Heart Failure. Further review revealed he was in a current Certification Period of 05/04/2025 through 07/02/2025 and lived at home with family. Review of Patient #13’s MSW Visit Frequency for the current Certification Period revealed, in part, an ordered MSW Visit frequency of two visits monthly, effective 05/15/2025. Review of Patient #13’s Initial MSW Assessment, performed by S5MSW on 05/15/20025, revealed, in part, the following:Psychosocial Assessment Notes: Patient endorsed periods of sadness/light depression. His condition worsened suddenly and it has been difficult for the patient and his spouse to adjust. Patient/Spouse asked for help applying for services through a local non-profit organization for meal delivery assistance and possible sitter services. Patient/Spouse requested assistance with acquiring a portable oxygen concentrator and a blood glucose monitor.Visit Comments: Identified multiple social needs to be addressed for Patient/Spouse: Applying for services through a local non-profit organization will help with meals on wheels and possibly providing a sitter/aide to assist with activities of daily living (ADL). In need of a portable oxygen concentrator and blood a glucose monitor. Review of Patient #13’s MSW Visits, dated 05/16/2025 through 06/30/2025, revealed, in part, the following:06/05/2025 by S5MSWPsychosocial Assessment Notes: Patient endorsed periods of sadness/light depression. His condition worsened suddenly and it has been difficult for the patient and his spouse to adjust. Patient/Spouse asked for help applying for services through a local non-profit organization for meal delivery assistance and possible sitter services. Patient/Spouse requested assistance with acquiring a portable oxygen concentrator and a blood glucose monitor.Visit Comments:Patient/Spouse had questions regarding a possible move to palliative care, what the Program of All-Inclusive Care for the Elderly (PACE) was and if Hospice care was the right fit for them at this time. S5MSW notified Patient/Spouse he would look into PACE for them and ensure palliative care contacted them soon. Patient/Spouse also asked about the status of applying for services through a local non-profit organization will help with meals on wheels and possibly providing a sitter/aide to assist with ADLs. S5MSW informed them he had no answers for them at this time. Further review revealed no additional MSW Visits were conducted from 06/05/2025 through 06/30/2025.Review of Patient #13’s POC, dated 05/16/2025 through 06/30/2025, revealed, in part, the following:05/20/2025 – POC UpdateProblem: Community ResourcesGoal: Assist with Community ResourcesIdentified: 03/05/2025Resolved: BLANK.Progress: 30%Outcome Timeframe: By time of death/dischargeInterventions: 1. Refer to appropriate resources as needed.2. Refer to appropriate resources for financial assistance 3. Assess the need for additional caregiver(s) resourcesActivities performed related to Intervention 1-3: 05/29/2025 – See MSW Visit Note. Problem: Emotional/Psychosocial NeedsGoal: Identify Psychosocial Needs and Appropriate SupportsIdentified: 03/05/2025Resolved: BLANK.Progress: 40%Outcome Timeframe: By time of death/dischargeInterventions: 1. Advocate and work with patient to ensure patient’s needs are communicated 2. Advocate and work with patient to ensure they have proper support 3. Provide therapeutic emotional support 4. Monitor for emotional/psychosocial needs – Regular check-ins by IDG team members to ensure that any new emotional or psychosocial concerns are addressed promptly, despite current stability.5. Assess the need for additional caregiver(s) resources.Activities performed related to Intervention 1-5: 05/09/2025 - MSW contacted patient to assess for psychosocial/community resource needs. Patient agreed to an in person visit from MSW. Further review of all POC updates, dated 05/16/2025 through 06/30/2025, revealed, in part, no documented evidence of any of Patient #13’s needs identified by the MSW on 05/15/2025 being met and/or updated. Review of Patient #13’s MSW Visits, dated 05/16/2025 through 06/30/2025, revealed, in part, no documented evidence of any needs identified by the MSW on 05/15/2025 being discussed, met and/or updated.Review of Patient #13’s IDG Meeting Notes, dated 05/15/2025 through 06/30/2025, revealed, in part, no documented evidence of any needs identified by the MSW on 05/15/2025 being discussed, met and/or updated with the members of the IDG.Review of Patient #13’s Communication Notes, dated 05/15/2025 through 06/30/2025, revealed, in part, no documented evidence of any needs identified by the MSW on 05/15/2025 being discussed, met and/or updated. Review of Patient #13’s Physician’s Orders for DME and Supplies, dated 05/15/2025 through 06/30/2025, revealed, in part, no documented evidence of an order written for a portable oxygen concentrator or blood glucose monitor. An interview was conducted on 06/30/2025 at 12:00 p.m. with S2DON. S2DON confirmed there was no documented evidence the aforementioned process was followed by S5MSW for Patient #13 and should have been. Patient #14Review of Patient #14’s Clinical Record revealed he was admitted to the Hospice agency on 04/29/2025 with a terminal diagnosis of Congestive Heart Failure and a co-morbidity of COPD. Further review revealed he was in a current Certification Period of 04/29/2025 through 07/27/2025 and lived at home with family. Review of Patient #14’s MSW Visit Frequency for the current Certification Period revealed, in part, an ordered MSW Visit frequency of one visit monthly. Review of Patient #14’s Initial MSW Assessment, performed by S5MSW on 05/04/2025, revealed, in part, the following:Visit Comments:Patient remains active and social despite his condition. His only concern is the loss of his portable oxygen concentrator, which will put a damper on his ability to attend meetings and Bingo at the local gathering space for veterans. Patient would like assistance to obtain another portable oxygen concentrator, possibly through his benefits with Veterans Affairs (VA). He would like MSW visit once a month.Review of Patient #14’s MSW Visits, dated 05/05/2025 through 06/30/2025, revealed, in part, no MSW Visits were conducted during the timeframe reviewed. Further review revealed a MSW Visit was scheduled for S5MSW on 06/09/2025 with no documented evidence the visit was conducted and/or no documented evidence of why the visit was missed and if the missed visit was approved. Review of Patient #14’s POC, dated 05/04/2025 through 06/30/2025, revealed, in part, the following:Problem: Emotional/Psychosocial SupportGoal: Regular check-ins to ensure any new concerns are addressed.Identified: 05/04/2025Resolved: BLANK.Progress: 20%Outcome Timeframe: By time of death/dischargeInterventions: 1. Advocate and work with patient to ensure needs are communicated. Activities performed related to Interventions: 05/04/2025 – See MSW Visit Note. Further review of all POC updates, dated 05/04/2025 through 06/30/2025, revealed, in part, no documented evidence of any of Patient #14’s needs identified by the MSW on 05/04/2025 being met and/or updated.Review of Patient #14’s IDG Meeting Notes, dated 05/04/2025 through 06/30/2025, revealed, in part, no documented evidence of any needs identified by the MSW on 05/04/2025 being discussed, met and/or updated with the members of the IDG. Further review revealed no documented evidence of the MSW Visit on 06/09/2025 being conducted, missed, discussed and/or approved by the IDG. Review of Patient #14’s Communication Notes, dated 05/04/2025 through 06/30/2025, revealed, in part, no documented evidence of any needs identified by the MSW on 05/04/2025 being discussed, met and/or updated. Further review revealed no documented evidence of the MSW Visit on 06/09/2025 being conducted, missed, discussed and/or approved. Review of Patient #14’s Physician’s Orders for DME and Supplies, dated 05/04/2025 through 06/30/2025, revealed, in part, no documented evidence of an order written for a portable oxygen concentrator. An interview was conducted on 06/30/2025 at 12:00 p.m. with S2DON. S2DON confirmed there was no documented evidence the aforementioned process was followed by S5MSW for Patient #14 and should have been.”

“Based on observations, interviews and record reviews, the Hospice agency failed to have a system in place to ensure care and services were provided in a matter consistent with accepted professional standards of practice and in compliance with all applicable laws. This deficient practice was evidenced by failure to ensure: 1. Physician ordered medications were provided in a timely manner to prevent missed doses for 1 (#6) of 3 (#5, #6, and #7) home visits conducted; 2. The RN assessed and documented wound measurements and wound descriptions every 7 days for 2 (#1 and #10) of 3 (#1, #5, and #10) patients reviewed for wounds;3. Current and accurate records were maintained for the disposition of all controlled substances provided by the Hospice agency to the patient for 8 of 8 (#5, #6, #8, #9, #10, #11, #12, and #13) patients reviewed safe use and disposition of controlled substances; 4. Compliance with LA RS 40:2191 for the safe disposal of unused controlled substances by a Hospice nurse following a patient’s death for 1 (#3) of 2 (#3 and #4) death records reviewed for controlled substances following death;5. An inpatient unit (IPU) was available for the management of pain control and symptom management for 2 of 2 (#4 and #13) patients reviewed for uncontrolled pain and symptoms; and 6. Medical Social Work (MSW) services were provided according to accepted professional standards of practice for 3 (#9, #13, and #14) of 10 (#5, #6, #7, #8, #9, #10, #11, #12, #13 and #14) patients reviewed for MSW services.This deficient practice had the potential to affect any of the 39 admissions during the past 12 months, a current census of 18 patients and any future admissions to the agency. Cross Reference: L523, L524, L531, L539, L545, L549, L552, L591, L594, L648, L651, L683, L686, L694, and L706. 1. Medications available for administration. Review of Patient #6’s Clinical Record revealed she was admitted to the Hospice agency on 05/03/2025 and lived at home with family. Further review revealed she was ordered to receive a Skilled Nurse Visit (SNV) twice weekly. Review of Patient #6’s Plan of Care (POC) and Physician’s Orders for the current Certification Period, as of 06/23/2025, revealed, in part, the following active orders: Lorazepam - 0.5 milligram (mg) tablet. Give 1 tablet by mouth every 4 hours as needed for anxiety; and Escitalopram Oxalate– 10mg tablet. Give 2 tablets twice daily for depression. Review of Patient #6’s Visit Calendar, dated 06/15/2025 through 06/24/2025, revealed, in part, the following Nurse Visits were conducted for a total of missed 3 opportunities to verify the patient did not run out of medications; 06/18/2025; 06/20/2025; and 06/24/2025.An observation was conducted on 06/24/2025 at 9:45 a.m. during Patient #5’s Home Visit. Medications present in Patient #6’s home were verified against the aforementioned active orders and with the following medications not present in the home: Lorazepam - 0.5mg Tablet; and Escitalopram Oxalate - 10mg tablet. An interview was conducted on 06/24/2025 at 9:55 a.m. with Patient #5 during her Home Visit. She confirmed all of her medications were either located on the table beside her bed or in the refrigerator and would not be located anywhere else in her home. She confirmed she suffered with extreme bouts of depression and anxiety and had for most of her life. She confirmed she ran out of her Lorazepam tablets and her Lexapro on Sunday (06/22/2025) morning so she had not taken her medications since. She confirmed she could not recall a time when the Hospice nurse(s) counted her medications during their visits. She stated the nurse(s) always asked her if she had enough of everything then ordered more if she needed something and she hadn’t realized she needed those refilled before the weekend. She stated she called and made S2DON aware she needed refills on Monday (06/23/2025) morning. Review of Patient #6’s Patient Profile from the Hospice agency’s contracted pharmacy, dated 06/22/2025 through 06/25/2025, revealed, in part, the following medications were shipped out on the following dates: Lorazepam - 0.5mg Tablet: Shipped - 06/24/2025; and Escitalopram Oxalate - 10mg tablet: Shipped - 06/23/2025. An interview was conducted 06/24/2025 at 3:40 p.m. with S2DON. S2DON stated she kept an eye on if Patient #6 required refills so she could make sure she didn’t run out of anything. S2DON confirmed she became aware on Monday (06/23/2025) after Patient #6 ran out of her Lorazepam tablets and her Escitalopram over the weekend so she ordered more from the pharmacy. S2DON confirmed medications were delivered next day in most cases. S2DON confirmed a patient should not run out of medications and she was not sure why Patient #6 had. 2. RN Assessment of Wounds. Review of the Louisiana Board of Nursing Declaratory Statement Scope of Practice for a RN - Wound Care Management, adapted 02/1999, revealed, in part, the following: RNs 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. RN 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 RN in the practice setting. The RN 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 RN 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 re-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.Patient #1Review of Patient #1’s Clinical Record revealed she was initially admitted to the Hospice agency on 03/06/2025 and readmitted on 03/26/2025 following revocation of benefits on 03/25/2025 with a terminal diagnosis of Senile Degeneration of the Brain. Further review revealed she had an active Stage 3 Pressure Ulcer to the Sacrum (#1) and a Stage 3 Pressure Ulcer to the Right Hip (#2) which were present upon her initial admission and both unrelated to her terminal diagnosis.Review of Patient #1’s POC and Physician’s Orders during Patient #1’s time with the Hospice agency revealed, in part, she was to receive a SNV frequency of twice weekly. Further review revealed, in part, active orders for the treatment of Wounds #1 and #2.Review of Patient #1’s RN Assessments revealed, in part, 3 missed opportunities for wound measurements by the RN on the following dates: 03/14/2025 – No wound measurements or description documented by RN; 04/04/2025 – No wound measurements or description documented by RN; and04/16/2025 – No wound measurements or description documented by RN.Review of Email Communication between Patient #1’s Daughter/Responsible Party and the Hospice agency in order to Revoke Patient #1’s Hospice Benefits revealed, in part, the following: Date/Time Email Received by Hospice agency: 04/18/2025 at 1:08 p.m.Email Written/Signed by Patient #1’s Daughter/Responsible Party.This letter serves as formal notification that our family is revoking Hospice services for our mother effective immediately today, 04/18/2025. After careful consideration, we have decided to admit our mother to the hospital for a thorough evaluation of her bedsores. We believe her condition was not sufficiently addressed under Hospice care. The lack of direct physician involvement contributed to insufficient symptom management and a reduced quality of care, given the progression and severity of our mother’s wounds. An interview was conducted on 06/30/2025 at 1:30 p.m. with S2DON. S2DON confirmed wounds should be measured and documented by a RN every 7 days at a minimum. S2DON confirmed wound measurements should be documented in the patient’s RN Assessment and nowhere else within their chart. S2DON reviewed Patient #1’s record and confirmed there was no documented evidence of wound measurements being performed for her every 7 days and should have been. Patient #10Review of Patient #10’s Clinical Record revealed she was admitted to the Hospice agency on 01/25/2022 and in a current Certification Period of 06/10/2025 through 08/08/2025 with a terminal diagnosis of Senile Degeneration of the Brain. Further review revealed she had an active Stage 3 Pressure Ulcer to the Left Heel (#1) identified on 03/18/2024, which was unrelated to her terminal diagnosis.Review of Patient #10’s POC and Physician’s Orders for the Certification Periods of 04/11/2025 through 06/09/2025 and 06/10/2025 through 08/08/2025, revealed, in part, she was to receive a SNV frequency of twice weekly. Further review revealed, in part, an active order for the treatment of Wound #1. Review of Patient #10’s RN Assessments for the Certification Periods of 04/11/2025 through 06/09/2025 and 06/10/2025 through 08/08/2025 revealed, in part, 6 missed opportunities for wound measurements by the RN on the following dates: 04/18/2025 – No wound measurements or description documented by RN;04/25/2025 – No wound measurements or description documented by RN;05/12/2025 – No wound measurements or description documented by RN;05/26/2025 – No wound measurements or description documented by RN;06/13/2025 – No wound measurements or description documented by RN; and 06/23/2025 – No wound measurements or description documented by RN.An interview was conducted on 06/30/2025 at 1:30 p.m. with S2DON. S2DON reviewed Patient #10’s record and confirmed there was no documented evidence of her conducting and/or documenting wound measurements every 7 days and should have been. 3. Disposition of Controlled Substances in a patient’s home. Review of the United States Government Accountability Office’s (GAO) Report titled “Preventing Drug Diversion”, published April 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 policy titled “Home Use and Disposal of Controlled Substances” last reviewed 11/2023, revealed, in part, no documented evidence of a system in place to ensure current and accurate records of the receipt and disposition of all controlled drugs were maintained.An interview was conducted on 06/24/2025 at 3:30 p.m. with S2DON. S2DON confirmed she was the Hospice agency’s Director of Nursing and one of the nurses who saw patients in the field. S2DON confirmed she did not perform and document a count of all controlled substances present in a patient’s home during her nurse visits. S2DON confirmed there was no expectation for the performance and documentation of a patient’s controlled substances during nurse visits. S2DON confirmed not maintaining accurate records for the receipt and disposition of all controlled substances would make it difficult to identify potentially dangerous situations; such as diversion and/or a patient taking more medication than prescribed. Patient #5Review of Patient #5’s Clinical Record revealed she was admitted to the Hospice agency on 03/19/2025 and lived at home with family. Further review revealed she was ordered to receive a SNV twice weekly. Review of Patient #5’s POC and Physician’s Orders for the current Certification Period revealed, in part, the following active orders for 4 controlled substances: 1 - Hydrocodone-Acetaminophen Oral Tablet 5-325mg. Give one tablet by mouth every 6 hours as needed for pain; 2 - Temazepam Oral Capsule 15mg. Give one capsule at bedtime as needed for difficulty sleeping; 3- Morphine Sulfate Concentrate 20mg/mL. Give 0.5mL every 2 hours as needed for pain, shortness of breath (SOB) or fast breathing; and 4 - Lorazepam Oral Concentrate 2mg/mL. Give 0.25mL every 4 hours as needed for SOB, anxiety, restlessness.Review of Patient #5’s Visit Calendar since she was admitted to the Hospice agency revealed, in part, the following Nurse Visits were conducted for a total of 28 opportunities to count/document the 4 aforementioned controlled substances present in the patient’s home:03/19/2025; 03/21/2025; 03/25/2025; 03/27/2025; 04/01/2025; 04/04/2025; 04/08/2025; 04/11/2025; 04/15/2025; 04/19’/2025; 04/22/2025; 04/25/2025; 04/30/2025; 05/01/2025; 05/06/2025; 05/07/2025; 05/14/2025; 05/16/2025; 05/21/2025; 05/23/2025; 05/28/2025; 05/30/2025; 06/04/2025; 06/06/2025; 06/10/2025; 06/13/2025; 06/20/2025; and 06/24/2025.Review of Patient #5’s Nurse Visits since she was admitted to the Hospice agency revealed, in part, no documented evidence of controlled substance counts being performed or documented during any of her 28 nurse visits conducted from 03/19/2025 through 06/24/2025.An observation was conducted on 06/24/2025 at 10:50 a.m. during Patient #5’s Home Visit with S2DON. Just prior to conclusion of the nurse visit, S2DON was observed asking Patient #5’s daughter if they needed any medication refills. Upon conclusion of the Home Visit, S2DON had not visualized any of Patient #5’s medications nor had she performed or documented the counts for Patient #5’s controlled substances at any time during the visit. An interview was conducted on 06/24/2025 at 10:55 a.m. with Patient #5’s daughter and primary caregiver. She confirmed S2DON did not always count or even visualize her mother’s medications during her visits, but she always asked if refills were needed and ensured they never ran out of anything she asked her to refill. Patient #6Review of Patient #6’s Clinical Record revealed she was admitted to the Hospice agency on 05/03/2025 and lived at home with family. Further review revealed she was ordered to receive a SNV twice weekly. Review of Patient #6’s POC and Physician’s Orders for the current Certification Period, as of 06/23/2025, revealed, in part, the following active orders for 7 controlled substances: 1 - Morphine Sulfate Extended Release (ER) - 30mg Tablet. Give 1 tablet by mouth every 12 hours for pain; 2 - Morphine Sulfate Concentrate - 20mg/mL Solution (Sol). Give 0.5mL by mouth every 2 hours as needed for pain, shortness of breath, fast breathing;3 - Oxycodone HCl - 10mg Tablet. Give 1 tablet by mouth every 4 hours as needed for pain;4 - Dilaudid - 4mg Tablet. Give 1 tablet by mouth every 4 hours as needed for pain; 5 - Lorazepam - 0.5mg Tablet. Give 1 tablet by mouth every 4 hours as needed for anxiety; 6 - Lorazepam Concentrate - 2mg/mL Soln. Give 0.25mL every 4 hours as needed for shortness of breath, anxiety, restlessness; and 7 – Temazepam Oral Capsule – 15mg. Give 1 capsule at bedtime as needed for difficulty sleeping.Review of Patient #6’s Visit Calendar, dated 05/03/2025 through 06/24/2025, revealed, in part, the following Nurse Visits were conducted for a total of 15 opportunities to count/document the 7 aforementioned controlled substances present in the patient’s home:05/03/2024; 05/04/2025; 05/07/2025; 05/11/2025; 05/12/2025; 05/16/2025; 05/20//2025; 05/28/2025; 05/30/2025; 06/03/2025; 06/06/2025; 06/10/2025; 06/18/2025; 06/20/2025; and 06/24/2025.Review of Patient #6’s Nurse Visits, dated 05/03/2025 through 06/24/2025, revealed, in part, no documented evidence of controlled substance counts being performed or documented during any of the aforementioned 15 nurse visits conducted.An observation was conducted on 06/24/2025 at 9:45 a.m. during Patient #6’s Home Visit. Medications present in Patient #6’s home were verified against the aforementioned active orders and pharmacy records with the following 6 controlled substances not being present in the home: 1- Morphine Sulfate ER - 15mg Tablet;2 - Temazepam Oral Capsule – 15mg capsule; 3 - Dilaudid - 4mg Tablet; 4 - Morphine Sulfate Concentrate - 20mg/mL Sol;5 - Lorazepam Oral Concentrate - 2mg/mL Sol; and 6 - Lorazepam - 0.5mg Tablet.An interview was conducted on 06/24/2025 at 9:55 a.m. with Patient #6 during her Home Visit. She confirmed she lived at home with her disabled son and did not have many visitors, aside from the Hospice staff and her son. She confirmed all of her medications were either located on the table beside her bed or in the refrigerator and would not be located anywhere else in her home. She confirmed she ran out of her Lorazepam tablets two and a half days ago but could not say what happened to any of the other unaccounted for controlled substances during her home visit. She confirmed she could not recall a time when the Hospice nurse(s) counted her medications during their visits. She stated the nurse(s) always asked her if she had enough of everything then ordered more if she needed something. Review of Patient #6’s Patient Profile from the Hospice agency’s contracted pharmacy, dated 03/01/2025 through 06/23/2025, revealed, in part, the following controlled substance quantities were delivered to the patients home on the following dates: 1- Morphine Sulfate ER - 15mg Tablet: Amount Dispensed: 40 tablets on 05/12/2025, 05/23/2025, 05/30/2025, and 06/12/2025; 2 - Temazepam Oral Capsule – 15mg: Amount Dispensed: 4 capsules on 05/12/2025, 05/23/2025, and 06/15/2025; 3 - Dilaudid - 4mg Tablet; Amount Dispensed: 30 tablets on 03/13/2025; 4 - Morphine Sulfate Concentrate - 20mg/mL Sol. Amount Dispensed: 600mg on 05/03/2025 and 06/06/2025; 5 - Lorazepam Oral Concentrate - 2mg/mL Sol. Amount Dispensed: 10mL on 05/03/2025; and 6 - Lorazepam - 0.5mg Tablet. Amount Dispensed: 30 tablets on 05/12/2025, 05/23/2025, and 05/30/2025.An interview was conducted 06/24/2025 at 3:40 p.m. with S2DON. S2DON confirmed the Hospice agency did not utilize lock boxes for controlled substances provided to a patient if the patient lived in a private home. S2DON confirmed she did have concerns with whether Patient #6 was taking her medications as ordered over the past month or so. S2DON confirmed she had spoken with Patient #6’s son about her concerns but had not conducted or documented counts of any of her medications. S2DON stated she kept an eye on if Patient #6 required refills so she could make sure she didn’t run out of anything. S2DON confirmed she became aware on Monday after Patient #6 ran out of her Lorazepam tablets over the weekend and she immediately ordered more from the pharmacy. S2DON could not account for the controlled substances that could not be located during the Home Visit. Patient #8Review of Patient #8’s Clinical Record revealed she was admitted to the Hospice agency on 05/04/2025 and lived at home with family. Further review revealed she was ordered to receive a SNV twice weekly. Review of Patient #8’s POC and Physician’s Orders for the current Certification Period revealed, in part, the following active orders for 4 controlled substances: 1 - Clonazepam 0.5mg. Give 1 tablet twice daily for anxiety; 2 - Temazepam Oral Capsule 15mg. Give one capsule at bedtime as needed for difficulty sleeping. Qty Dispensed: 4 capsules; 3- Morphine Sulfate Concentrate 20mg/mL. Give 0.5mL every 2 hours as needed for pain, shortness of breath (SOB) or fast breathing. Qty Dispensed: 15mL; and 4 - Lorazepam Oral Concentrate 2mg/mL. Give 0.25mL every 4 hours as needed for SOB, anxiety, restlessness. Qty Dispensed: 10mL.Review of Patient #8’s Visit Calendar since she was admitted to the Hospice agency revealed, in part, the following Nurse Visits were conducted for a total of 17 opportunities to count/document the 4 aforementioned controlled substances present in the patient’s home:05/04/2025; 05/06/2025; 05/09/2025; 05/13/2025; 05/15/2025; 05/20/2025; 05/24/2025; 05/29/2025; 05/31/2025; 06/03/2025; 06/05/2025; 06/10/2025; 06/12/2025; 06/17/2025; 06/19/2025; 06/24/2025; and 06/27/2025. Review of Patient #8’s Nurse Visits since she was admitted to the Hospice agency revealed, in part, no documented evidence of controlled substance counts being performed or documented during any of her 17 nurse visits conducted from 05/04/2025 through 06/27/2025.Patient #9Review of Patient #9’s Clinical Record revealed she was admitted to the Hospice agency on 05/22/2025 and lived at home with family. Further review revealed she was ordered to receive a SNV once weekly. Review of Patient #9’s POC and Physician’s Orders for the current Certification Period revealed, in part, the following active orders for 4 controlled substances: 1 – Hydrocodone-Acetaminophen 5/325mg tablet. Give 1 tablet every 6 hours as needed for pain; 2 - Temazepam Oral Capsule 15mg. Give one capsule at bedtime as needed for difficulty sleeping; 3- Morphine Sulfate Concentrate 20mg/mL. Give 0.5mL every 2 hours as needed for pain, shortness of breath (SOB) or fast breathing; and 4 - Lorazepam Oral Concentrate 2mg/mL. Give 0.25mL every 4 hours as needed for SOB, anxiety, restlessness.Review of Patient #9’s Visit Calendar since she was admitted to the Hospice agency revealed, in part, the following Nurse Visits were conducted for a total of 6 opportunities to count/document the 4 aforementioned controlled substances present in the patient’s home:05/22/2025; 05/27/2025; 06/03/2025; 06/10/2025; 06/17/2025; and 06/27/2025. Review of Patient #9’s Nurse Visit Notes for the aforementioned visits revealed, in part, no documented evidence of the documented count of all controlled substances present in the home for a total of 6 missed opportunities for monitoring of controlled substances provided to the patient by the Hospice agency. Patient #10Review of Patient #10’s POC and Physician’s Orders for the current Certification Period revealed, in part, the following active orders for 5 controlled substances: 51 – Oxycodone – 10mg tablet. Give 1 tablet every 8 hours as needed for pain; 2 - Temazepam Oral Capsule 15mg. Give one capsule at bedtime as needed for difficulty sleeping; 3- Morphine Sulfate Concentrate 20mg/mL. Give 0.5mL every 2 hours as needed for pain, shortness of breath (SOB) or fast breathing; 4 - Lorazepam Oral Concentrate 2mg/mL. Give 0.25mL every 4 hours as needed for SOB, anxiety, restlessness; and 5 - Lorazepam 1mg / Diphenhydramine 12.5mg / Haloperidol 2 topical gel 1mg/12.5mg/2mg per 1mL. Apply contents of syringe (1mL) to inner wrist every 6 hours as needed for anxiety and/or restlessness.Review of Patient #10’s Visit Calendar for the Certification Periods of 04/11/2025 through 06/09/2025 and 06/10/2025 through 08/08/2025, revealed, in part, the following Nurse Visits were conducted for a total of 23 opportunities to count/document the 5 aforementioned controlled substances present in the patient’s home:04/12/2025; 04/16/2025; 04/18/2025; 04/24/2025; 04/26/2025; 04/29/2025; 05/01/2025; 05/05/2025; 05/09/2025; 05/12/2025; 05/15/2025; 05/19/2025; 05/24/2025; 05/27/2025; 05/31/2025; 06/02/2025; 06/06/2025; 06/09/2025; 06/13/2025; 06/16/2025; 06/21/2025; 06/23/2025; and 06/25/2025. Review of Patient #10’s Nurse Visit Notes for the aforementioned visits revealed, in part, no documented evidence of the documented count of all controlled substances present in the home for a total of 23 missed opportunities for monitoring of controlled substances provided to the patient by the Hospice agency. Patient #11Review of Patient #11’s Clinical Record revealed he was admitted to the Hospice agency on 08/05/2024 and lived at home with family. Further review revealed he was ordered to receive a SNV twice weekly. Review of Patient #11’s POC and Physician’s Orders for the Certification Period of 08/05/2024 through 09/30/2024 revealed, in part, the following active order for 1 controlled substance: 1 – Lorazepam– 0.5mg tablet. Give 1 tablet twice daily as needed for restlessness and/or agitation.Review of Patient #11’s Visit Calendar for the Certification Period of 08/05/2024 through 09/30/2024, revealed, in part, the following Nurse Visits were conducted for a total of 15 opportunities to count/document the 1 aforementioned controlled substance present in the patient’s home:08/05/2024; 08/06/2024; 08/12/2024; 08/142024; 08/21/2024; 08/29/2024; 09/03/2024; 09/04/2024; 09/09/2024; 09/10/2024; 09/18/2024; 09/20/2024; 09/23/2024; 09/25/2024; and 09/30/2024. Review of Patient #11’s Nurse Visit Notes for the aforementioned visits revealed, in part, no documented evidence of the documented count of all controlled substances present in the home for a total of 14 missed opportunities for monitoring of controlled substances provided to the patient by the Hospice agency. Patient #12Review of Patient #12’s Clinical Record revealed she was admitted to the Hospice agency on 06/28/2024 and lived at home with family. Further review revealed she was ordered to receive a SNV twice weekly. Review of Patient #12’s POC and Physician’s Orders for the Certification Period of 11/18/2024 through 11/30/2024 revealed, in part, the following active orders for 3 controlled substances: 1 – Morphine Sulfate Concentrate 20mg/mL. Give 0.5mL every 2 hours as needed for pain, shortness of breath (SOB) or fast breathing; 2 - Lorazepam Oral Concentrate 2mg/mL. Give 0.25mL every 4 hours as needed for SOB, anxiety, restlessness; and 3 - Temazepam Oral Capsule 15mg. Give one capsule at bedtime as needed for difficulty sleeping.Review of Patient #12’s Visit Calendar for the Certification Period of 11/18/2024 through 11/30/2024, revealed, in part, the following Nurse Visits were conducted for a total of 8 opportunities to count/document the 3 aforementioned controlled substances present in the patient’s home:11/18/2024; 11/19/2024; 11/20/2024; 11/21/2024; 11/22/024; 11/25/2024; 11/27/2024; and 11/29/2024.Review of Patient #12’s Nurse Visit Notes for the aforementioned visits revealed, in part, no documented evidence of the documented count of all controlled substances present in the home for a total of 8 missed opportunities for monitoring of controlled substances provided to the patient by the Hospice agency. Patient #13Review of Patient #13’s Clinical Record revealed he was admitted to the Hospice agency on 11/22/2024 and lived at home with family. Further review revealed he was ordered to receive a SNV twice weekly. Review of Patient #13’s POC and Physician’s Orders for the Certification Period of 05/04/2025 through 07/02/2025 revealed, in part, the following active orders for 3 controlled substances: 1 – Hydrocodone-Acetaminophen 5/325mg tablet. Give 1 tablet every 8 hours as needed for pain; 2 – Morphine Sulfate Concentrate 20mg/mL. Give 0.5mL every 2 hours as needed for pain, shortness of breath (SOB) or fast breathing; and 3 - Lorazepam Oral Concentrate 2mg/mL. Give 0.25mL every 4 hours as needed for SOB, anxiety, restlessness. Review of Patient #13’s Visit Calendar for the Certification Period of 05/04/2025 through 07/02/2025, revealed, in part, the following Nurse Visits were conducted for a total of 16 opportunities to count/document the 3 aforementioned controlled substances present in the patient’s home:05/06/2025; 05/08/2025; 05/13/2025; 05/15/2025; 05/18/2025; 05/24/2025; 05/27/2025; 05/29/2025; 06/03/2025; 06/05/2025; 06/10/2025; 06/12/2025; 06/17/2025; 06/19/2025; 06/24/2025; and 06/28/2025.Review of Patient #13’s Nurse Visit Notes for the aforementioned visits revealed, in part, no documented evidence of the documented count of all controlled substances present in the home for a total of 16 missed opportunities for monitoring of controlled substances provided to the patient by the Hospice agency. An interview was conducted on 06/30/2025 at 2:00 p.m. with S2DON. S2DON confirmed the Hospice agency did not have a system in place to utilize lock boxes to secure controlled substances provided to the patient by the Hospice agency when the patient lived in a private home. S2DON confirmed the Hospice agency’s nurses were not currently expected to and did not perform and/or document counts of controlled substances provided to the patient by the Hospice agency during the aforementioned 123 nurse visits conducted for Patient #5, #6, #8, #9, #10, #11, #12, and #13. S2DON stated the agency should have been monitoring the use of the controlled substances provided to their patients by the agency in order to monitor for possible diversion, noncompliance with the ordered medication regimen, and effectiveness of a patient’s current pain regimen. 4. Compliance with Louisiana Revised Statute (LA RS) 40:2191.Review of the memo issued by the state’s licensing authority, dated 06/25/2018, revealed the following, in part: In accordance with Act 23 of the 2018 Regular Legislative Session, regarding the 2018 Regular Legislative Session, the state’s licensing authority is issuing this notice to all licensed hospice providers. Effective 08/01/2018, Act 23 amends and reenacts LA RS 40:2191 relative to disposal of controlled substances by hospice providers; to provide for ownership; to provide for written procedures; to provide for patient records; to provide for disposal; to provide for patient notification; and to provide for related matters. Review of Louisiana Revised Statute (LA RS) 40:2191 revealed the following, in part: Disposal of deceased patient’s unused controlled substances:A. Upon death of a patient receiving hospice services, ownership of the patient’s unused Schedule II, III, IV, or V controlled substances under 21 CFR 1308 may transfer to the hospice for immediate disposal pursuant to the following provisions:(1) Each hospice shall establish a written procedure to ensure safe disposal of unused controlled substances by a hospice nurse at the time of a patient’s death.(2) Upon the death of a patient receiving hospice services, in the presence of a witness, the hospice nurse shall record in the medical record the name and quantity of each unused controlled substance.(3)(a) The hospice nurse shall conduct immediate disposal of the controlled substance at the site of care … (b) … the hospice nurse shall perform the disposal in the presence of a witness, who shall sign a document indicating their witnessing the disposal. (5) The hospice nurse shall record the method of disposal in the medical record.Review of the agency’s policy titled “Home Use and Disposal of Controlled Substances” last reviewed 11/2023, revealed it did not meet the aforementioned requirements established in LA RS 40:2191. An interview was conducted on 06/30/2025 at 1:30 p.m. with S2DON. S2DON confirmed the agency’s policy did not reflect the requirements of LA RS 40:2191 and should. An interview was conducted on 06/30/2025 at 3:30 p.m. with S1ADM. S1ADM confirmed the agency’s policy did not reflect the requirements of LA RS 40:2191 and should. Review of Patient #3’s Clinical Reco rd revealed she was admitted to the Hospice agency on 11/07/2024 and expired at home with family present on 11/11/2024. Review of Patient #3’s Physician’s Orders for Controlled Substances for her most recent Certification Period revealed, in part, the following active orders at the time of her death: 1 - Lorazepam Oral Concentrate 2mg/mL – Give 0.25mL by mouth every 4 hours as needed for anxiety or restlessness;2 - Morphine Sulfate Oral Concentrate 20mg/5mL – Give 0.5mL every 2 hours as needed for SOB, pain, fast breathing; 3 - Alprazolam Oral Tablet 0.5mg – Give 0.5mg twice daily for anxiety;4 - Hydrocodone 10mg/Acetaminophen 325mg – Give 1 tablet every 4 hours as needed for pain. Qty Dispensed: 20 tablets; and 5 - Tramadol HCl 50mg Tablet – Give 1 tablet every 6 hours as needed for pain.Review of Patient #3’s Death Visit Note, performed on 11/11/2024 by S2DON, revealed, in part, the following: The following controlled substances were counted then disposed of via med disposal bag:1 - Morphine 20 milligrams (mg)/milliliters (mL) – 6 mL; and 2 - Lorazepam 2mg/mL - 10.5mL. Witness: The typed name of the witness present with no documented signature of the witness. Further review revealed no documented evidence of the final count and/or destruction of Alprazolam Oral Tablets 0.5mg; Hydrocodone 10mg/Acetaminophen 325mg; and/or Tramadol HCl 50mg Tablets. An interview was conducted on 06/26/2025 at 12:30 p.m. with S2DON. S2DON provided a list with all of Patient #3’s active medications which would have been present in the home at the time of her death and confirmed the list was accurate. S2DON confirmed the list of counted/destroyed medications did not match the list of active medications that should have been accounted for at the time of her death and should have. S2DON confirmed Patient #3’s Death Visit did not include a documented signature of the witness present for the final count and destruction of narcotics and should have. 5. IPU for the management of pain and symptoms. Review of the Louisiana Medicaid Hospice Revocation and Discharge Guidelines, Chapter 24 Section 24.7, issued 02/07/2022, revealed, in part, the following:Revocations:A beneficiary or his/her legal representative may revoke the election of Hospice care at any time during an election period. This is a right that belongs solely and exclusively to the beneficiary or legal representative.At no time is the Hospice provider to demand a revocation. In the event it is discovered during the verification process that a Hospice provider encouraged revocation for the purpose of potentially avoiding Hospice related charges, and the beneficiary or legal representative is in agreement, the revocation will not be honored.Discharge/Revocation Due to Hospital Admit:It is against Medicaid Hospice policy to encourage beneficiaries to revoke Hospice services when they have an inpatient admission, emergency room visit, ambulance transport or other outpatient services and re-elect Hospice after services are delivered. These cases will be verified and closely monitored by the Hospice Prior Authorization Unit for Hospice Care (PAU) for referral to Program Integrity.Review of the Hospice agency’s Contract for Inpatient Services was attempted throughout the course of the survey with no documented evidence available for review. Patient #4Review of Patient #4’s Clinical Record revealed she was admitted to the Hospice agency on 04/11/2024 with a current Certification Period of 04/11/2024 through 05/20/2024 and a terminal diagnosis of Malignant Neoplasm of the Pancreas and a co-morbidity of Secondary Malignant Neoplasm of Unspecified Lung. Review of Patient #4’s Communication Note, dated 05/19/2024, revealed, in part, On-call nurse received a call from patient’s son at 2:38 p.m. stating his mother was experiencing increased abdominal swelling which was causing increased pain. Patient’s son reported her current medications were not relieving the pain. Review of Patient #3’s Nurse Assessment, written by S7LPN on 05/20/2025, revealed, in part, the following: Pain Intervention: Patient going to the Emergency Department (ED) due to uncontrolled pain with any movement. Notes: Patient’s son expressed patient had been up all night complaining of having a feeling of smothering and increased generalized pain. Edematous +4 to both bilateral upper and lower extremities. Abdomen large and distended with ascites. Observed to be very short of breath even with oxygen in use. Patient started to cry “please help me I have been suffering all night.” Review of Patient #4’s Revocation of Hospice Benefits revealed, in part, the form was signed on 05/20/2024 when in effort to better manage the patient’s persistent, uncontrolled pain and shortness of breath her family opted for ED Evaluation due to the Hospice agency not having an IPU available. Review of Patient #4’s Nurse Revocation Statement, written by S7LPN on 05/20/2024, revealed, in part, patient complained of increased shortness of breath and stated “please help me I feel terrible”. Noted +4 edema to bilateral lower extremities. Increased ascites present to the abdomen with increased pain of 10/10. Patient’s son stated he wanted her to go to the ED for pain management because he could not watch her suffer. Review of Patient #4’s Clinical Record for her Second Admission revealed she was re-admitted to the Hospice agency on 05/22/2024 once her pain and symptoms were controlled. An interview was conducted on 06/26/2024 at 3:45 p.m. with S2DON. S2DON confirmed the Hospice agency did not have an IPU contract in place to send patients with uncontrolled pain and symptoms. S2DON confirmed she was not aware they were required to have an IPU available for their patients. S2DON confirmed if the agency had an IPU available, Patient #4 would not have required treatment in the ED. S2DON reviewed Patient #4’s record and confirmed once her pain and symptoms were controlled, she was discharged from the hospital and re-admitted to Hospice services. S2DON stated “now that she thinks about it, Patient #4 would have been a ‘picture perfect’ candidate for an IPU”. Patient #13Review of Patient #13’s Communication Note, dated 03/01/2025, revealed, in part, S2DON received a call at 4:30 p.m. from Patient #13’s spouse indicating he was experiencing uncontrolled pain, swelling and redness to bilateral lower extremities.Review of Patient #13’s Revocation of Hospice Benefits revealed, in part, the form was signed on 03/01/2025 when in effort to better manage the patient’s uncontrolled pain and symptoms his family opted for ED Evaluation due to the Hospice agency not having an IPU available. Review of Patient #13’s Nurse Revocation Statement, written by S2DON on 03/01/2025, revealed, in part, patient’s family took him to the ED due to swelling in bilateral lower extremities. Review of Patient #13’s Clinical Record for his Second Admission revealed he was re-admitted to the Hospice agency on 03/05/2025 once his pain and symptoms were controlled. An interview was conducted on 06/30/2025 at 11:00 a.m. with S2DON. S2DON confirmed once Patient #13 was evaluated in the ED and they were able to get his pain and symptoms controlled, he was discharged from the hospital and re-admitted to Hospice services. An interview was conducted on 06/25/2025 at 10:25 a.m. with S3LPN. S3LPN confirmed she was the Office Manager and responsible for managing and serving as the “go between” for the Governing Body. S3LPN confirmed the Hospice agency did not have a current contract for IPU services and had not had one since pre-Covid. S3LPN confirmed when they used contracted IPUs in the past, other Hospice agency’s “poached their patients” so they got rid of the contracts. S3LPN confirmed the Hospice agency managed all pain and symptoms at home and did not feel an IPU would be beneficial to their patients. S3LPN confirmed if a patient/family were not satisfied with the home treatment of uncontrolled pain and symptoms, the patient/family would need to sign a Revocation of Hospice Benefits and take them to the ED. S3LPN confirmed she was not aware they were required to have an IPU available for their patients. 6. Provision of MSW services. Review of the National Association of Social Workers (NASW) “Standards for Palliative and End of Life Care”, from the NASW Code of Ethics-2000, revealed, in part, the following: Standard 3. Assessment The MSW shall assess clients and include comprehensive information to develop interventions and treatment planning. Standard 4. Intervention/Treatment Planning MSWs shall incorporate assessments in developing and implementing intervention plans that enhance the clients’ abilities and decisions in palliative and end of life care. Standard 6. Empowerment and Advocacy The MSW shall advocate for the needs, decisions, and rights of clients in palliative and end of life care. The MSW shall engage in social and political action that seeks to ensure that people have equal access to resources to meet their biopsychosocial needs in palliative and end of life care. Standard 7. Documentation MSWs shall document all practice with clients in either the client record.Standard 8. Interdisciplinary Teamwork The MSW should be part of an interdisciplinary effort for the comprehensive delivery of palliative and end of life services. MSWs shall strive to collaborate with team members and advocate for clients’ needs.Patient #9Review of Patient #9’s MSW Visit Frequency for the current Certification Period revealed, in part, an ordered MSW Visit frequency of one visit monthly. Review of Patient #9’s Initial MSW Assessment, performed by S5MSW on 05/28/20025, revealed, in part, the following:Effect of Illness on Everyday Activities: Patient #9 requested help in acquiring a forehead (temporal) thermometer and an oxygen meter (pulse oximeter). She is open to transportation benefits and assistance with obtaining “priority reconnection” status with her electric company. Review of Patient #9’s Plan of Care (POC) for the current Certification Period revealed, in part, the following:05/28/2025 - POC UpdateProblem: Psychosocial SupportDescription: Limited Support SystemProgress: 0%Intervention: 1. Evaluate current financial resources and needs.Activities performed related to Intervention 1: 05/28/2025 - Patient endorses no financial or community resource needs, only minor Durable Medical Equipment (DME) needs. 2. Assess the need for additional patient/caregiver resources.Activities performed related to Intervention 2: BLANK. DME and Supplies:No documented evidence of a forehead (temporal) thermometer and an oxygen meter (pulse oximeter) being ordered/provided.Further review of all POC updates, dated 05/28/2025 through 06/30/2025, revealed, in part, no documented evidence of any of Patient #9’s needs identified by the MSW on 05/28/2025 being met and/or updated.Review of Patient #9’s MSW Visits, IDG Meeting Notes and Communication Notes, dated 05/28/2025 through 06/30/2025, revealed, in part, no documented evidence of any needs identified by the MSW on 05/28/2025 being discussed, met and/or updated with the members of the IDG..Review of Patient #9’s Physician’s Orders for DME and Supplies, dated 05/28/2025 through 06/30/2025, revealed, in part, no documented evidence of an order written for a temporal thermometer or pulse oximeter. An interview was conducted on 06/30/2025 at 12:00 p.m. with S2DON. S2DON confirmed any needs/concerns identified by any discipline during a patient assessment should be communicated immediately to the relevant members of the IDG then discussed and documented during the next IDG Meeting an should be reflected in the patient’s POC with all status updates documented to ensure needs were being met. S2DON confirmed there was no documented evidence the aforementioned process was followed by S5MSW for Patient #9 and should have been. Patient #13Review of Patient #13’s MSW Visit Frequency for the current Certification Period revealed, in part, an ordered MSW Visit frequency of two visits monthly, effective 05/15/2025. Review of Patient #13’s Initial MSW Assessment, performed by S5MSW on 05/15/20025, revealed, in part, the following:Psychosocial Assessment Notes: Patient endorsed periods of sadness/light depression. His condition worsened suddenly and it has been difficult for the patient and his spouse to adjust. Patient/Spouse asked for help applying for services through a local non-profit organization for meal delivery assistance and possible sitter services. Patient/Spouse requested assistance with acquiring a portable oxygen concentrator and a blood glucose monitor.Visit Comments: Identified multiple social needs to be addressed for Patient/Spouse: Applying for services through a local non-profit organization will help with meals on wheels and possibly providing a sitter/aide to assist with activities of daily living (ADL). In need of a portable oxygen concentrator and blood a glucose monitor. Review of Patient #13’s MSW Visits, dated 05/16/2025 through 06/30/2025, revealed, in part, the following:06/05/2025 by S5MSWPsychosocial Assessment Notes: Patient endorsed periods of sadness/light depression. His condition worsened suddenly and it has been difficult for the patient and his spouse to adjust. Patient/Spouse asked for help applying for services through a local non-profit organization for meal delivery assistance and possible sitter services. Patient/Spouse requested assistance with acquiring a portable oxygen concentrator and a blood glucose monitor.Visit Comments:Patient/Spouse had questions regarding a possible move to palliative care, what the Program of All-Inclusive Care for the Elderly (PACE) was and if Hospice care was the right fit for them at this time. S5MSW notified Patient/Spouse he would look into PACE for them and ensure palliative care contacted them soon. Patient/Spouse also asked about the status of applying for services through a local non-profit organization will help with meals on wheels and possibly providing a sitter/aide to assist with ADLs. S5MSW informed them he had no answers for them at this time. Further review revealed no additional MSW Visits were conducted from 06/05/2025 through 06/30/2025.Review of Patient #13’s POC, dated 05/16/2025 through 06/30/2025, revealed, in part, the following:05/20/2025 – POC UpdateProblem: Community ResourcesGoal: Assist with Community ResourcesIdentified: 03/05/2025Resolved: BLANK.Progress: 30%Outcome Timeframe: By time of death/dischargeInterventions: 1. Refer to appropriate resources as needed.2. Refer to appropriate resources for financial assistance 3. Assess the need for additional caregiver(s) resourcesActivities performed related to Intervention 1-3: 05/29/2025 – See MSW Visit Note. Problem: Emotional/Psychosocial NeedsGoal: Identify Psychosocial Needs and Appropriate SupportsIdentified: 03/05/2025Resolved: BLANK.Progress: 40%Outcome Timeframe: By time of death/dischargeInterventions: 1. Advocate and work with patient to ensure patient’s needs are communicated 2. Advocate and work with patient to ensure they have proper support 3. Provide therapeutic emotional support 4. Monitor for emotional/psychosocial needs – Regular check-ins by IDG team members to ensure that any new emotional or psychosocial concerns are addressed promptly, despite current stability.5. Assess the need for additional caregiver(s) resources.Activities performed related to Intervention 1-5: 05/09/2025 - MSW contacted patient to assess for psychosocial/community resource needs. Patient agreed to an in person visit from MSW. Further review of all POC updates, dated 05/16/2025 through 06/30/2025, revealed, in part, no documented evidence of any of Patient #13’s needs identified by the MSW on 05/15/2025 being met and/or updated. Review of Patient #13’s MSW Visits, IDG Meeting Notes and Communication Notes, dated 05/15/2025 through 06/30/2025, revealed, in part, no documented evidence of any needs identified by the MSW on 05/15/2025 being discussed, met and/or updated with the members of the IDG.Review of Patient #13’s Physician’s Orders for DME and Supplies, dated 05/15/2025 through 06/30/2025, revealed, in part, no documented evidence of an order written for a portable oxygen concentrator or blood glucose monitor. An interview was conducted on 06/30/2025 at 12:00 p.m. with S2DON. S2DON confirmed there was no documented evidence the aforementioned process was followed by S5MSW for Patient #13 and should have been. Patient #14Review of Patient #14’s Clinical Record revealed he was admitted to the Hospice agency on 04/29/2025 with a terminal diagnosis of Congestive Heart Failure and a co-morbidity of COPD. Further review revealed he was in a current Certification Period of 04/29/2025 through 07/27/2025 and lived at home with family. Review of Patient #14’s MSW Visit Frequency for the current Certification Period revealed, in part, an ordered MSW Visit frequency of one visit monthly. Review of Patient #14’s Initial MSW Assessment, performed by S5MSW on 05/04/2025, revealed, in part, the following:Visit Comments:Patient remains active and social despite his condition. His only concern is the loss of his portable oxygen concentrator, which will put a damper on his ability to attend meetings and Bingo at the local gathering space for veterans. Patient would like assistance to obtain another portable oxygen concentrator, possibly through his benefits with Veterans Affairs (VA). He would like MSW visit once a month.Review of Patient #14’s MSW Visits, dated 05/05/2025 through 06/30/2025, revealed, in part, no MSW Visits were conducted during the timeframe reviewed. Further review revealed a MSW Visit was scheduled for S5MSW on 06/09/2025 with no documented evidence the visit was conducted and/or no documented evidence of why the visit was missed and if the missed visit was approved. Review of Patient #14’s POC, dated 05/04/2025 through 06/30/2025, revealed, in part, the following:Problem: Emotional/Psychosocial SupportGoal: Regular check-ins to ensure any new concerns are addressed.Identified: 05/04/2025Resolved: BLANK.Progress: 20%Outcome Timeframe: By time of death/dischargeInterventions: 1. Advocate and work with patient to ensure needs are communicated. Activities performed related to Interventions: 05/04/2025 – See MSW Visit Note. Further review of all POC updates, dated 05/04/2025 through 06/30/2025, revealed, in part, no documented evidence of any of Patient #14’s needs identified by the MSW on 05/04/2025 being met and/or updated.Review of Patient #14’s IDG Meeting Notes and Communication Notes, dated 05/04/2025 through 06/30/2025, revealed, in part, no documented evidence of any needs identified by the MSW on 05/04/2025 being discussed, met and/or updated with the members of the IDG. Further review revealed no documented evidence of the MSW Visit on 06/09/2025 being conducted, missed, discussed and/or approved by the IDG. Review of Patient #14’s Physician’s Orders for DME and Supplies, dated 05/04/2025 through 06/30/2025, revealed, in part, no documented evidence of an order written for a portable oxygen concentrator. An interview was conducted on 06/30/2025 at 12:00 p.m. with S2DON. S2DON confirmed there was no documented evidence the aforementioned process was followed by S5MSW for Patient #14 and should have been. An interview was conducted on 06/26/2025 at 2:50 p.m. with S1ADM. S1ADM confirmed she would expect staff to follow the Hospice agency’s policies and procedures at all times. S1ADM confirmed she also expected staff to follow all accepted professional standards of practice for their discipline, as well as all regulations and laws at all times.”

“Based on record review and interview, the Hospice agency failed to have a system in place to ensure a patient’s Discharge Summary was provided to the patient’s Attending Physician and/or receiving facility following their Transfer or Revocation of Hospice Benefits. This deficient practice was evidenced by failure to complete a Discharge Summary, which included, a summary of the patient’s stay including treatments, symptoms and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that would assist in post-discharge continuity of care or that is specifically requested: 1. Upon the patients Revocation of Hospice Benefits for 6 of 6 (#1, #2, #3, #4, #6 and #13) patients reviewed for Revocation; and 2. Upon the patients Transfer to another Hospice agency for 1 of 1 (#11) patient reviewed for Transfer. This deficient practice had the potential to affect any of the 102 admissions during the past 12 months, a current census of 28 patients and any future admissions to the agency. 1. Upon Revocation of Hospice Benefits. Patient #1Review of Patient #1’s Clinical Record for her Initial Admission revealed she was admitted to the Hospice agency on 03/06/2025 for a Certification Period of 03/06/2025 through 03/25/2025. Review of Patient #1’s Revocation of Hospice Benefits revealed, in part, the form was signed by her daughter on 03/25/2025 when her family opted for Emergency Room Evaluation following a fall at which resulted in uncontrolled pain due to a fractured humerus. Review of Patient #1’s Discharge Summary for the Revocation of Hospice Benefits signed on 03/25/2025 was attempted throughout the course of the survey with no documented evidence available for review. Review of Patient #1’s Clinical Record for her Second Admission revealed she was admitted to the Hospice agency on 03/26/2025 for a Certification Period of 03/26/2025 through 04/18/2025. Review of Patient #1’s Revocation of Hospice Benefits, revealed, in part, the form was signed by her daughter on 04/18/2025 when her family opted to seek another opinion due to concerns with the quality of wound care being provided by the Hospice agency.Review of Patient #1’s Discharge Summary for the Revocation of Hospice Benefits signed on 04/18/2025 was attempted throughout the course of the survey with no documented evidence available for review. Patient #2Review of Patient #2’s Clinical Record revealed he was admitted to the Hospice agency on 11/13/2024 with a Certification Period of 11/13/2024 through 02/10/2025. Review of Patient #2’s Revocation of Hospice Benefits revealed, in part, the form was signed on 11/24/2024 when the patient’s PEG tube became displaced resulting in an Emergency Room visit to have it replaced. Review of Patient #2’s Discharge Summary for the Revocation of Hospice Benefits signed on 11/24/2024 was attempted throughout the course of the survey with no documented evidence available for review. Patient #3Review of Patient #3’s Clinical Record revealed she was admitted to the Hospice agency on 04/27/2021 with a current Certification Period of 10/01/2024 through 11/05/2024.Review of Patient #3’s Revocation of Hospice Benefits revealed, in part, the form was signed on 11/05/2024 when her family opted for Emergency Room Evaluation after the patient began experiencing uncontrolled vomiting following a fall with possible head injury. Review of Patient #3’s Discharge Summary for the Revocation of Hospice Benefits signed on 11/05/2024 was attempted throughout the course of the survey with no documented evidence available for review. Patient #4Review of Patient #4’s Clinical Record revealed she was admitted to the Hospice agency on 04/11/2024 with a current Certification Period of 04/11/2024 through 05/20/2024. Review of Patient #4’s Revocation of Hospice Benefits revealed, in part, the form was signed on 05/20/2024 when in effort to better manage the patient’s persistent, uncontrolled pain, which began on 05/19/2025 and remained uncontrolled until 05/20/2025, her family opted for Emergency Room Evaluation due to the Hospice agency not having an inpatient unit available. Review of Patient #4’s Discharge Summary for the Revocation of Hospice Benefits signed on 05/20/2025 was attempted throughout the course of the survey with no documented evidence available for review. Patient #6Review of Patient #6’s Clinical Record revealed she was admitted to the Hospice agency on 06/20/2024 with a Certification Period of 04/16/2025 through 04/25/2025. Review of Patient #6’s Revocation of Hospice Benefits revealed, in part, the form was signed on 04/25/2025 when the patient’s son found her unresponsive and foaming at the mouth so he opted for Emergency Room Evaluation. Review of Patient #6’s Discharge Summary for the Revocation of Hospice Benefits signed on 04/25/2025 was attempted throughout the course of the survey with no documented evidence available for review. Patient #13Review of Patient #13’s Clinical Record revealed he was admitted to the Hospice agency on 11/22/2024 with a Certification Period of 02/20/2025 through 03/01/2025. Review of Patient #13’s Revocation of Hospice Benefits revealed, in part, the form was signed on 03/01/2025 when in effort to better manage the patient’s uncontrolled pain and symptoms his family opted for Emergency Room Evaluation due to the Hospice agency not having an inpatient unit available. Review of Patient #13’s Discharge Summary for the Revocation of Hospice Benefits signed on 03/01/2025 was attempted throughout the course of the survey with no documented evidence available for review. An interview was conducted on 06/25/2025 at 10:25 a.m. with S3LPN. S3LPN confirmed the Hospice agency did not create and/or provide the patient/family and/or their physician with a Discharge Summary if the discharge was due to a Revocation of Hospice Benefits. S3LPN reviewed Patient #1, #2, #3, #4, #6, and #13’s Clinical Records and confirmed a Discharge Summary was not created upon their Revocation of Hospice Benefits and should have been. 2. Upon Transfer to Another Hospice Agency.Patient #11Review of Patient #11’s Clinical Record revealed he was admitted to the Hospice agency on 08/05/2024 with a Certification Period of 08/05/2024 through 09/30/2024. Further review revealed he was transferred to another local Hospice agency upon his family’s request on 08/05/2024.Review of Patient #11’s Discharge Summary following his transfer on 08/05/2024 was attempted throughout the course of the survey with no documented evidence available for review. An interview was conducted on 06/25/2025 at 10:25 a.m. with S3LPN. S3LPN reviewed Patient #11’s Clinical Record and confirmed a Discharge Summary was not created upon his transfer to another agency and should have been.”

“Based on interviews and record review, the Hospice agency failed to have a system in place to ensure the safe use, management and disposal of controlled drugs in the patient’s home in accordance with all applicable laws, regulations and accepted standards of practice. This deficient practice was evidenced by failure to: 1. Establish a written policy and procedure to ensure the safe disposal of unused controlled substances by the Hospice nurse immediately following a patient’s death;2. Ensure immediately upon a patient’s death, the Hospice nurse, in the presence of a witness, documented the name and remaining counts of all controlled substances for 1 (#3) of 2 (#3 and #4) death records reviewed for controlled substances upon death; 3. Ensure immediately upon a patient’s death, the Hospice nurse, in the presence of a witness, performed the disposal of all controlled substances with documentation of the witness’ signature for 1 (#3) of 2 (#3 and #4) death records reviewed for controlled substances upon death; 4. Establish a written policy and procedure to maintain current and accurate records of the disposition of all controlled substances provided by the Hospice agency to the patient; and 5. Ensure current and accurate records were maintained of the disposition of all controlled substances provided by the Hospice agency to the patient for 8 of 8 (#5, #6, #8, #9, #10, #11, #12, and #13) patients reviewed for safe use and disposition of controlled substances. This deficient practice had the potential to affect any of the 102 patients admitted during the past 12 months, a current census of 28 patients and any future admissions to the agency. Cross reference: L686. Review of the memo issued by the state’s licensing authority, dated 06/25/2018, revealed the following, in part: In accordance with Act 23 of the 2018 Regular Legislative Session, regarding the 2018 Regular Legislative Session, the state’s licensing authority is issuing this notice to all licensed hospice providers. Effective 08/01/2018, Act 23 amends and reenacts LA RS 40:2191 relative to disposal of controlled substances by hospice providers; to provide for ownership; to provide for written procedures; to provide for patient records; to provide for disposal; to provide for patient notification; and to provide for related matters. Review of Louisiana Revised Statute (LA RS) 40:2191 revealed the following, in part: Disposal of deceased patient’s unused controlled substances:A. Upon death of a patient receiving hospice services, ownership of the patient’s unused Schedule II, III, IV, or V controlled substances under 21 CFR 1308 may transfer to the hospice for immediate disposal pursuant to the following provisions:(1) Each hospice shall establish a written procedure to ensure safe disposal of unused controlled substances by a hospice nurse at the time of a patient’s death.(2) Upon the death of a patient receiving hospice services, in the presence of a witness, the hospice nurse shall record in the medical record the name and quantity of each unused controlled substance.(3)(a) The hospice nurse shall conduct immediate disposal of the controlled substance at the site of care … (b) … the hospice nurse shall perform the disposal in the presence of a witness, who shall sign a document indicating their witnessing the disposal. (5) The hospice nurse shall record the method of disposal in the medical record.Review of the United States Government Accountability Office’s (GAO) Report titled “Preventing Drug Diversion”, published April 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. 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. 1. Written policy and procedure for disposal of controlled substances upon death. Review of the agency’s policy titled “Home Use and Disposal of Controlled Substances” last reviewed 11/2023, revealed it did not meet the aforementioned requirements established in LA RS 40:2191. An interview was conducted on 06/30/2025 at 1:30 p.m. with S2DON. S2DON confirmed the agency’s policy did not reflect the requirements of LA RS 40:2191 and should. An interview was conducted on 06/30/2025 at 3:30 p.m. with S1ADM. S1ADM confirmed the agency’s policy did not reflect the requirements of LA RS 40:2191 and should. 2. and 3. Upon death, perform/document the witness signature to counts, and destruction of controlled substances.Patient #3Review of Patient #3’s Clinical Record revealed she was admitted to the Hospice agency on 11/07/2024 and expired at home with family present on 11/11/2024. Review of Patient #3’s Physician’s Orders for Controlled Substances active at the time of her death revealed, in part, the following: Lorazepam Oral Concentrate 2mg/mL – Give 0.25mL by mouth every 4 hours as needed for anxiety or restlessness;Morphine Sulfate Oral Concentrate 20mg/5mL – Give 0.5mL every 2 hours as needed for SOB, pain, fast breathing; Alprazolam Oral Tablet 0.5mg – Give 0.5mg twice daily for anxiety. Quantity (Qty) dispensed: 30);Hydrocodone 10mg/Acetaminophen 325mg – Give 1 tablet every 4 hours as needed for pain. Qty Dispensed: 20 tablets; and Tramadol HCl 50mg Tablet – Give 1 tablet every 6 hours as needed for pain. Qty Dispensed: 30 tabs.Review of Patient #3’s Death Visit Note, performed on 11/11/2024 by S2DON, revealed, in part, the following: The following controlled substances were counted then disposed of via med disposal bag:Morphine 20 milligrams (mg)/milliliters (mL) – 6 mL; and Lorazepam 2mg/mL - 10.5mL. Witness: The typed name of the witness present with no documented signature of the witness. Further review revealed no documented evidence of the final count and/or destruction of Alprazolam Oral Tablets 0.5mg; Hydrocodone 10mg/Acetaminophen 325mg; and/or Tramadol HCl 50mg Tablets. An interview was conducted on 06/26/2025 at 12:30 p.m. with S2DON. S2DON provided a list with all of Patient #3’s active medications which would have been present in the home at the time of her death and confirmed the list was accurate. S2DON confirmed the list of counted/destroyed medications did not match the list of active medications that should have been accounted for at the time of her death and should have. S2DON confirmed Patient #3’s Death Visit did not include a documented signature of the witness present for the final count and destruction of narcotics and should have. 4. Written policy and procedure for the safe management, use and disposition of controlled substances in a patient’s home.Review of the agency’s policy titled “Home Use and Disposal of Controlled Substances” last reviewed 11/2023, revealed, in part, no documented evidence of a system to maintain current and accurate records of the receipt and disposition of all controlled drugs.An interview was conducted on 06/24/2025 at 3:30 p.m. with S2DON. S2DON confirmed she was the Hospice agency’s Director of Nursing and one of the nurses who saw patients in the field. S2DON confirmed she did not perform and document a count of all controlled substances present in a patient’s home during her nurse visits. S2DON stated sometimes she shook the bottle to see if anything was inside and other times she would ask if refills were needed. S2DON confirmed there was no expectation for the performance and documentation of a patient’s controlled substances during nurse visits. S2DON confirmed not maintaining accurate records for the receipt and disposition of all controlled substances would make it difficult to identify potentially dangerous situations; such as diversion and/or a patient taking more medication than prescribed. 5. Perform/document counts of controlled substances in the home during Nurse Visits.Patient #5Review of Patient #5’s Clinical Record revealed she was admitted to the Hospice agency on 03/19/2025 and lived at home with family. Further review revealed she was ordered to receive a Skilled Nurse Visit (SNV) twice weekly. Review of Patient #5’s POC and Physician’s Orders for the Certification Periods of 03/19/2025 through 06/16/2025 and 06/17/2025 through 09/14/2025 revealed, in part, the following active orders for 5 controlled substances: 1 - Hydrocodone-Acetaminophen Oral Tablet 5-325mg. Give one tablet by mouth every 6 hours as needed for pain. Quantity (Qty) Dispensed: 30 tablets; 2 - Temazepam Oral Capsule 15mg. Give one capsule at bedtime as needed for difficulty sleeping. Qty Dispensed: 4 capsules; 3- Morphine Sulfate Concentrate 20mg/mL. Give 0.5mL every 2 hours as needed for pain, shortness of breath (SOB) or fast breathing. Qty Dispensed: 15mL; 4 - Lorazepam Oral Concentrate 2mg/mL. Give 0.25mL every 4 hours as needed for SOB, anxiety, restlessness. Qty Dispensed: 10mL; and 5 - Atropine Sulfate Solution 1%. Give 5 drops under the tongue every 6 hours as needed for excessive secretions. Qty Dispensed 5mL.Review of Patient #5’s Visit Calendar since she was admitted to the Hospice agency revealed, in part, the following Nurse Visits were conducted for a total of 28 opportunities to count/document the 5 aforementioned controlled substances present in the patient’s home:03/19/2025; 03/21/2025; 03/25/2025; 03/27/2025; 04/01/2025; 04/04/2025; 04/08/2025; 04/11/2025; 04/15/2025; 04/19’/2025; 04/22/2025; 04/25/2025; 04/30/2025; 05/01/2025; 05/06/2025; 05/07/2025; 05/14/2025; 05/16/2025; 05/21/2025; 05/23/2025; 05/28/2025; 05/30/2025; 06/04/2025; 06/06/2025; 06/10/2025; 06/13/2025; 06/20/2025; and 06/24/2025.Review of Patient #5’s Nurse Visits since she was admitted to the Hospice agency revealed, in part, no documented evidence of controlled substance counts being performed or documented during any of her 28 nurse visits conducted from 03/19/2025 through 06/24/2025.An observation was conducted on 06/24/2025 at 10:50 a.m. during Patient #5’s Home Visit with S2DON. Just prior to conclusion of the nurse visit, S2DON was observed asking Patient #5’s daughter if they needed any medication refills. Upon conclusion of the Home Visit, S2DON had not visualized any of Patient #5’s medications nor had she performed or documented the counts for Patient #5’s controlled substances at any time during the visit. An interview was conducted on 06/24/2025 at 10:55 a.m. with Patient #5’s daughter and primary caregiver. She confirmed S2DON did not always count or even visualize her mother’s medications during her visits, but she always asked if refills were needed and filled whatever she asked her for. Patient #6Review of Patient #6’s Clinical Record revealed she was admitted to the Hospice agency on 05/03/2025 and lived at home with family. Further review revealed she was ordered to receive a SNV twice weekly. Review of Patient #6’s POC and Physician’s Orders for the current Certification Period, as of 06/23/2025, revealed, in part, the following active orders for 8 controlled substances: 1 - Morphine Sulfate Extended Release (ER) - 30mg Tablet. Give 1 tablet by mouth every 12 hours for pain. Qty Dispensed: 30 tablets; 2 - Morphine Sulfate Concentrate - 20mg/mL Solution (Sol). Give 0.5mL by mouth every 2 hours as needed for pain, shortness of breath, fast breathing. Qty Dispensed: 15mL (600mg);3 - Oxycodone HCl - 10mg Tablet. Give 1 tablet by mouth every 4 hours as needed for pain. Qty Dispensed: 30 tablets;4 - Dilaudid - 4mg Tablet. Give 1 tablet by mouth every 4 hours as needed for pain. Qty Dispensed: 30 tablets; 5 - Lorazepam - 0.5mg Tablet. Give 1 tablet by mouth every 4 hours as needed for anxiety. Qty Dispensed: 30 tablets; 6 - Lorazepam Concentrate - 2mg/mL Soln. Give 0.25mL every 4 hours as needed for shortness of breath, anxiety, restlessness. Qty Dispensed: 10mL; 7 – Temazepam Oral Capsule – 15mg. Give 1 capsule at bedtime as needed for difficulty sleeping. Qty Dispensed: 4 capsules; and8 - Atropine Sulfate Sol 1%. Give 5 drops under the tongue every 6 hours as needed for excessive secretions. Qty Dispensed 5mL.Review of Patient #6’s Visit Calendar, dated 05/03/2025 through 06/24/2025, revealed, in part, the following Nurse Visits were conducted for a total of 15 opportunities to count/document the 6 aforementioned controlled substances present in the patient’s home:05/03/2024; 05/04/2025; 05/07/2025; 05/11/2025; 05/12/2025; 05/16/2025; 05/20//2025; 05/28/2025; 05/30/2025; 06/03/2025; 06/06/2025; 06/10/2025; 06/18/2025; 06/20/2025; and 06/24/2025.Review of Patient #6’s Nurse Visits, dated 05/03/2025 through 06/24/2025, revealed, in part, no documented evidence of controlled substance counts being performed or documented during any of the aforementioned 15 nurse visits conducted.An observation was conducted on 06/24/2025 at 9:45 a.m. during Patient #6’s Home Visit. Medications present in Patient #6’s home were verified against the aforementioned active orders and pharmacy records with the following 6 controlled substances not being present in the home: 1- Morphine Sulfate ER - 15mg Tablet;2 - Temazepam Oral Capsule – 15mg capsule; 3 - Dilaudid - 4mg Tablet; 4 - Morphine Sulfate Concentrate - 20mg/mL Sol;5 - Lorazepam Oral Concentrate - 2mg/mL Sol; and 6 - Lorazepam - 0.5mg Tablet.An interview was conducted on 06/24/2025 at 9:55 a.m. with Patient #6 during her Home Visit. She confirmed she lived at home with her disabled son . She confirmed all of her medications were either located on the table beside her bed or in the refrigerator and would not be located anywhere else in her home. She confirmed she ran out of her Lorazepam tablets two and a half days ago but could not say what happened to any of the other unaccounted for controlled substances during her home visit. She confirmed she could not recall a time when the Hospice nurse(s) counted her medications during their visits. She stated the nurse(s) always asked her if she had enough of everything then ordered more if she told her needed something. Review of Patient #6’s Patient Profile from the Hospice agency’s contracted pharmacy, dated 03/01/2025 through 06/23/2025, revealed, in part, the following controlled substance quantities were delivered to the patients home on the following dates: 1- Morphine Sulfate ER - 15mg Tablet: Amount Dispensed: 40 tablets on 05/12/2025, 05/23/2025, 05/30/2025, and 06/12/2025; 2 - Temazepam Oral Capsule – 15mg: Amount Dispensed: 4 capsules on 05/12/2025, 05/23/2025, and 06/15/2025; 3 - Dilaudid - 4mg Tablet; Amount Dispensed: 30 tablets on 03/13/2025; 4 - Morphine Sulfate Concentrate - 20mg/mL Sol. Amount Dispensed: 600mg on 05/03/2025 and 06/06/2025; 5 - Lorazepam Oral Concentrate - 2mg/mL Sol. Amount Dispensed: 10mL on 05/03/2025; and 6 - Lorazepam - 0.5mg Tablet. Amount Dispensed: 30 tablets on 05/12/2025, 05/23/2025, and 05/30/2025.An interview was conducted 06/24/2025 at 3:40 p.m. with S2DON. S2DON confirmed the Hospice agency did not utilize lock boxes for controlled substances provided to a patient if the patient lived in a private home. S2DON confirmed she did have concerns with whether Patient #6 was taking her medications as ordered over the past month or so. S2DON confirmed she had spoken with Patient #6’s son about her concerns but had not conducted or documented counts of any of her medications. S2DON could not account for the controlled substances that could not be located during the Home Visit. Patient #8Review of Patient #8’s Clinical Record revealed she was admitted to the Hospice agency on 05/04/2025 and lived at home with family. Further review revealed she was ordered to receive a SNV twice weekly. Review of Patient #8’s POC and Physician’s Orders for the Certification Period of 05/04/2025 through 08/01/2025 revealed, in part, the following active orders for 5 controlled substances: 1 - Clonazepam 0.5mg. Give 1 tablet twice daily for anxiety; 2 - Temazepam Oral Capsule 15mg. Give one capsule at bedtime as needed for difficulty sleeping. Qty Dispensed: 4 capsules; 3- Morphine Sulfate Concentrate 20mg/mL. Give 0.5mL every 2 hours as needed for pain, shortness of breath (SOB) or fast breathing. Qty Dispensed: 15mL; 4 - Lorazepam Oral Concentrate 2mg/mL. Give 0.25mL every 4 hours as needed for SOB, anxiety, restlessness. Qty Dispensed: 10mL; and 5 - Atropine Sulfate Solution 1%. Give 5 drops under the tongue every 6 hours as needed for excessive secretions. Qty Dispensed 5mL.Review of Patient #8’s Visit Calendar, dated 05/04/2025 through 06/28/2025, revealed, in part, the following Nurse Visits were conducted for a total of 17 opportunities to count/document the 5 aforementioned controlled substances present in the patient’s home:05/04/2025; 05/06/2025; 05/09/2025; 05/13/2025; 05/15/2025; 05/20/2025; 05/24/2025; 05/29/2025; 05/31/2025; 06/03/2025; 06/05/2025; 06/10/2025; 06/12/2025; 06/17/2025; 06/19/2025; 06/24/2025; and 06/27/2025. Review of Patient #8’s Nurse Visits since she was admitted to the Hospice agency revealed, in part, no documented evidence of controlled substance counts being performed or documented during any of her 17 nurse visits conducted from 05/04/2025 through 06/27/2025.Patient #9Review of Patient #9’s Clinical Record revealed she was admitted to the Hospice agency on 05/22/2025 and lived at home with family. Further review revealed she was ordered to receive a SNV once weekly. Review of Patient #9’s POC and Physician’s Orders for the Certification Period of 05/22/2025 through 08/19/2025 revealed, in part, the following active orders for 5 controlled substances: 1 – Hydrocodone-Acetaminophen 5/325mg tablet. Give 1 tablet every 6 hours as needed for pain; 2 - Temazepam Oral Capsule 15mg. Give one capsule at bedtime as needed for difficulty sleeping; 3- Morphine Sulfate Concentrate 20mg/mL. Give 0.5mL every 2 hours as needed for pain, shortness of breath (SOB) or fast breathing; 4 - Lorazepam Oral Concentrate 2mg/mL. Give 0.25mL every 4 hours as needed for SOB, anxiety, restlessness; and 5 - Atropine Sulfate Solution 1%. Give 5 drops under the tongue every 6 hours as needed for excessive secretions.Review of Patient #9’s Visit Calendar since she was admitted to the Hospice agency revealed, in part, the following Nurse Visits were conducted for a total of 6 opportunities to count/document the 5 aforementioned controlled substances present in the patient’s home:05/22/2025; 05/27/2025; 06/03/2025; 06/10/2025; 06/17/2025; and 06/27/2025. Review of Patient #9’s Nurse Visit Notes for the aforementioned visits revealed, in part, no documented evidence of the documented count of all controlled substances present in the home for a total of 6 missed opportunities for monitoring of controlled substances provided to the patient by the Hospice agency. Patient #10Review of Patient #10’s Clinical Record revealed she was admitted to the Hospice agency on 01/25/2022 and lived at home with family. Further review revealed she was ordered to receive a SNV twice weekly. Review of Patient #10’s current POC and Physician’s Orders revealed, in part, the following active orders for 5 controlled substances: 1 – Oxycodone – 10mg tablet. Give 1 tablet every 8 hours as needed for pain; 2 - Temazepam Oral Capsule 15mg. Give one capsule at bedtime as needed for difficulty sleeping; 3- Morphine Sulfate Concentrate 20mg/mL. Give 0.5mL every 2 hours as needed for pain, shortness of breath (SOB) or fast breathing; 4 - Lorazepam Oral Concentrate 2mg/mL. Give 0.25mL every 4 hours as needed for SOB, anxiety, restlessness; and 5 - Lorazepam 1mg / Diphenhydramine 12.5mg / Haloperidol 2 topical gel 1mg/12.5mg/2mg per 1mL. Apply contents of syringe (1mL) to inner wrist every 6 hours as needed for anxiety and/or restlessness.Review of Patient #10’s Visit Calendar for the Certification Periods of 04/11/2025 through 06/09/2025 and 06/10/2025 through 08/08/2025, revealed, in part, the following Nurse Visits were conducted for a total of 23 opportunities to count/document the 5 aforementioned controlled substances present in the patient’s home:04/12/2025; 04/16/2025; 04/18/2025; 04/24/2025; 04/26/2025; 04/29/2025; 05/01/2025; 05/05/2025; 05/09/2025; 05/12/2025; 05/15/2025; 05/19/2025; 05/24/2025; 05/27/2025; 05/31/2025; 06/02/2025; 06/06/2025; 06/09/2025; 06/13/2025; 06/16/2025; 06/21/2025; 06/23/2025; and 06/25/2025. Review of Patient #10’s Nurse Visit Notes for the aforementioned visits revealed, in part, no documented evidence of the documented count of all controlled substances present in the home for a total of 23 missed opportunities for monitoring of controlled substances provided to the patient by the Hospice agency. Patient #11Review of Patient #11’s Clinical Record revealed he was admitted to the Hospice agency on 08/05/2024 and lived at home with family. Further review revealed he was ordered to receive a SNV twice weekly. Review of Patient #11’s POC and Physician’s Orders for the Certification Period of 08/05/2024 through 09/30/2024 revealed, in part, the following active order for 1 controlled substance: 1 – Lorazepam– 0.5mg tablet. Give 1 tablet twice daily as needed for restlessness and/or agitation.Review of Patient #11’s Visit Calendar for the Certification Period of 08/05/2024 through 09/30/2024, revealed, in part, the following Nurse Visits were conducted for a total of 15 opportunities to count/document the 1 aforementioned controlled substance present in the patient’s home:08/05/2024; 08/06/2024; 08/12/2024; 08/14/2024; 08/21/2024; 08/29/2024; 09/03/2024; 09/04/2024; 09/09/2024; 09/10/2024; 09/18/2024; 09/20/2024; 09/23/2024; 09/25/2024; and 09/30/2024. Review of Patient #11’s Nurse Visit Notes for the aforementioned visits revealed, in part, no documented evidence of the documented count of all controlled substances present in the home for a total of 15 missed opportunities for monitoring of controlled substances provided to the patient by the Hospice agency. Patient #12Review of Patient #12’s Clinical Record revealed she was admitted to the Hospice agency on 06/28/2024 and lived at home with family. Further review revealed she was ordered to receive a SNV twice weekly. Review of Patient #12’s POC and Physician’s Orders for the Certification Period of 11/18/2024 through 11/30/2024 revealed, in part, the following active orders for 4 controlled substances: 1 – Morphine Sulfate Concentrate 20mg/mL. Give 0.5mL every 2 hours as needed for pain, shortness of breath (SOB) or fast breathing; 2 - Lorazepam Oral Concentrate 2mg/mL. Give 0.25mL every 4 hours as needed for SOB, anxiety, restlessness; and 3 - Temazepam Oral Capsule 15mg. Give one capsule at bedtime as needed for difficulty sleeping.Review of Patient #12’s Visit Calendar for the Certification Period of 11/18/2024 through 11/30/2024, revealed, in part, the following Nurse Visits were conducted for a total of 8 opportunities to count/document the 3 aforementioned controlled substances present in the patient’s home:11/18/2024; 11/19/2024; 11/20/2024; 11/21/2024; 11/22/024; 11/25/2024; 11/27/2024; and 11/29/2024.Review of Patient #12’s Nurse Visit Notes for the aforementioned visits revealed, in part, no documented evidence of the documented count of all controlled substances present in the home for a total of 8 missed opportunities for monitoring of controlled substances provided to the patient by the Hospice agency. Patient #13Review of Patient #13’s Clinical Record revealed he was admitted to the Hospice agency on 11/22/2024 and lived at home with family. Further review revealed he was ordered to receive a SNV twice weekly. Review of Patient #13’s POC and Physician’s Orders for the Certification Period of 05/04/2025 through 07/02/2025 revealed, in part, the following active orders for 4 controlled substances: 1 – Hydrocodone-Acetaminophen 5/325mg tablet. Give 1 tablet every 8 hours as needed for pain; 2 – Morphine Sulfate Concentrate 20mg/mL. Give 0.5mL every 2 hours as needed for pain, shortness of breath (SOB) or fast breathing; and3 - Lorazepam Oral Concentrate 2mg/mL. Give 0.25mL every 4 hours as needed for SOB, anxiety, restlessness.Review of Patient #13’s Visit Calendar for the Certification Period of 05/04/2025 through 07/02/2025, revealed, in part, the following Nurse Visits were conducted for a total of 16 opportunities to count/document the 3 aforementioned controlled substances present in the patient’s home:05/06/2025; 05/08/2025; 05/13/2025; 05/15/2025; 05/18/2025; 05/24/2025; 05/27/2025; 05/29/2025; 06/03/2025; 06/05/2025; 06/10/2025; 06/12/2025; 06/17/2025; 06/19/2025; 06/24/2025; and 06/28/2025.Review of Patient #13s Nurse Visit Notes for the aforementioned visits revealed, in part, no documented evidence of the documented count of all controlled substances present in the home for a total of 16 missed opportunities for monitoring of controlled substances provided to the patient by the Hospice agency. An interview was conducted on 06/30/2025 at 2:00 p.m. with S2DON. S2DON confirmed the Hospice agency did not have a system in place to utilize lock boxes to secure controlled substances provided to the patient by the Hospice agency when the patient lived in a private home. S2DON confirmed the Hospice agency’s nurses were not currently expected to and did not perform and/or document counts of controlled substances provided to the patient by the Hospice agency during the aforementioned 123 nurse visits conducted for Patient #5, #6, #8, #9, #10, #11, #12, and #13. S2DON stated the agency should have been monitoring the use of the controlled substances provided to their patients by the agency in order to monitor for possible diversion, noncompliance with the ordered medication regimen, and effectiveness of a patient’s current pain regimen.”

“Based on interviews and record review, the Hospice agency failed to make inpatient care available for the management of pain control and symptom management for 2 of 2 (#4 and #13) patients reviewed for uncontrolled pain and symptoms. This deficient practice had the potential to affect any of the 39 admissions during the past 12 months, a current census of 18 patients and any future admissions to the agency. Review of the Louisiana Medicaid Hospice Revocation and Discharge Guidelines, Chapter 24 Section 24.7, issued 02/07/2022, revealed, in part, the following:Revocations:A beneficiary or his/her legal representative may revoke the election of Hospice care at any time during an election period. This is a right that belongs solely and exclusively to the beneficiary or legal representative.At no time is the Hospice provider to demand a revocation. In the event it is discovered during the verification process that a Hospice provider encouraged revocation for the purpose of potentially avoiding Hospice related charges, and the beneficiary or legal representative is in agreement, the revocation will not be honored.Discharge/Revocation Due to Hospital Admit:It is against Medicaid Hospice policy to encourage beneficiaries to revoke Hospice services when they have an inpatient admission, emergency room visit, ambulance transport or other outpatient services and re-elect Hospice after services are delivered. These cases will be verified and closely monitored by the Hospice Prior Authorization Unit for Hospice Care (PAU) for referral to Program Integrity. Review of the Hospice agency’s Contract for Inpatient Services was attempted throughout the course of the survey with no documented evidence available for review. Patient #4Review of Patient #4’s Clinical Record revealed she was admitted to the Hospice agency on 04/11/2024 with a current Certification Period of 04/11/2024 through 05/20/2024 and a terminal diagnosis of Malignant Neoplasm of the Pancreas and a co-morbidity of Secondary Malignant Neoplasm of Unspecified Lung. Review of Patient #4’s Communication Note, dated 05/19/2024, revealed, in part, On-call nurse received a call from patient’s son at 2:38 p.m. stating his mother was experiencing increased abdominal swelling which was causing increased pain. Patient’s son reported her current medications were not relieving the pain. Review of Patient #3’s Nurse Assessment, written by S7LPN on 05/20/2025, revealed, in part, the following: Pain Intervention: Patient going to the Emergency Department (ED) due to uncontrolled pain with any movement. Notes: Patient’s son expressed patient had been up all night complaining of having a feeling of smothering and increased generalized pain. Edematous +4 to both bilateral upper and lower extremities. Abdomen large and distended with ascites. Observed to be very short of breath even with oxygen in use. Patient started to cry “please help me I have been suffering all night.” Review of Patient #4’s Revocation of Hospice Benefits revealed, in part, the form was signed on 05/20/2024 when in effort to better manage the patient’s persistent, uncontrolled pain and shortness of breath her family opted for ED Evaluation due to the Hospice agency not having an IPU available. Review of Patient #4’s Nurse Revocation Statement, written by S7LPN on 05/20/2024, revealed, in part, patient complained of increased shortness of breath and stated “please help me I feel terrible”. Noted +4 edema to bilateral lower extremities. Increased ascites present to the abdomen with increased pain of 10/10. Patient’s son stated he wanted her to go to the ED for pain management because he could not watch her suffer. Review of Patient #4’s Clinical Record for her Second Admission revealed she was re-admitted to the Hospice agency on 05/22/2024 once her pain and symptoms were controlled. An interview was conducted on 06/26/2024 at 3:45 p.m. with S2DON. S2DON confirmed the Hospice agency did not have an IPU contract in place to send patients with uncontrolled pain and symptoms. S2DON confirmed she was not aware they were required to have an IPU available for their patients. S2DON confirmed if the agency had an IPU available, Patient #4 would not have required treatment in the ED. S2DON reviewed Patient #4’s record and confirmed once her pain and symptoms were controlled, she was discharged from the hospital and re-admitted to Hospice services. S2DON stated “now that she thinks about it, Patient #4 would have been a ‘picture perfect’ candidate for an IPU”. Patient #13Review of Patient #13’s Clinical Record revealed he was admitted to the Hospice agency on 11/22/2024 with a Certification Period of 02/20/2025 through 03/01/2025 and a terminal diagnosis of COPD. Review of Patient #13’s Communication Note, dated 03/01/2025, revealed, in part, S2DON received a call at 4:30 p.m. from Patient #13’s spouse indicating he was experiencing uncontrolled pain, swelling and redness to bilateral lower extremities. Review of Patient #13’s Revocation of Hospice Benefits revealed, in part, the form was signed on 03/01/2025 when in effort to better manage the patient’s uncontrolled pain and symptoms his family opted for ED Evaluation due to the Hospice agency not having an IPU available. Review of Patient #13’s Nurse Revocation Statement, written by S2DON on 03/01/2025, revealed, in part, patient’s family took him to the ED due to swelling in bilateral lower extremities. Review of Patient #13’s Clinical Record for his Second Admission revealed he was re-admitted to the Hospice agency on 03/05/2025 once his pain and symptoms were controlled. An interview was conducted on 06/30/2025 at 11:00 a.m. with S2DON. S2DON confirmed once Patient #13 was evaluated in the ED and they were able to get his pain and symptoms controlled, he was discharged from the hospital and re-admitted to Hospice services. An interview was conducted on 06/25/2025 at 10:25 a.m. with S3LPN. S3LPN confirmed she was the Office Manager and responsible for managing and serving as the “go between” for the Governing Body. S3LPN confirmed the Hospice agency did not have a current contract for IPU services and had not had one since pre-Covid. S3LPN confirmed when they used contracted IPUs in the past, other Hospice agency’s “poached their patients” so they got rid of the contracts. S3LPN confirmed the Hospice agency managed all pain and symptoms at home and did not feel an IPU would be beneficial to their patients. S3LPN confirmed if a patient/family were not satisfied with the home treatment of uncontrolled pain and symptoms, the patient/family would need to sign a Revocation of Hospice Benefits and take them to the ED. S3LPN confirmed she was not aware they were required to have an IPU available for their patients.”

“Based on interviews and record review, the Hospice agency failed to meet the Condition of Participation for Organization and Administration of Services by failing to organize, manage and administer its resources to provide the Hospice care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness and related conditions. This failure is evidenced by the Governing Body’s failure to be responsible for the management of a continuous Quality Assessment and Performance Improvement (QAPI) Program as evidenced by failure to create, implement and monitor a Performance Improvement Plan (PIP) following an allegation of patient visits not being conducted as documented by the Medical Social Worker (MSW) for 1 (#1) of 3 (#1, #2, #3) patients reviewed in the sample (See Findings in L651). This deficient practice had the potential to affect any of the 25 patients with MSW Visits ordered at the time the allegation was made, any of the 15 patients admitted since the allegation was made and a current census of 35 patients. See Findings in L651. See Findings in L651.”

“Based on interviews and record reviews, the Hospice agency failed to develop an individualized, patient-centered Plan of Care (POC) for each patient with goals and interventions for the problems identified during each assessment for 3 of 3 (#1, #2, and #3) patients reviewed in the sample. This deficient practice had the potential to affect a current census of 35 patients. Review of the Hospice agency’s Interdisciplinary Group (IDG) Membership and Responsibilities Policy, revised November 2020, revealed, in part, the following: Policy: The IDG will collaborate with the patients attending physician to develop an individualized written POC. Procedure:1. The Hospice IDG membership includes, at a minimum:c. Social Worker; and 3. The IDG responsibilities include, but are not limited to: a. Consulting with the patient’s attending physician, completes the initial comprehensive assessment within five (5) calendar days after the Election of Hospice Benefits (EOB). b. Participation in the establishment of the POC for each patient admitted. c. Participation in the periodic review and updating of the POC for each patient. j. Participating in performance improvement activities. Review of the Hospice agency’s IDG Coordination of Care Policy, revised November 2020, revealed, in part, the following: Policy: The IDG will retain professional management responsibilities for the provision of services, and will ensure that services are furnished in a safe and effective manner. The Hospice agency will utilize a case management system to guide an IDG to provide comprehensive, coordinated health care to patients and families/caregivers services by the Hospice agency. The type and scope of services provided by the IDG will be based upon comprehensive and ongoing assessments regarding the needs of the patient and family/caregivers problems, goals and interventions. The exact combination of services and the level of care will be unique to each patient and family/caregiver unit and will change as the needs of the patient and family/caregiver evolve over the course of their involvement with the Hospice agency. Procedure: 4. The Hospice agency personnel will communicate changes in a timely manner via telephone, one-to-one meetings, IDG meetings and home visits. Documentation of all communication will be included in the clinical record on a communication note, IDG meeting form, and/or clinical note. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication. 6. Written evidence of care coordination will be found in the POC and/or the IDG meetings in the patient’s clinical record, and will involve the Hospice physician. 7. Care will be provided by an IDG made up of social workers and clergy. 8. The IDG will conduct assessments, develop and update the POC, and review the effectiveness of care a minimum of every 15 calendar days. The attending physician will receive a copy of the POC updates. 12. Continuity of care will be maintained throughout the patient’s course with Hospice. Exchange of information between Hospice staff will be documented in the clinical record. 13. The IDG will provide ongoing support for the patient and family/caregivers. 14. Core Hospice services (Social Work and Clergy/Counselors) will be available 24 hours a day, seven days a week. Review of the Hospice agency’s IDG Meeting Policy, revised November 2020, revealed, in part, the following: Policy: The IDG will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the POC, deaths, and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients. Each patient’s POC will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient’s condition requires. Procedure:2. Referrals and admissions will be reviewed to establish appropriateness for Hospice care. Obstacles for access of care issues will be identified and resolved. Admissions will be reviewed to ensure compliance with Hospice policies and procedures. 3. Level of services will be reviewed for new and ongoing patients based on Hospice team assessments. The IDG will approve recommendation for a change in the level of care. 4. The patient’s POC will be updated no less frequently than every 15 days or more frequently if the patient’s condition requires. 5. A POC update will be completed for each patient and family/caregiver no less frequently than every 15 days utilizing the ongoing comprehensive assessment. 6. An IDG Meeting POC update form will be used for update of the patient, family/caregiver and the physician. It will note changes, response to treatment and progress toward targeted outcomes, which may include:a. Pharmacotherapuetic effectiveness of symptom management outcomes; b. An increase or decrease in symptoms or acuity; c. Increase or decrease in frequency of visits by team members and the reason for the change: 1. Missed visits will be explained and adjustment to the POC will be made if appropriate; e. Psychosocial and other consultations/conferences with patient and family/caregiver; f. Changes that may contribute to risk for pathological grief; g. Ongoing spiritual support; h. Plan for changes in treatments or procedures.10. Problem solving for optimal care of the patient and family/caregiver will occur, and changes will be documented in the IDG meeting form. 12. Grievances and issues of ethical concern will be discussed. Review of the Hospice agency’s POC Policy, revised November 2020, revealed, in part, the following: Policy: A written individualized patient and family/caregiver POC will be established and maintained for each individual admitted to the Hospice agency. The care provided to the patient must be provided in accordance with the POC. The POC will meet the documentation requirements of the physician-directed medical orders and the care planning process. The POC will be based on initial and ongoing comprehensive assessments performed by members of the IDG and will be reviewed on a regular basis and no less than every 15 days. This plan will focus on identified problems, goals and interventions. Procedure:4. The POC will identify the patient’s needs and services to meet those needs. 7. Each patient will be monitored for his/her response to care or services provided against established patient goas and patient outcomes to evaluate progress toward goals. 8. Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments and analysis of patient response to care against goals and outcomes. 9. The POC will be reviewed and revised as frequently as deemed necessary and no less often than every 15 days by the IDG based on ongoing comprehensive assessments of the patient and family/caregiver. 10. Any changes in the patient’s condition must result in a change in the POC. 12. The written POC will contain, but not be limited to, the following: b. Identification of patient and family/caregiver needs, including psychosocial, spiritual, counseling. l. Individualized interventions to assist with end of life care. n. Statement of treatment goals and documentation of the progress of outcomes. o. Information from the patient’s updated comprehensive assessment. v. Measureable outcomes anticipated from implementing and coordinating the POC.x. Patient or representative’s level of understanding, involvement and agreement with the POC. 15. Care provided to the patient will be in accordance with the POC. Patient #1Review of Patient #1’s Clinical Record revealed she was admitted to the Hospice agency on 08/26/2024 and her current Certification Period was 02/22/2025 through 04/04/2025. Further review revealed she was discharged to another agency on 04/04/2025 per family request.Review of Patient #1’s Physician’s Orders, dated 08/26/2024 through 04/04/2025, revealed, in part, she was to receive a MSW Visit once monthly and 5 as needed (PRN). Further review revealed an order entered by S4OM on 03/18/2025 to hold MSW services. An interview was conducted on 04/23/2025 at 12:30 p.m. with S1ADM. S1ADM confirmed Patient #1 was ordered MSW services due to her daughter experiencing on-going caregiver role strain. S1ADM confirmed Patient #1’s caregiver’s role strain was present from admission through discharge. Review of Patient #1’s Comprehensive POC from her admission on 08/26/2024 through her discharge on 04/04/2025 revealed, in part, no documented evidence of the identification of the aforementioned psychosocial problems with individualized, patient-specific goals, interventions and updates added to the POC. Patient #2Review of Patient #2’s Clinical Record revealed she was admitted to the Hospice agency on 07/12/2024 and her current Certification Period was 03/09/2025 through 05/07/2025. Review of Patient #2’s Physician’s Orders, dated 07/12/2024 through 05/07/2025, revealed, in part, she was to receive a MSW Visit twice a month and 3 PRN. Further review revealed an order written by S4OM on 03/06/2025 to hold MSW services. An interview was conducted on 04/23/2025 at 10:44 a.m. with S1ADM. S1ADM confirmed Patient #2 was ordered twice monthly MSW visits because there were some family dynamic issues that required the MSW’s assistance and support to work through. S1ADM confirmed Patient #2’s family dynamics were present upon admission and remained current at this time. Review of Patient #2’s Comprehensive POC from admission on 07/12/2025 through 04/23/2025 revealed, in part, no documented evidence of the identification of the aforementioned psychosocial problems with individualized, patient-specific goals, interventions and updates added to the POC. Patient #3Review of Patient #3’s Clinical Record revealed he was admitted to the Hospice agency on 11/08/2024 and his current Certification Period was 02/06/2025 through 05/06/2025.Review of Patient #3’s Physician’s Orders, dated 11/08/2024 through 04/23/2025, revealed, in part, he was to receive a MSW Visit twice a month and 5 PRN. Further review revealed an order written by S4OM on 03/13/2025 to hold MSW services. An interview was conducted on 04/23/2025 at 10:44 a.m. with S1ADM. S1ADM confirmed Patient #3 was ordered twice monthly MSW visits because his family required the extra support while coming to terms with his illness and prognosis. S1ADM confirmed Patient #3’s family required the extra support of the MSW upon admission and it remained current at this time. Review of Patient #3’s Comprehensive POC from admission on 11/08/2024 through 04/23/2025 revealed, in part, no documented evidence of the identification of the aforementioned psychosocial problems with individualized, patient-specific goals, interventions and updates added to the POC. An interview was conducted on 04/23/2025 at 10:44 a.m. with S1ADM. S1ADM reviewed Patient #1, #2 and #3’s POC and confirmed the aforementioned psychosocial information was not reflected in their POC and should have been. S1ADM confirmed all POC’s should be individualized and patient-centered to reflect their specific situation and current needs, including their goals, interventions and progress updates.”

“Based on interviews and record reviews, the Hospice agency failed to take action aimed at Performance Improvement and, after implementing those actions, measure success and track performance to ensure improvements were sustained. The Hospice agency failed to have a system in place to ensure a Performance Improvement Plan (PIP) was created, implemented and monitored following an allegation of patient visits not being conducted as documented by the Medical Social Worker (MSW) for 1 (#1) of 3 (#1, #2, #3) patients reviewed in the sample.This deficient practice had the potential to affect any of the 25 patients with MSW Visits ordered at the time the allegation was made, any of the 15 patients admitted since the allegation was made and a current census of 35 patients. Review of the Hospice agency’s undated Quality Assurance and Performance Improvement (QAPI) Plan, as of 04/23/2025, revealed, in part, the following: Guiding Principle #3: The Hospice agency strives to create an environment of teamwork and participation, where, through continuous performance improvement, people pursue excellence and take pride in their work, the organization, and personal development. Guiding Principle #4: The Hospice agency uses QAPI to make decisions and guide our day to day operations.Guiding Principle #5:The Hospice agency’s QAPI includes all employees, all departments and all services provided.Guiding Principle #6:The Hospice agency makes decisions based on data, which includes the input and experience of caregivers, clients/residents, health care practitioners, families and other stakeholders. Purpose: The purpose of the Hospice’s QAPI Plan is to provide a strategy for systematic organization-wide implementation of quality assessment and performance improvement activities. This will ensure the organization is providing appropriate, high-value, effective and efficient services in accordance with the mission and current standards of practice. Through QAPI activities, the organization provides a mechanism for identification and prioritization of opportunities for problem identification and improvement in care and operations. Our QAPI will collect and analyze patient care and administrative data and use that data to identify, prioritize, implement, and evaluate performance improvement projects to improve the quality of services furnished to Hospice patients. Design and Scope: Our Services include Social Services and Spiritual Services. Governance and Leadership:QAPI Committee Members: Owners, Medical Director (MD), Administrator, Director of Nursing (DON), Infection Preventionist (ICP), Office Manager (OM).Review of the Hospice agency’s Grievance Log, dated 04/01/2024 through 04/21/2025, revealed, in part, the following: 03/05/2025 – Grievance filed by Patient #1’s daughter related to MSW Services.Patient #1Review of Patient #1’s Clinical Record revealed she was admitted to the Hospice agency on 08/26/2024 with an initial Certification Period of 08/26/2024 through 11/23/2024. Further review revealed she was discharged to another agency on 04/04/2025 per family request.Review of Patient #1’s Grievance filed on 03/05/2025 revealed, in part, the following: Grievance filed by: Patient #1’s daughterGrievance received by: S4OM. Description: Patient #1’s daughter reports she has not seen S5MSW since Patient #1 was admitted to the Hospice agency.Action Taken: Reported to S1ADM and S2OWN. S2OWN performed investigation into Patient #1’s EHR and visit signatures. S2OWN terminated S5MSW. Review of the Hospice agency’s Grievance Investigation for the aforementioned Grievance, dated 03/05/2025, revealed, in part, the following: 03/05/2025: S6NP contacted S4OM after Patient #1’s daughter reported she had not received visits from S5MSW. S4OM notified S2OWN of the allegations. S2OWN performed a chart audit for Patient #1 which revealed 6 documented visits by S5MSW with electronic visit signatures present on each visit conducted on 06/30/2024, 10/14/2024, 11/04/2024, 12/20/2024, 01/07/2025, 02/06/2025 and no GPS location stamp indicating the location in which the signature was obtained. It was determined the GPS location stamp within the Electronic Health Record (EHR) software could only be turned on/off by the clinician performing the visit.03/07/2025: S2OWN contacted S5MSW by phone to discuss the Grievance allegations filed on behalf of Patient #1. S5MSW did not deny the allegations even after repeated prompting by S2OWN. S5MSW offered no response when questioned about the GPS Location Stamp setting in the EHR. S2OWN terminated S5MSW effective immediately. 03/07/2025: S2OWN contacted Patient #1’s daughter to provide an update on his investigation and steps taken. She was informed S5MSW was no longer employed by the agency.Follow Up Actions: 1. S5MSW terminated effective immediately on 03/07/2025. 2. All clinicians will be notified on 03/08/2025 daily morning call that GPS location stamping for patient/caregiver signatures must be turned on in the EHR for all electronic visit signatures. 3. Immediate action will be taken to hire a MSW. 4. Patients who need MSW visits will be notified of the gap in MSW coverage and can either request to be transferred to another agency or other disciplines will assist with MSW services as able and appropriate. 5. S2OWN discussed with S3OWN then notified the MD of the Grievance allegations, investigation findings and what actions were taken. S2OWN and S3OWN decided given the GPS location tracking capability of the EHR, no further action other than hiring a replacement MSW was required at this time. Compliance with GPS location stamping for all electronic visit signatures will be tracked.Review of the Hospice agency’s PIP regarding the aforementioned Grievance was attempted on 04/21/2025, 04/22/2025 and 04/23/2025 with no documented evidence available for review. Review of the Hospice agency’s Policy regarding GPS Location Stamps and Visit Signatures following the aforementioned Grievance was attempted on 04/21/2025, 04/22/2025 and 04/23/2025 with no documented evidence available for review. Review of the Hospice agency’s Meeting Minutes and/or Staff In-Services regarding the Expectation for 100% Compliance with GPS Location Stamps and Visit Signatures following the aforementioned Grievance was attempted on 04/21/2025, 04/22/2025 and 04/23/2025 with no documented evidence available for review. Review of the Hospice agency’s Monitoring for Compliance of GPS Location Stamps and Visit Signatures following the aforementioned Grievance was attempted on 04/21/2025, 04/22/2025 and 04/23/2025 with no documented evidence available for review. An interview was conducted on 04/21/2025 at 3:50 p.m. with S7LPN. S7LPN stated while in Patient #1’s home for a visit, she and Patient #1’s daughter were discussing possible nursing home placement. S7LPN stated she informed Patient #1’s daughter she would have S5MSW reach out to provide information and assist with the process. S7LPN stated Patient #1’s daughter informed her, she nor her mother had seen S5MSW since shortly after admission. S7LPN confirmed she immediately reported the allegations to S1ADM and S4OM. S7LPN confirmed during the daily morning meeting, S2OWN informed staff of S5MSW’s termination the day prior. S7LPN confirmed she did not receive any additional training following the termination of S5MSW and was not aware of any monitoring being performed by anyone with the Hospice agency. S7LPN confirmed she was required to obtain an electronic Visit Signature from the patient or family/caregiver for every visit she performed. S7LPN stated she was unaware she was required to have a GPS Location Stamp attached to each Visit Signature. An interview was conducted on 04/21/2025 at 12:30 p.m. with S4OM. S4OM confirmed S5MSW was terminated from the Hospice agency on 03/07/2025 after concerns were discovered with S5MSW not performing his job duties up to standard and with the visits for Patient #1 not being performed as he documented. S4OM provided a copy of the Grievance filed by Patient #1’s daughter and of the Grievance Investigation conducted by S2OWN. S4OM confirmed she could not provide a QAPI/PIP regarding the aforementioned Grievance because the Hospice agency did not open one. S4OM confirmed S2OWN told her the situation did not require a QAPI/PIP because it was a personnel performance issue and did not affect patients in any way. S4OM confirmed there was no documented evidence of any staff training or discussion during meetings regarding the aforementioned Grievance or expected next steps for staff. S4OM confirmed there was no documented evidence of monitoring for compliance of GPS Location Stamps and Visit Signatures following the aforementioned Grievance. S4OM confirmed she did not perform any monitoring of compliance for the GPS Location Stamps. S4OM confirmed payroll only monitored if a Visit Signature was present, not if the signature contained the GPS Location Stamp.An interview was conducted on 04/21/2025 at 3:50 p.m. with S1ADM. S1ADM confirmed S7LPN made her aware immediately upon Patient #1’s daughter reporting they had not seen S5MSW since admission. S1ADM confirmed she immediately notified S2OWN who took over investigation of the allegations and terminated S5MSW. S1ADM confirmed there was no audit performed of S5MSW’s patients to determine if the problem occurred for any additional patients. S1ADM confirmed no audit was performed for any other staff to ensure the problem was not more widespread. S1ADM confirmed the MSW was a Core Service the agency was required to provide patients. S1ADM confirmed if visits were not being performed as ordered and/or were being falsely documented as performed, this would have the potential to affect patients and/or their families/caregivers. An interview was conducted on 04/22/2025 at 9:30 a.m. with S3OWN. S3OWN confirmed no policy changes were made following the aforementioned Grievance. S3OWN confirmed there was no documented evidence of any audits to ensure patient visits occurred as ordered and as documented following the aforementioned Grievance. An interview was conducted on 04/22/2025 at 9:30 a.m. with S2OWN. S2OWN stated he was made aware of the allegations regarding S5MSW by S6NP. S2OWN confirmed he contacted S5MSW by phone to discuss the discrepancies, and S5MSW was unable to provide an explanation. S2OWN confirmed he terminated S5MSW effective immediately for falsifying records and visits. S2OWN confirmed prior to the Grievance filed by Patient #1’s daughter, there were ongoing issues with S5MSW not performing visits as he should and not obtaining electronic Visit Signatures from the patient or family/caregivers during visits as he should. S2OWN confirmed the Hospice agency did not open a QAPI/PIP following the aforementioned Grievance. S2OWN confirmed the Hospice agency could not provide any documented evidence of staff training, audits or monitoring following the aforementioned Grievance. S2OWN confirmed the Hospice agency required electronic Visit Signatures for all visits to ensure all services were being provided as ordered and as documented but did not have a written policy for it. S2OWN confirmed no policy changes were made following the aforementioned Grievance.”

“Based on interviews and record reviews, the Hospice agency failed to provide the Core Service of Medical Social Work (MSW) Services through a Hospice employee or contracted staff in a manner consistent with acceptable standards of practice for 3 of 3 (#1, #2, and #3) patients reviewed in the sample.This deficient practice had the potential to affect any of the 25 patients with MSW Visits ordered prior to the lapse in MSW coverage and 15 patient admissions during the lapse in MSW coverage, as well as, a current census of 35 patients. Review of the Hospice agency’s Interdisciplinary Group (IDG) Membership and Responsibilities Policy, revised November 2020, revealed, in part, the following: Policy: The IDG will collaborate with the patients attending physician to develop an individualized written Plan of Care (POC). Procedure:1. The Hospice IDG membership includes, at a minimum:c. Social Worker.3. The IDG responsibilities include, but are not limited to: a. Completes the initial comprehensive assessment within 5 calendar days after the Election of Hospice Benefits. b. Participation in the establishment of the POC for each patient admitted. c. Participation in the periodic review and updating of the POC for each patient. j. Participating in performance improvement activities. Review of the Hospice agency’s IDG Coordination of Care Policy, revised November 2020, revealed, in part, the following: Policy: The IDG will retain professional management responsibilities for the provision of services, including inpatient care, and will ensure that services are furnished in a safe and effective manner. The Hospice agency will utilize a case management system to guide an IDG to provide comprehensive, coordinated health care to patients and families/caregivers services by the Hospice agency. The type and scope of services provided by the IDG will be based upon comprehensive and ongoing assessments regarding the needs of the patient and family/caregivers problems, goals and interventions. The exact combination of services and the level of care will be unique to each patient and family/caregiver unit and will change as the needs of the patient and family/caregiver evolve over the course of their involvement with the Hospice agency. Procedure: 4. The Hospice agency personnel will communicate changes in a timely manner via telephone, one-to-one meetings, IDG meetings and home visits. 7. Care will be provided by an IDG made up of social workers. 8. The IDG will conduct assessments, develop and update the POC, and review the effectiveness of care a minimum of every 15 calendar days. 12. Continuity of care will be maintained throughout the patient’s course with Hospice. 13. The IDG will provide ongoing support for the patient and family/caregivers. 14. Core Hospice services (Social Work) will be available 24 hours a day, seven days a week. Review of the Hospice agency’s IDG Meeting Policy, revised November 2020, revealed, in part, the following: Policy: The IDG will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the POC, deaths, and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients. Each patient’s POC will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient’s condition requires. Procedure:2. Referrals and admissions will be reviewed to establish appropriateness for Hospice care. Obstacles for access of care issues will be identified and resolved. 3. Level of services will be reviewed for new and ongoing patients based on Hospice team assessments. The IDG will approve recommendation for a change in the level of care. 4. The patient’s POC will be updated no less frequently than every 15 days or more frequently if the patient’s condition requires. 5. A POC update will be completed for each patient and family/caregiver no less frequently than every 15 days utilizing the ongoing comprehensive assessment. Review of the Hospice agency’s POC Policy, revised November 2020, revealed, in part, the following: Policy: A written individualized patient and family/caregiver POC will be established and maintained for each individual admitted to the Hospice agency. The care provided to the patient must be provided in accordance with the POC. The POC will be based on initial and ongoing comprehensive assessments performed by members of the IDG and will be reviewed on a regular basis and no less than every 15 days. This plan will focus on identified problems, goals and interventions. Procedure:4. The POC will identify the patient’s needs and services to meet those needs. 7. Each patient will be monitored for his/her response to care or services provided against established patient goals and patient outcomes to evaluate progress toward goals. 8. Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments and analysis of patient response to care against goals and outcomes. 9. The POC will be reviewed and revised as frequently as deemed necessary and no less often than every 15 days by the IDG based on ongoing comprehensive assessments of the patient and family/caregiver. Patient #1Review of Patient #1’s Clinical Record revealed she was admitted to the Hospice agency on 08/26/2024 and her current Certification Period was 02/22/2025 through 04/04/2025. Further review revealed she was discharged to another agency on 04/04/2025 per family request.Review of Patient #1’s Physician’s Orders, dated 08/26/2024 through 04/04/2025, revealed, in part, she was to receive a MSW Visit once monthly and 5 as needed (PRN). Further review revealed an order entered by S4OM on 03/18/2025 to hold MSW services. Review of Patient #1’s Visit Calendar, dated 02/07/2025 through her discharge on 04/04/2025, revealed, in part, no MSW visits were conducted. Review of Patient #1’s Comprehensive Assessments and POC Updates, dated 02/07/2025 through her discharge on 04/04/2025, was attempted with no documented evidence of the required MSW updates. An interview was conducted on 04/23/2025 at 12:30 p.m. with S1ADM. S1ADM confirmed Patient #1 was ordered once monthly MSW services due to her daughter experiencing on-going caregiver role strain. S1ADM confirmed Patient #1’s caregiver’s role strain was present from admission through discharge. Patient #2Review of Patient #2’s Clinical Record revealed she was admitted to the Hospice agency on 07/12/2024 and her current Certification Period was 03/09/2025 through 05/07/2025. Review of Patient #2’s Physician’s Orders, dated 07/12/2024 through 05/07/2025, revealed, in part, she was to receive a MSW Visit twice a month and 3 PRN. Further review revealed an order written by S4OM on 03/06/2025 to hold MSW services. Review of Patient #2’s Visit Calendar, dated 03/07/2025 through 04/23/2025, revealed, in part, no MSW visits were conducted. Review of Patient #2’s Comprehensive Assessments and POC Updates, dated 03/07/2025 through 04/23/2025, was attempted with no documented evidence of the required MSW updates. An interview was conducted on 04/23/2025 at 10:44 a.m. with S1ADM. S1ADM confirmed Patient #2 was ordered twice monthly MSW visits because there were some family dynamic issues to work through that required the MSW’s assistance and support. S1ADM confirmed Patient #2’s family dynamics were present upon admission and remained current at this time. Patient #3Review of Patient #3’s Clinical Record revealed he was admitted to the Hospice agency on 11/08/2024 and his current Certification Period was 02/06/2025 through 05/06/2025.Review of Patient #3’s Physician’s Orders, dated 11/08/2024 through 04/23/2025, revealed, in part, he was to receive a MSW Visit twice a month and 5 PRN. Further review revealed an order written by S4OM on 03/13/2025 to hold MSW services. Review of Patient #3’s Visit Calendar, dated 03/07/2025 through 04/23/2025, revealed, in part, no MSW visits were conducted. Review of Patient #3’s Comprehensive Assessments and POC Updates, dated 03/07/2025 through 04/23/2025, was attempted with no documented evidence of the required MSW updates. An interview was conducted on 04/23/2025 at 10:44 a.m. with S1ADM. S1ADM confirmed Patient #3 was ordered twice monthly MSW visits because his family required the extra support while coming to terms with his illness and prognosis. S1ADM confirmed Patient #3’s family required the extra support of the MSW upon admission and it remained current at this time. Review of S5MSW’s Personnel File revealed, in part, he was terminated on 03/07/2025. Review of S8MSW’s Personnel File revealed, in part, he was hired on 04/07/2025. Review of the Personnel File for the agency’s MSW employed from 03/07/2025 through 04/07/2025 was attempted with no documented evidence available for review. Review of the Hospice agency’s Written Agreements for the provision of MSW Services from 03/07/2025 through 04/07/2025 was attempted with no documented evidence available for review. An interview was conducted on 04/23/2025 at 1:47 p.m. with S8MSW. S8MSW confirmed he began working part time with the Hospice agency on 04/07/2025 and began seeing patients on 04/10/2025. S8MSW confirmed prior to that, the Hospice agency had a lapse in MSW coverage after S5MSW was terminated. An interview was conducted on 04/22/2025 at 10:50 a.m. with S4OM. S4OM confirmed S5MSW was terminated on 03/07/2025 which created a lapse in MSW coverage until S8MSW began seeing newly admitted patients on 04/10/2025. S4OM confirmed as of 04/22/2024, S8MSW had not begun to see any of the current patient’s previously on S5MSW’s caseload; which would include Patient #2 and #3. S4OM confirmed prior to S5MSW being terminated, he provided MSW services to 25 patients. S4OM confirmed during the lapse in MSW coverage, the Hospice agency admitted a total of 15 patients. S4OM confirmed upon S5MSW’s termination, she entered an order to hold MSW services for all patients who were ordered to receive MSW services in order to prevent a missed MSW visit on the patient’s calendar. S4OM confirmed the order to hold MSW services was entered because the Hospice agency could not provide the service from 03/07/2025 to 04/10/2025, not because the patient no longer required the service. An interview was conducted on 04/23/2025 at 10:44 a.m. with S1ADM. S1ADM confirmed the MSW was a Core Service Hospice agencies were required to provide their patients. S1ADM confirmed the Hospice agency had a lapse in MSW coverage from 03/07/2025 through 04/10/2025, which led to no MSW Visits, no MSW initial entries or updates to the Comprehensive Assessment and no MSW POC initial entries or updates. S1ADM confirmed prior to S5MSW being terminated, he provided services to 25 patients. S1ADM confirmed during the lapse in MSW coverage, the Hospice agency admitted a total of 15 patients. S1ADM confirmed the orders entered by S4OM to hold MSW services was entered because the Hospice agency could not provide the service at the time, not because the patients and/or family/caregivers no longer required the service. An interview was conducted on 04/22/2025 at 9:30 a.m. with S2OWN. S2OWN confirmed he terminated S5MSW on 03/07/2025 effective immediately. S2OWN confirmed the MSW was a Core Service Hospice agencies were required to provide their patients. S2OWN confirmed the Hospice agency had a lapse in MSW coverage from 03/07/2025 through 04/10/2025.”

“Based on interviews and record reviews, the Hospice agency’s Governing Body failed to be responsible for the management of a continuous Quality Assessment and Performance Improvement (QAPI) Program as evidenced by failure to create, implement and monitor a Performance Improvement Plan (PIP) following an allegation of patient visits not being conducted as documented by the Medical Social Worker (MSW) for 1 (#1) of 3 (#1, #2, #3) patients reviewed in the sample. This deficient practice had the potential to affect any of the 25 patients with MSW Visits ordered at the time the allegation was made, any of the 15 patients admitted since the allegation was made and a current census of 35 patients. Cross Reference: L648. Review of the Hospice agency’s undated Quality Assurance and Performance Improvement (QAPI) Plan, as of 04/23/2025, revealed, in part, the following: Guiding Principle #3: Our QAPI is committed to excellence. The Hospice agency strives to create an environment of teamwork and participation, where, through continuous performance improvement, people pursue excellence and take pride in their work, the organization, and personal development. Guiding Principle #4: The Hospice agency uses QAPI to make decisions and guide our day to day operations.Guiding Principle #5:The Hospice agency’s QAPI includes all employees, all departments and all services provided.Guiding Principle #6:The Hospice agency makes decisions based on data, which includes the input and experience of caregivers, clients/residents, health care practitioners, families and other stakeholders. Purpose: The purpose of the Hospice’s QAPI Plan is to provide a strategy for systematic organization-wide implementation of quality assessment and performance improvement activities. This will ensure the organization is providing appropriate, high-value, effective and efficient services in accordance with the mission and current standards of practice. Through QAPI activities, the organization provides a mechanism for identification and prioritization of opportunities for problem identification and improvement in care and operations. Our QAPI will collect and analyze patient care and administrative data and use that data to identify, prioritize, implement, and evaluate performance improvement projects to improve the quality of services furnished to Hospice patients. Design and Scope: Our Services include Social Services and Spiritual Services. Governance and Leadership:QAPI Committee Members: Owners, Medical Director (MD), Administrator, Director of Nursing (DON), Infection Preventionist (ICP), Office Manager (OM).Meeting Frequency: QuarterlyQAPI Steering Committee: Owners, MD, Administrator, DON, ICP, OM.Meeting Frequency: Monthly phone calls. Review of the Hospice agency’s Grievance Log, dated 04/01/2024 through 04/21/2025, revealed, in part, the following: 03/05/2025 – Grievance filed by Patient #1’s daughter related to MSW Services.Patient #1Review of Patient #1’s Clinical Record revealed she was admitted to the Hospice agency on 08/26/2024 with an initial Certification Period of 08/26/2024 through 11/23/2024. Further review revealed she was discharged to another agency on 04/04/2025 per family request.Review of Patient #1’s Grievance filed on 03/05/2025 revealed, in part, the following: Grievance filed by: Patient #1’s daughterGrievance received by: S4OM. Description: Patient #1’s daughter reports she has not seen S5MSW since Patient #1 was admitted to the Hospice agency.Action Taken: Reported to S1ADM and S2OWN. S2OWN performed investigation into Patient #1’s EHR and visit signatures. S2OWN terminated S5MSW. Review of the Hospice agency’s Grievance Investigation for the aforementioned Grievance, dated 03/05/2025, revealed, in part, the following: 03/05/2025: S6NP contacted S4OM after Patient #1’s daughter reported she had not received visits from S5MSW. S4OM notified S2OWN of the allegations. S2OWN performed a chart audit for Patient #1 which revealed 6 documented visits by S5MSW with electronic visit signatures present on each visit conducted on 06/30/2024, 10/14/2024, 11/04/2024, 12/20/2024, 01/07/2025, 02/06/2025 and no Global Positioning System (GPS) location stamp indicating the location in which the signature was obtained. It was determined the GPS location stamp within the Electronic Health Record (EHR) software could only be turned on/off by the clinician performing the visit.03/07/2025: S2OWN contacted S5MSW by phone to discuss the Grievance allegations filed on behalf of Patient #1. S5MSW did not deny the allegations even after repeated prompting by S2OWN. S5MSW offered no response when questioned about the GPS Location Stamp setting in the EHR. S2OWN terminated S5MSW effective immediately. 03/07/2025: S2OWN contacted Patient #1’s daughter to provide an update on his investigation and steps taken. She was informed S5MSW was no longer employed by the agency.Follow Up Actions: 1. S5MSW terminated effective immediately on 03/07/2025. 2. All clinicians will be notified on 03/08/2025 daily morning call that GPS location stamping for patient/caregiver signatures must be turned on in the EHR for all electronic visit signatures. 3. Immediate action will be taken to hire a MSW. 4. Patients who need MSW visits will be notified of the gap in MSW coverage and can either request to be transferred to another agency or other disciplines will assist with MSW services as able and appropriate. 5. S2OWN discussed with S3OWN then notified the MD of the Grievance allegations, investigation findings and what actions were taken. S2OWN and S3OWN decided given the GPS location tracking capability of the EHR, no further action other than hiring a replacement MSW was required at this time. Compliance with GPS location stamping for all electronic visit signatures will be tracked.Review of the Hospice agency’s PIP documentation regarding the aforementioned Grievance was attempted on 04/21/2025, 04/22/2025 and 04/23/2025 with no documented evidence available for review. An interview was conducted on 04/21/2025 at 3:50 p.m. with S7LPN. S7LPN stated while in Patient #1’s home for a visit, she and Patient #1’s daughter were discussing possible nursing home placement and she informed Patient #1’s daughter she would have S5MSW reach out to provide information and assist with the process. S7LPN stated Patient #1’s daughter informed her, she nor her mother had seen S5MSW since shortly after admission. S7LPN stated she showed Patient #1’s daughter the Visit Signatures present on the MSW Visit Notes and she denied them being her signature. S7LPN confirmed she reported the allegations to S1ADM and S4OM immediately. S7LPN confirmed during the daily morning meeting, S2OWN informed staff of S5MSW’s termination the day prior. S7LPN confirmed she did not receive any additional training following the termination of S5MSW and was not aware of any monitoring being performed by anyone with the Hospice agency. S7LPN confirmed she was required to obtain an electronic Visit Signature from the patient or family/caregiver for every visit she performed but was not aware she was required to have a GPS Location Stamp attached to each Visit Signature. An interview was conducted on 04/21/2025 at 12:30 p.m. with S4OM. S4OM confirmed the Hospice agency discovered concerns with S5MSW not performing his job duties up to standard and with the visits for Patient #1 not being performed as he documented so he was terminated on 03/07/2025 by S2OWN. S4OM provided a copy of the Grievance filed by Patient #1’s daughter and of the Grievance Investigation conducted by S2OWN. S4OM confirmed she could not provide a QAPI/PIP regarding the aforementioned Grievance because the Hospice agency did not open one. S4OM confirmed S2OWN told her the situation did not require a QAPI/PIP because it was a personnel performance issue and did not affect patients in any way. An interview was conducted on 04/21/2025 at 3:50 p.m. with S1ADM. S1ADM confirmed S7LPN made her aware immediately of the aforementioned Grievance. S1ADM confirmed she immediately notified S2OWN who took over investigation of the allegations and terminated S5MSW. S1ADM confirmed following the aforementioned Grievance, S5MSW was terminated and nothing further was done by the Hospice agency since “he was the problem”. S1ADM confirmed the MSW was a Core Service the agency was required to provide patients. S1ADM confirmed if visits were not being performed as ordered and/or were being falsely documented as performed when they really were not, this would have the potential to effect patients and/or their families/caregivers so it would not be strictly a personnel issue. An interview was conducted on 04/22/2025 at 9:30 a.m. with S3OWN. S3OWN confirmed she was a member of the Hospice agency’s Governing Body. S3OWN confirmed no policy changes were made following the aforementioned Grievance. S3OWN confirmed there was no documented evidence of any audits or monitoring to ensure patient visits occurred as ordered and as documented following the aforementioned Grievance. An interview was conducted on 04/22/2025 at 9:30 a.m. with S2OWN. S2OWN confirmed he was the Chief Executive Officer for the Hospice agency’s Governing Body. S2OWN stated he was made aware of the allegations regarding S5MSW by S6NP. S2OWN confirmed he contacted S5MSW by phone to discuss the discrepancies, and S5MSW was unable to provide an explanation. S2OWN confirmed he terminated S5MSW effective immediately for falsifying records and visits. S2OWN confirmed prior to the Grievance filed by Patient #1’s daughter, there were ongoing issues with S5MSW not performing visits as he should and not obtaining electronic Visit Signatures from the patient or family/caregivers during visits as he should. S2OWN confirmed the Hospice agency did not open a QAPI/PIP following the aforementioned Grievance. S2OWN confirmed the Hospice agency could not provide any documented evidence of staff training, audits or monitoring following the aforementioned Grievance. S2OWN confirmed the Hospice agency required electronic Visit Signatures for all visits to ensure all services were being provided as ordered and as documented but did not have a written policy for it. S2OWN confirmed no policy changes were made following the aforementioned Grievance. S2OWN confirmed the Hospice agency did not open a QAPI/PIP following the aforementioned Grievance because he felt it was an internal personnel performance issue and not patient related.”