Heart of Hospice, LLC

“Based on interviews and record reviews, the Hospice agency failed to meet the Condition of Participation for Initial and Comprehensive Assessment of the Patient. This deficient practice is evidenced by failure to conduct and document a patient-specific Comprehensive Assessment which identifies the patient’s need for Hospice care and services and the patient’s need for physical, psychosocial, emotional and spiritual care. The Hospice agency failed to have a system in place to:1. Ensure the completion of the MSW’s Initial Comprehensive Assessment within 5 days after the Election of Hospice Benefits for 7 (#7, #8, #10, #11, #13, #18, and #19) of 14 (#6 through #19) live patients reviewed in the sample (See findings in L523); 2. Ensure the completion of the Chaplain’s Initial Comprehensive Assessment within 5 days after the Election of Hospice Benefits for 5 (#7, #9, #12, #15, and #17) of 14 (#6 through #19) live patients reviewed in the sample (See findings in L523);3. Ensure the completion of the Psychosocial Assessment to identify needs to be addressed related to the terminal illness within 5 days after the Election of Hospice Benefits for 7 (#7, #8, #10, #11, #13, #18, and #19) of 14 (#6 through #19) live patients reviewed in the sample (See findings in L524);4. Ensure completion of the Spiritual Assessment to identify needs to be addressed related to the terminal illness within 5 days after the Election of Hospice Benefits for 5 (#7, #9, #12, #15, and #17) of 14 (#6 through #19) live patients reviewed in the sample (See findings in L524);5. Maintain employment of a MSW from 08/28/2024 through 03/03/2025 resulting in 0% Comprehensive Assessment updates performed to the Psychosocial Assessment during the lapse in coverage for 7 (#8, #10, #11, #13, #18, and #19) of 14 (#6 through #19) live patients reviewed in the sample (See findings in L533);6. Maintain employment of a Spiritual Counselor/Chaplain from 12/28/2023 through 05/13/2024 resulting in 0% Comprehensive Assessment updates performed to the Spiritual Assessment performed during the lapse in coverage for 1 (#9) of 14 (#6 through #19) live patients reviewed in the sample (See findings in L533); and7. Maintain employment of a Bereavement Counselor/Chaplain from 12/28/2023 through 05/13/2024 resulting in 0% Comprehensive Assessment updates performed to the Bereavement Assessment performed during the lapse in coverage for 3 of 3 (#3, #4, and #5) records reviewed for bereavement (See findings in L533).This deficient practice had the potential to affect any of the 158 patient deaths and 218 patient admissions during the lapse in Core Services coverage, as well as, a current census of 58 patients. Cross reference: L523, L524, L533, L536, L539, L541, L543, L545, L546, L552, L587, L594, L596, L598, L648, and L652. See findings in L523, L524, and L533. See findings in L523, L524, and L533.”

“Based on interviews and record reviews, the Hospice agency failed to meet the Condition of Participation for IDG, Care Planning and Coordination of Services. This deficient practice is evidenced by failure to maintain a complete IDG to create, review and revise the POC to ensure the provision of care and services necessary to meet the patient and family’s specific needs as identified during assessment(s). The Hospice agency failed to have an effective system in place to:1. Ensure the IDG maintained a system of communication, coordination, and integration of services for 2 (#8 and #9) of 14 (#6 - #19) live patients reviewed in the sample (See Findings in L539); 2. Maintain employment of a MSW from 08/28/2024 through 03/03/2025 resulting in an incomplete IDG during the lapse in coverage (See Findings in L541); 3. Maintain employment of a Counselor/Chaplain from 12/28/2023 through 05/13/2024 resulting in an incomplete IDG during the lapse in coverage (See Findings in L541);6. Ensure MSW Visits were performed as ordered for 2 (#13 and #18) of 14 (#6 - #19) live patients in the sample (See Findings in L543); 7. Ensure Chaplain Visits were performed as ordered for 1 (#12) of 14 (#6 - #19) live patients in the sample (See Findings in L543); 8. Develop an individualized, patient-centered POC for each patient with goals and interventions for the problems identified during each assessment for 5 (#7, #8, #9, #10, and #11) of 14 (#6 - #19) live patients sampled (See Findings in L545);9. Develop an individualized, patient-centered POC with interventions to promote quality of life and prevent distress through pain and symptom management for 4 (#7, #8, #9, and #10) of 14 (#6 - #19) live patients sampled (See Findings in L546); 10. Maintain employment of a MSW from 08/28/2024 through 03/03/2025 resulting in 0% POC reviews and documented revisions performed during the lapse in coverage (See Findings in L552); and11. Maintain employment of a Counselor/Chaplain from 12/28/2023 through 05/13/2024 resulting in 0% POC reviews and documented revisions performed to the POC during the lapse in coverage (See Findings in L552). This deficient practice had the potential to affect any of the 158 patient deaths and 218 patient admissions during the lapse in IDG coverage, as well as, a current census of 58 patients. Cross reference: L520, L523, L524, L533, L539, L541, L543, L545, L546, L552, L587, L594, L596, L598, L629, L648, L652 and L694. See findings in L539, L541, L543, L545, L546, and L552. See findings in L539, L541, L543, L545, L546, and L552.”

“Based on interviews and record reviews, the Hospice agency failed to meet the Condition of Participation for Core Services. This deficient practice was evidenced by failure to provide MSW services, Bereavement Counseling services, and Spiritual Counseling/Chaplain services through a Hospice employee or contracted staff and in a manner consistent with acceptable standards of practice. The Hospice agency failed to have a system in place to: 1. Provide MSW Services in order to meet the patient’s and family’s psychosocial needs for 7 (#7, #8, #10, #11, #13, #18, and #19) of 14 (#6 through #19) live patients reviewed in the sample (See Findings in L594);2. Provide Bereavement Services under the supervision of a qualified professional (See Findings in L596); 3. Implement the Bereavement Services program and the Bereavement Plan of Care (POC) for 3 of 3 (#3, #4, and #5) records reviewed for bereavement for 3 of 3 (#3, #4, and #5) records reviewed for bereavement (See Findings in L596); and4. Provide Spiritual Counseling/Chaplain Services in order to meet the patient’s and family’s spiritual needs for 5 (#7, #9, #12, #15, and #17) of 14 (#6 through #19) live patients reviewed in the sample (See Findings in L598).This deficient practice had the potential to affect any of the 158 patient deaths and 218 patient admissions during the lapse in Core Services coverage, as well as, a current census of 58 patients. Cross Reference: L520, L523, L524, L533, L536, L539, L541, L543, L545, L546, L552, L587, L594, L596, L598, L629, L648, L652, and 694.See findings in L594, L596, and L598. See findings in L594, L596, and L598.”

“Based on interviews and record reviews, the Hospice Agency failed to meet the Condition of Participation for Organization and Administration of Services. This deficient practice was evidenced by failure to administer resources to provide hospice care and services to patients necessary for the palliation and management of the terminal illness and related conditions. This deficient practice was evidenced by failure to be primarily engaged in providing care and services consistent with accepted standards of practice for Medical Social Services (MSW) and Counseling/Chaplain Services. The provider failed to:Medical Social Services:1. Maintain employment of a MSW from 08/28/2024 through 03/03/2025 which resulted in:a. An incomplete IDG during the lapse in coverage from 08/28/2024 through 03/03/2025 (See findings in L541); b. MSW Services not being provided to meet the patient’s and family’s psychosocial needs for 7 (#7, #8, #10, #11, #13, #18, and #19) of 14 (#6 through #19) live patients reviewed in the sample (See findings in L594);c. 0% Comprehensive Assessment updates performed to the Psychosocial Assessment during the lapse in coverage for 6 (#8, #10, #11, #13, #18, and #19) of 14 (#6 - #19) live patients reviewed in the sample (See findings in L533);d. 0% POC reviews and documented revisions for Medical Social Services were performed during the lapse in coverage from 08/28/2024 through 03/03/2025 (See findings in L552); ande. MSW Services (Initial Visit, Assessment or Psychosocial Assessment) were not provided within the required 5 day window, to meet the patients’ and families’ psychosocial needs (See findings in L524).Counseling/Chaplain Services: 1. Maintain employment of a Spiritual Counselor/Chaplain from 12/28/2023 through 05/13/2024 which resulted in:a. Absence of a Counselor/Chaplain from 12/28/2023 through 05/13/2024 resulted in an incomplete IDG during the lapse in coverage (See findings in L541);b. Bereavement Services not being provided by or under the supervision of a qualified professional (See findings in L596);c. Failure to ensure the completion of the Chaplain’s Initial Comprehensive Assessment and Spiritual Assessment within 5 days after the Election of Hospice Benefits for 5 (#7, #9, #12, #15, and #17) of 14 (#6 - #19) live patients reviewed in the sample (See findings in L524);d. Failure to implement the Bereavement Services program and the Bereavement Plan of Care (POC) for 3 of 3 (#3, #4, and #5) records reviewed for bereavement (L596); ande. Failure to meet the patients’ and families’ spiritual needs due to lack of Spiritual Counseling/Chaplain Services for 5 (#7, #9, #12, #15, and #17) of 14 (#6 through #19) live patients reviewed in the sample (See findings in L552).Cross reference: L520, L523, L524, L533, L536, L539, L541, L543, L545, L546, L552, L587, L594, L596, L598, L629, L652 and L694. See Findings in L652. See Findings in L652.”

“Based on interviews and record reviews, the Hospice agency’s IDG failed to: 1. Ensure the completion of the MSW’s Initial Comprehensive Assessment within 5 days after the Election of Hospice Benefits for 7 (#7, #8, #10, #11, #13, #18, and #19) of 14 (#6 through #19) live patients reviewed in the sample; and 2. Ensure the completion of the Chaplain’s Initial Comprehensive Assessment within 5 days after the Election of Hospice Benefits for 5 (#7, #9, #12, #15, and #17) of 14 (#6 through #19) live patients reviewed in the sample. This deficient practice had the potential to affect any of the 158 patient deaths and 218 patient admissions during the lapse in Core Services coverage, as well as, a current census of 58 patients. Cross Reference: L520, L524, and L533. Review of the Hospice agency’s Interdisciplinary Group (IDG) Membership and Responsibilities Policy, revised on 02/01/2025, revealed, in part, the following: Purpose:To define the roles and responsibilities of the IDG. Procedure: 1. The Hospice IDG membership includes, but is not limited to: a. MSWb. Pastoral or Spiritual Counselor. 3. In Louisiana, agencies will need to update the POC at least every 14 days. a. Maintaining responsibility for directing, coordinating, and supervising the care and services provided. c. Ensuring the care and services provided are based on all assessments of the patient and family needs. Review of the Hospice agency’s Initial and Comprehensive Admission Assessment and POC Policy, revised 04/01/2022, revealed, in part, the following: Purpose: To describe the initial and comprehensive Hospice patient assessment. The comprehensive assessment will be completed no later than 5 calendar days after the date of Election of Hospice Services and includes a thorough assessment if the patient’s physical, psychosocial, emotional and spiritual status related to the terminal illness and related conditions and the caregiver’s and family’s willingness and capability to care for the patient. The information gathered during the comprehensive assessment will be incorporated into an interdisciplinary POC. Procedure: 5. The MSW will complete a Psychosocial Evaluation identifying goals and interventions, including the Initial Bereavement Risk Assessment, no later than 5 days after the date of Hospice Election as part of the comprehensive assessment. In the event the patient is imminently dying, the MSW will complete the Initial Psychosocial and Bereavement Assessment as soon as possible but no greater than 72 hours after the date of election. 6. The Chaplain will complete the spiritual evaluation identifying goals and interventions needed no later than 5 days after the date of hospice election as part of the comprehensive assessment. In the event the patient is imminently dying, the Chaplain will complete the initial spiritual assessment as soon as possible but no greater than 72 hours after the date of election. 1. Ensure the MSW completed their Initial Comprehensive Assessment within 5 days after the Election of Hospice Benefits. Patient #7Review of Patient #7’s Clinical Record revealed he was admitted to the agency and signed his Election of Hospice Benefits on 02/28/2025. Further review revealed a current Certification Period of 02/28/2025 through 05/28/2025. Review of Patient #7’s RN Initial Assessment, dated 02/28/2025, revealed, in part, the following: Is the patient accepting MSW services? Yes. Review of Patient #7’s POC and Physician’s Orders for the Certification Period of 02/28/2025 through 05/28/2025, revealed, in part, MSW Visit Frequency: Once monthly. Review of Patient #’s Visit Calendar, dated 02/28/2025 through 03/04/2025, revealed, in part, no documented evidence of a MSW Visit being attempted or conducted within the required 5 day window. Review of Patient #7’s MSW Initial Assessment, dated 02/28/2025 through 03/04/2025, was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed the aforementioned information and confirmed Patient #7 did not receive an Initial MSW Comprehensive Assessment within the required 5 day window and should have. Patient #8Review of Patient #8’s Clinical Record revealed she was admitted to the agency with the Election of Hospice Benefits Form signed on 02/09/2025. Further review revealed a current Certification Period of 02/09/2025 through 05/09/2025. Review of Patient #8’s RN Initial Assessment, dated 02/09/2025, revealed, in part, the following: Is patient accepting Social Work services? Yes. Review of Patient #8’s POC and Physician’s Orders for the Certification Period of 02/09/2025 through 05/09/2025, revealed, in part, MSW Visit Frequency: Once every two months. Review of Patient #’8s Visit Calendar, dated 02/09/2025 through 02/13/2025, revealed, in part, no documented evidence of a MSW Visit being attempted or conducted within the required 5 day window. Review of Patient #8’s MSW Initial Assessment, dated 02/09/2025 through 02/13/2025, was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed the aforementioned information and confirmed Patient #8 did not receive an Initial MSW Comprehensive Assessment within the required 5 day window and should have. Patient #10Review of Patient #10’s Clinical Record revealed he was admitted to the agency with the Election of Hospice Benefits Form signed on 01/25/2025. Further review revealed a current Certification Period of 01/25/2025 through 03/21/2025. Review of Patient #10’s RN Initial Assessment, dated 01/25/2025, revealed, in part, the following: Is patient accepting Social Work services? Yes. Review of Patient #10’s POC and Physician’s Orders for the Certification Period of 01/25/2025 through 03/21/2025, revealed, in part, MSW Visit Frequency: Once monthly. Review of Patient #’10s Visit Calendar, dated 01/25/2025 through 01/29/2025, revealed, in part, no documented evidence of a MSW Visit being attempted or conducted within the required 5 day window. Review of Patient #10’s MSW Initial Assessment, 01/25/2025 through 01/29/2025, was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed the aforementioned information and confirmed Patient #10 did not receive an Initial MSW Comprehensive Assessment within the required 5 day window and should have. Patient #11Review of Patient #11’s Clinical Record revealed he was admitted to the agency with his Election of Hospice Benefits Form signed on 02/11/2025. Further review revealed a current Certification Period of 02/11/2025 through 05/11/2025. Review of Patient #11’s RN Initial Assessment, dated 02/11/2025, revealed in part, the following:Is patient accepting Social Work services? Yes. Review of Patient #11’s POC and Physician’s Orders for the Certification Period of 02/11/2025 through 05/11/2025, revealed, in part, no order for MSW Visit frequency. Review of Patient #11’s Visit Calendar, dated 02/11/2025 through 02/15/2025, revealed, in part, no documented evidence of a MSW Visit being attempted or conducted within the required 5 day window. Review of Patient #11’s Initial MSW Assessment, dated 02/11/2025 through 02/15/2025, was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed the aforementioned information and confirmed Patient #11 did not receive an Initial MSW Comprehensive Assessment within the required 5 day window and should have. Patient #13Review of Patient #13’s Clinical Record revealed he was admitted to the agency with his Election of Hospice Benefits Form signed on 12/04/2024. Further review revealed a current Certification Period of 03/04/2025 through 06/01/2025. Review of Patient #13’s POC and Physician’s Orders for the Certification Period of 03/04/2025 through 06/01/2025, revealed, in part, no order for MSW Visit frequency upon admission. Review of Patient #13’s Visit Calendar, dated 12/04/2024 through 12/08/2024, revealed, in part, no documented evidence of a MSW Visit being attempted or conducted within the required 5 day window. Review of Patient #13’s Initial MSW Assessment, dated 12/04/2024 through 12/08/2024, was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed the aforementioned information and confirmed Patient #13 did not receive an Initial MSW Comprehensive Assessment within the required 5 day window and should have. Patient #18Review of Patient #18’s Clinical Record revealed she was admitted to the agency with her Election of Hospice Benefits Form signed on 02/10/2025. Further review revealed a current Certification Period of 02/10/2025 through 05/10/2025.Review of Patient #18’s RN Initial Assessment, dated 02/10/2025, revealed in part, the following:Is patient accepting Social Work services? Yes. Review of Patient #18’s POC and Physician’s Orders for the Certification Period of 02/10/2025 through 05/10/2025, revealed, in part, MSW Visit Frequency: Once monthly. Review of Patient #18’s Visit Calendar, dated 02/10/2025 through 02/14/2025, revealed, in part, no documented evidence of a MSW Visit being attempted or conducted within the required 5 day window. Review of Patient #18’s Initial MSW Assessment, dated 02/10/2025 through 02/14/2025, was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed the aforementioned information and confirmed Patient #18 did not receive an Initial MSW Comprehensive Assessment within the required 5 day window and should have. Patient #19Review of Patient #19’s Clinical Record revealed he was admitted to the agency with his Election of Hospice Benefits Form signed on 08/28/2024. Further review revealed a current Certification Period of 02/24/2025 through 04/24/2025. Review of Patient #19’s Initial RN Visit Assessment, dated 8/28/2024, revealed in part, the following:Is patient accepting Social Work services? Yes. Review of Patient #19’s POC and Physician’s Orders for the Certification Period of 03/04/2025 through 06/01/2025, revealed, in part, MSW Visit Frequency: Once monthly. Review of Patient #18’s Visit Calendar, dated 08/28/2024 through 09/01/2024, revealed, in part, no documented evidence of a MSW Visit being attempted or conducted within the required 5 day window. Review of Patient #19’s Initial MSW Assessment, dated 08/28/2024 through 09/01/2024, was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed the aforementioned information and confirmed Patient #19 did not receive an Initial MSW Comprehensive Assessment within the required 5 day window and should have. S1ED confirmed the MSW was a member of the IDG and was required to perform an Initial Assessment of a newly admitted patient within 5 days of their admission and signing of their Election of Hospice Benefits Form. S1ED confirmed the Hospice agency did not have a MSW on staff from 08/28/2024 through 03/03/2025 and the newly hired MSW would not complete orientation to begin seeing patients independently until 03/27/2025. S1ED confirmed during the lapse in MSW coverage, the agency admitted 111 new patients and had a current census of 58 patients. S1ED confirmed not having a MSW on staff meant the Hospice agency was not able to perform the required Initial Assessment upon admission so she could not confirm if all needs of the patient were being met. 2. Ensure the Chaplain completed their Initial Comprehensive Assessment within 5 days after the Election of Hospice Benefits. Patient #7Review of Patient #7’s Clinical Record revealed he was admitted to the agency and signed his Election of Hospice Benefits Form on 02/28/2025. Further review revealed a current Certification Period of 02/28/2025 through 05/28/2025. Review of Patient #7’s RN Initial Assessment, dated 02/28/2025, revealed, in part, the following: Is the patient accepting to spiritual caregiver services? Yes. Indicate spiritual/existential concerns of patient/caregiver: Referral made to spiritual caregiver/pastoral counselor.Review of Patient #7’s POC and Physician’s Orders for the Certification Period of 02/28/2025 through 05/28/2025, revealed, in part, Chaplain Visit Frequency: Once monthly.Review of Patient #’s Visit Calendar, dated 02/28/2025 through 03/04/2025, revealed, in part, no documented evidence of a Chaplain Visit being attempted or conducted within the required 5 day window. Review of Patient #7’s Chaplain Initial Assessment, dated 02/28/2025 through 03/04/2025, was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed the aforementioned information and confirmed Patient #7 did not receive an Initial Chaplain Comprehensive Assessment within the required 5 day window and should have. Patient #9Review of Patient #9’s Clinical Record revealed he was admitted to the agency and signed his Election of Hospice Benefits Form on 06/12/2024. Further review revealed a current Certification Period of 02/07/2025 through 04/07/2025. Review of Patient #9’s RN Initial Assessment, dated 06/12/2024, revealed, in part, the following: Is the patient accepting to spiritual caregiver services? Yes. Indicate spiritual/existential concerns of patient/caregiver: Referral made to spiritual caregiver/pastoral counselor.Review of Patient #9’s POC and Physician’s Orders, during his Initial Certification Period of 06/12/2024 through 09/09/2024, revealed, in part, Chaplain Visit Frequency: Once monthly. Review of Patient #9’s Visit Calendar, dated 06/12/20024 through 06/16/2024, revealed, in part, no documented evidence of a Chaplain Visit being attempted or conducted within the required 5 day window. Review of Patient #9’s Chaplain Initial Assessment, dated 06/12/20024 through 06/16/2024, was attempted with no documented evidence available for review. An interview was conducted on 03/20/2025 at 1:15 p.m. with S1ED. S1ED reviewed the aforementioned information and confirmed Patient #9 did not receive an Initial Chaplain Comprehensive Assessment within the required 5 day window and should have. Patient #12Review of Patient #12’s Clinical Record revealed he was admitted to the agency and signed his Election of Hospice Benefits Form on 04/09/2024. Further review revealed a current Certification Period of 02/03/2025 through 03/16/2025.Review of Patient #12’s RN Initial Assessment, dated 04/09/2024, revealed, in part, the following: Is patient accepting Chaplain Services? Yes. Indicate spiritual/existential concerns of patient and/or caregivers: Referral made to spiritual caregiver/pastoral counselor. Review of Patient #12’s POC and Physician’s Orders, during his Initial Certification Period of 04/09/2024 through 07/07/2024, revealed, in part, Chaplain Visit Frequency: Once monthly. Review of Patient #12’s Visit Calendar from 04/09/2024 through 04/13/2024, revealed, in part, no documented evidence of a Chaplain Visit being attempted or conducted within the required 5 day window. Review of Patient #12’s Chaplain Initial Assessment, dated 04/09/2024 through 04/13/2024, was attempted with no documented evidence available for review. An interview was conducted on 03/20/2025 at 1:15 p.m. with S1ED. S1ED reviewed the aforementioned information and confirmed Patient #12 did not receive an Initial Chaplain Comprehensive Assessment within the required 5 day window and should have. Patient #15Review of Patient #15’s Clinical Record revealed he was admitted to the agency with his Election of Hospice Benefits Form signed on 05/02/2024. Further review revealed a current Certification Period of 02/06/2025 through 04/06/2025. Review of Patient #15’s RN Initial Assessment, dated 05/02/2024, revealed in part, the following:Is patient accepting Chaplain services? Yes. Review of Patient #15’s POC and Physician’s Orders, during his Initial Certification Period of 05/02/2024 through 06/10/2024, revealed, in part, Chaplain Visit Frequency: Once monthly. Review of Patient #15’s Visit Calendar from 05/02/2024 through 05/06/2024, revealed, in part, no documented evidence of a Chaplain Visit being attempted or conducted within the required 5 day window. Review of Patient #15’s Chaplain Initial Assessment, dated 05/02/2024 through 05/06/2024, was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed the aforementioned information and confirmed Patient #15 did not receive an Initial Chaplain Comprehensive Assessment within the required 5 day window and should have. Patient #17Review of Patient #17’s Clinical Record revealed she was admitted to the agency with her Election of Hospice Benefits Form signed on 05/08/2024. Further review revealed a current Certification Period of 03/04/2025 through 05/02/2025. Review of Patient #17’s RN Initial Assessment, dated 05/08/2024, revealed in part, the following:Is patient accepting Chaplain services? Yes. Review of Patient #17’s Visit Calendar from 05/08/2024 through 05/12/2024, revealed, in part, no documented evidence of a Chaplain Visit being attempted or conducted within the required 5 day window. Review of Patient #17’s Chaplain Initial Assessment, dated 05/08/2024 through 05/12/2024, was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed the aforementioned information and confirmed Patient #17 did not receive an Initial Chaplain Comprehensive Assessment within the required 5 day window and should have. S1ED confirmed the Chaplain was a member of the IDG and all members of the IDG were required to perform an Initial Assessment of a newly admitted patient within 5 days of their admission and signing of their Election of Hospice Benefits Form. S1ED confirmed the Hospice agency did not have a Chaplain on staff from 12/28/2023 through 05/13/2024 and the newly hired Chaplain did not complete orientation to begin seeing patients independently until 06/24/2024. S1ED confirmed during the lapse in Chaplain coverage, the agency admitted 107 new patients and had a current census of 58 patients. S1ED confirmed not having a Chaplain on staff meant the Hospice agency was not able to perform the required Initial Assessment upon admission so they could not guarantee all needs of the patient were being met.”

“Based on interviews and record reviews, the Hospice agency failed to ensure the completion of all components of the Comprehensive Assessment as evidenced by failure to:1. Complete the Psychosocial Assessment to identify needs to be addressed related to the terminal illness within 5 days after the Election of Hospice Benefits for 7 (#7, #8, #10, #11, #13, #18, and #19) of 14 (#6 through #19) live patients reviewed in the sample; and 2. Complete the Spiritual Assessment to identify needs to be addressed related to the terminal illness within 5 days after the Election of Hospice Benefits for 5 (#7, #9, #12, #15, and #17) of 14 (#6 through #19) live patients reviewed in the sample. This deficient practice had the potential to affect any of the 158 patient deaths and 218 patient admissions during the lapse in Core Services coverage, as well as, a current census of 58 patients. Cross Reference: L520, L523, and L533. Review of the Hospice agency’s Interdisciplinary Group (IDG) Membership and Responsibilities Policy, revised on 02/01/2025, revealed, in part, the following: Purpose:To define the roles and responsibilities of the IDG. Procedure: 1. The Hospice IDG membership includes, but is not limited to: a. MSW b. Pastoral or Spiritual Counselor. 3. In Louisiana, agencies will need to update the POC at least every 14 days. a. Maintaining responsibility for directing, coordinating, and supervising the care and services provided. c. Ensuring the care and services provided are based on all assessments of the patient and family needs. Review of the Hospice agency’s Initial and Comprehensive Admission Assessment and POC Policy, revised 04/01/2022, revealed, in part, the following: Purpose: To describe the initial and comprehensive Hospice patient assessment. The comprehensive assessment will be completed no later than 5 calendar days after the date of Election of Hospice Services and includes a thorough assessment of the patient’s psychosocial and spiritual status related to the terminal illness and related conditions and the caregiver’s and family’s willingness and capability to care for the patient. The information gathered during the comprehensive assessment will be incorporated into an interdisciplinary POC. Procedure: |5. The MSW will complete a Psychosocial Evaluation identifying goals and interventions, including the Initial Bereavement Risk Assessment, no later than 5 days after the date of Hospice Election as part of the comprehensive assessment. In the event the patient is imminently dying, the MSW will complete the Initial Psychosocial and Bereavement Assessment as soon as possible but no greater than 72 hours after the date of election. 6. The Chaplain will complete the Spiritual Evaluation identifying goals and interventions needed no later than 5 days after the date of hospice election as part of the comprehensive assessment. In the event the patient is imminently dying, the Chaplain will complete the initial spiritual assessment as soon as possible but no greater than 72 hours after the date of election. 1. Complete the Psychosocial Assessment to identify needs to be addressed related to the terminal illness within 5 days after the Election of Hospice Benefits. Patient #7Review of Patient #7’s Clinical Record revealed he was admitted to the agency and signed his Election of Hospice Benefits on 02/28/2025. Further review revealed a current Certification Period of 02/28/2025 through 05/28/2025. Review of Patient #7’s Initial Psychosocial Assessment, dated 02/28/2025 through 03/04/2025, was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed Patient #7’s record and confirmed Patient #7 did not receive an Initial Psychosocial Assessment within the required 5 day window and should have. Patient #8Review of Patient #8’s Clinical Record revealed she was admitted to the agency with the Election of Hospice Benefits Form signed on 02/09/2025. Further review revealed a current Certification Period of 02/09/2025 through 05/09/2025. Review of Patient #8’s Initial Psychosocial Assessment, dated 02/09/2025 through 02/13/2025, was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed Patient #8’s record and confirmed Patient #8 did not receive an Initial Psychosocial Assessment within the required 5 day window and should have. Patient #10Review of Patient #10’s Clinical Record revealed he was admitted to the agency with the Election of Hospice Benefits Form signed on 01/25/2025. Further review revealed a current Certification Period of 01/25/2025 through 03/21/2025. Review of Patient #10’s Initial Psychosocial Assessment, 01/25/2025 through 01/29/2025, was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed Patient #10’s record and confirmed Patient #10 did not receive an Initial Psychosocial Assessment within the required 5 day window and should have. Patient #11Review of Patient #11’s Clinical Record revealed he was admitted to the agency with his Election of Hospice Benefits Form signed on 02/11/2025. Further review revealed a current Certification Period of 02/11/2025 through 05/11/2025. Review of Patient #11’s Initial Psychosocial Assessment, dated 02/11/2025 through 02/15/2025, was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed Patient #11’s record and confirmed Patient #11 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 agency with his Election of Hospice Benefits Form signed on 12/04/2024. Further review revealed a current Certification Period of 03/04/2025 through 06/01/2025. Review of Patient #13’s Initial Psychosocial Assessment, dated 12/04/2024 through 12/08/2024, was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed Patient #13’s record and confirmed Patient #13 did not receive an Initial Psychosocial Assessment within the required 5 day window and should have. Patient #18Review of Patient #18’s Clinical Record revealed she was admitted to the agency with her Election of Hospice Benefits Form signed on 02/10/2025. Further review revealed a current Certification Period of 02/10/2025 through 05/10/2025. Review of Patient #18’s Initial Psychosocial Assessment, dated 02/10/2025 through 02/14/2025, was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed Patient #18’s record and confirmed Patient #18 did not receive an Initial Psychosocial Assessment within the required 5 day window and should have. Patient #19Review of Patient #19’s Clinical Record revealed he was admitted to the agency with his Election of Hospice Benefits Form signed on 08/28/2024. Further review revealed a current Certification Period of 02/24/2025 through 04/24/2025. Review of Patient #19’s Initial Psychosocial Assessment, dated 08/28/2024 through 09/01/2024, was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed Patient #19’s record and confirmed Patient #19 did not receive an Initial Psychosocial Assessment within the required 5 day window and should have. S1ED confirmed the MSW was a member of the IDG and was required to perform an Initial Psychosocial Assessment of a newly admitted patient within 5 days of their admission and signing of their Election of Hospice Benefits Form. S1ED confirmed the Hospice agency did not have a MSW on staff from 08/28/2024 through 03/03/2025 and the newly hired MSW would not complete orientation to begin seeing patients independently until 03/27/2025. S1ED confirmed during the lapse in MSW coverage, the agency admitted 111 new patients and had a current census of 58 patients. S1ED confirmed not having a MSW on staff meant the Hospice agency was not able to perform the required Initial Psychosocial Assessment upon admission so she could not confirm if all needs of the patient were being met. 2. Complete the Spiritual Assessment to identify needs to be addressed related to the terminal illness within 5 days after the Election of Hospice Benefits.Patient #7Review of Patient #7’s Clinical Record revealed he was admitted to the agency and signed his Election of Hospice Benefits Form on 02/28/2025. Further review revealed a current Certification Period of 02/28/2025 through 05/28/2025. Review of Patient #7’s Initial Spiritual Assessment, dated 02/28/2025 through 03/04/2025, was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed Patient #7’s record and confirmed Patient #7 did not receive an Initial Spiritual Assessment within the required 5 day window and should have. Patient #9Review of Patient #9’s Clinical Record revealed he was admitted to the agency and signed his Election of Hospice Benefits Form on 06/12/2024. Further review revealed a current Certification Period of 02/07/2025 through 04/07/2025. Review of Patient #9’s Initial Spiritual Assessment, dated 06/12/2024 through 06/16/2024, was attempted with no documented evidence available for review. An interview was conducted on 03/20/2025 at 1:15 p.m. with S1ED. S1ED reviewed Patient #9’s record and confirmed Patient #9 did not receive an Initial Spiritual Assessment within the required 5 day window and should have. Patient #12Review of Patient #12’s Clinical Record revealed he was admitted to the agency and signed his Election of Hospice Benefits Form on 04/09/2024. Further review revealed a current Certification Period of 02/03/2025 through 03/16/2025.Review of Patient #12’s Initial Spiritual Assessment, dated 04/09/2024 through 04/13/2024, was attempted with no documented evidence available for review. An interview was conducted on 03/20/2025 at 1:15 p.m. with S1ED. S1ED reviewed Patient #12’s record and confirmed Patient #12 did not receive an Initial Spiritual Assessment within the required 5 day window and should have. Patient #15Review of Patient #15’s Clinical Record revealed he was admitted to the agency with his Election of Hospice Benefits Form signed on 05/02/2024. Further review revealed a current Certification Period of 02/06/2025 through 04/06/2025. Review of Patient #15’s Initial Spiritual Assessment, dated 05/02/2024 through 05/06/2024, was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed Patient #15’s record and confirmed Patient #15 did not receive an Initial Spiritual Assessment within the required 5 day window and should have. Patient #17Review of Patient #17’s Clinical Record revealed she was admitted to the agency with her Election of Hospice Benefits Form signed on 05/08/2024. Further review revealed a current Certification Period of 03/04/2025 through 05/02/2025. Review of Patient #17’s Initial Spiritual Assessment, dated 05/08/2024 through 05/12/2024, was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed Patient #17’s record and confirmed Patient #17 did not receive an Initial Spiritual Assessment within the required 5 day window and should have. S1ED confirmed the Chaplain was a member of the IDG and was required to perform an Initial Spiritual Assessment of a newly admitted patient within 5 days of their admission and signing of their Election of Hospice Benefits Form. S1ED confirmed the Hospice agency did not have a Chaplain on staff from 12/28/2023 through 05/13/2024 and the newly hired Chaplain did not complete orientation to begin seeing patients independently until 06/24/2024. S1ED confirmed during the lapse in Chaplain Coverage, the agency admitted 107 new patients and had a current census of 58 patients. S1ED confirmed not having a Chaplain on staff meant the Hospice agency was not able to perform the required Initial Spiritual Assessment upon admission so they could not guarantee all needs of the patient were being met.”

“Based on interviews and record reviews, the Hospice agency failed to ensure all required members of the IDG updated the Comprehensive Assessment to reflect progress toward desired outcomes and a reassessment of the response to care as needed and no less frequently than every 15 days. This deficient practice is evidenced by failure to:1. Maintain employment of a MSW from 08/28/2024 through 03/03/2025 resulting in 0% Comprehensive Assessment updates performed to the Psychosocial Assessment during the lapse in coverage for 7 (#8, #10, #11, #13, #18, and #19) of 14 (#6 through #19) live patients reviewed in the sample;2. Maintain employment of a Spiritual Counselor/Chaplain from 12/28/2023 through 05/13/2024 resulting in 0% Comprehensive Assessment updates performed to the Spiritual Assessment performed during the lapse in coverage for 1 (#9) of 14 (#6 through #19) live patients reviewed in the sample; and3. Maintain employment of a Bereavement Counselor/Chaplain from 12/28/2023 through 05/13/2024 resulting in 0% Comprehensive Assessment updates performed to the Bereavement Assessment performed during the lapse in coverage for 3 of 3 (#3, #4, and #5) records reviewed for bereavement. This deficient practice had the potential to affect any of the 158 patient deaths and 218 patient admissions during the lapse in Core Services coverage, as well as, a current census of 58 patients. Cross Reference: L520, L523, and L524. Review of the Hospice agency’s IDG Membership and Responsibilities Policy, revised on 02/01/2025, revealed, in part, the following: Purpose:To define the roles and responsibilities of the IDG. Policy: The Hospice IDG collaborates with the patient’s attending physician to develop and maintain a patient-directed, individualized POC. The Executive Director coordinates the overall functioning of the IDG. Procedure: 1. The Hospice IDG membership includes, but is not limited to: c. MSWd. Pastoral or Spiritual Counselor. 3. In Louisiana, agencies will need to update the POC at least every 14 days. a. Maintaining responsibility for directing, coordinating, and supervising the care and services provided. c. Ensuring the care and services provided are based on all assessments of the patient and family needs. d. Providing for and ensuring the ongoing sharing of information between all disciplines providing care and services in all settings.1. Failure to maintain employment of a MSW from 08/28/2024 through 03/03/2025 resulting in 0% Comprehensive Assessment updates performed to the Psychosocial Assessment during the lapse in coverage.Review of the Hospice agency’s Psychosocial Assessment Policy, revised 02/01/2023, revealed, in part, the following: Purpose: To provide guidance for the assessment and reassessment of the psychosocial needs of hospice patients and families/caregivers. Policy: A thorough psychosocial assessment will be initiated at the time of admission and continued throughout the course of care. Psychosocial assessment will be completed by a qualified hospice MSW. Procedure: 4. The MSW will continue to visit the patient/family at intervals designated by the POC. 5. Each visit or call will be documented in the patient’s medical record. 6. The psychosocial POC will be updated as needed, but at least every 15 days, with changes documented and discussed with the IDG. 7. The MSW will coordinate resources to meet patient/family needs and will document those efforts in the patient’s medical record. Patient #8Review of Patient #8’s Clinical Record revealed she was admitted to the agency with the Election of Hospice Benefits Form signed on 02/09/2025. Further review revealed a current Certification Period of 02/09/2025 through 05/09/2025. Review of Patient #8’s RN Initial Assessment, dated 02/09/2025, revealed, in part, the following: Is patient accepting Social Work services? Yes. Review of Patient #8’s POC and Physician’s Orders for the Certification Period of 02/09/2025 through 05/09/2025, revealed, in part, MSW Visit Frequency: Once every two months. Review of Patient #’8s Visit Calendar, dated 02/09/2025 through 02/26/2025, revealed, in part, no documented evidence of a MSW Visit being attempted or conducted. Review of Patient #8’s MSW Comprehensive Assessment update, dated 02/09/2025 through 02/26/2025, was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed the aforementioned information and confirmed Patient #8 did not receive an update to the MSW’s comprehensive assessment within the required window and should have. Patient #10Review of Patient #10’s Clinical Record revealed he was admitted to the agency with the Election of Hospice Benefits Form signed on 01/25/2025. Further review revealed a current Certification Period of 01/25/2025 through 03/21/2025. Review of Patient #10’s RN Initial Assessment, dated 01/25/2025, revealed, in part, the following: Is patient accepting Social Work services? Yes. Review of Patient #10’s POC and Physician’s Orders for the Certification Period of 01/25/2025 through 03/21/2025, revealed, in part, MSW Visit Frequency: Once monthly. Review of Patient #’10s Visit Calendar, dated 01/25/2025 through 03/02/2025, revealed, in part, no documented evidence of a MSW Visit being attempted or conducted.Review of Patient #10’s MSW Comprehensive Assessment update, 01/25/2025 through 03/21/2025, was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed the aforementioned information and confirmed Patient #10 did not receive updates to the MSW’s Comprehensive Assessment from the time he was admitted on 01/25/2025 until 03/22/2025 when the MSW completed his Initial Assessment and should have. Patient #11Review of Patient #11’s Clinical Record revealed he was admitted to the agency with his Election of Hospice Benefits Form signed on 02/11/2025. Further review revealed a current Certification Period of 02/11/2025 through 05/11/2025. Review of Patient #11’s RN Initial Assessment, dated 02/11/2025, revealed in part, the following:Is patient accepting Social Work services? Yes. Review of Patient #11’s POC and Physician’s Orders for the Certification Period of 02/11/2025 through 05/11/2025, revealed, in part, no order for MSW Visit frequency. Review of Patient #11’s Visit Calendar, dated 02/11/2025 through 03/12/2025, revealed, in part, no documented evidence of a MSW Visit being attempted or conducted.Review of Patient #11’s MSW Comprehensive Assessment update, dated 02/11/2025 through 03/12/2025, was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed the aforementioned information and confirmed Patient #11 did not receive updates to the MSW’s Comprehensive Assessment from the time he was admitted on 02/11/2025 until 03/13/2025 when the MSW completed his Initial Assessment and should have. Patient #13Review of Patient #13’s Clinical Record revealed he was admitted to the agency with his Election of Hospice Benefits Form signed on 12/04/2024. Further review revealed a current Certification Period of 03/04/2025 through 06/01/2025. Review of Patient #13’s POC and Physician’s Orders for the Certification Period of 03/04/2025 through 06/01/2025, revealed, in part, no order for MSW Visit frequency upon admission. Review of Patient #13’s Visit Calendar, dated 12/04/2024 through 01/23/2025, revealed, in part, no documented evidence of a MSW Visit being attempted or conducted.Review of Patient #13’s MSW Comprehensive Assessment updates, dated 12/04/2024 through 01/23/2025, was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed the aforementioned information and confirmed Patient #13 did not receive updates to the MSW’s Comprehensive Assessment from the time he was admitted on 12/04/2024 until 01/24/2025 when the MSW completed his Initial Assessment and should have.Patient #18Review of Patient #18’s Clinical Record revealed she was admitted to the agency with her Election of Hospice Benefits Form signed on 02/10/2025. Further review revealed a current Certification Period of 02/10/2025 through 05/10/2025.Review of Patient #18’s RN Initial Assessment, dated 02/10/2025, revealed in part, the following:Is patient accepting Social Work services? Yes. Review of Patient #18’s POC and Physician’s Orders for the Certification Period of 02/10/2025 through 05/10/2025, revealed, in part, MSW Visit Frequency: Once monthly. Review of Patient #18’s Visit Calendar, dated 02/10/2025 through 03/19/2025, revealed, in part, no documented evidence of a MSW Visit being attempted or conducted.Review of Patient #18’s MSW Comprehensive Assessment updates, dated 02/10/2025 through 03/19/2025, was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed the aforementioned information and confirmed Patient #18 did not receive updates to the MSW’s Comprehensive Assessment from the time she was admitted on 02/10/2025 until 03/20/2025 when the MSW completed her Initial Assessment and should have.Patient #19Review of Patient #19’s Clinical Record revealed he was admitted to the agency with his Election of Hospice Benefits Form signed on 08/28/2024. Further review revealed a current Certification Period of 02/24/2025 through 04/24/2025. Review of Patient #19’s Initial RN Visit Assessment, dated 8/28/2024, revealed in part, the following:Is patient accepting Social Work services? Yes. Review of Patient #19’s POC and Physician’s Orders for the Certification Period of 03/04/2025 through 06/01/2025, revealed, in part, MSW Visit Frequency: Once monthly. Review of Patient #18’s Visit Calendar, dated 08/28/2024 through 03/11/2025, revealed, in part, no documented evidence of a MSW Visit being attempted or conducted.Review of Patient #19’s MSW Comprehensive Assessment update, dated 08/28/2024 through 03/11/2025, was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed the aforementioned information and confirmed Patient #19 did not receive updates to the MSW’s Comprehensive Assessment from the time he was admitted on 08/28/2024 until 03/12/2025 when the MSW completed his Initial Assessment and should have.Review attempted of the Personnel File for the agency’s MSW employed from 08/28/2024 through 03/03/2024 with no documented evidence available for review. Review of the Hospice agency’s Written Agreements for the provision of MSW Services from 08/28/2024 through 03/03/2024 was attempted with no documented evidence available for review. An interview was conducted on 03/25/2025 at 1:00 p.m. with S3MSW. S3MSW confirmed she recently started her role as MSW with the Hospice agency during the first week of March 2025 and would not be released to take patients on her own until 03/27/2025. S3MSW confirmed prior to her being hired, the Hospice agency did not have a MSW available on staff for patients and families since August of 2024. An interview was conducted on 03/27/2025 at 2:45 p.m. with S1ED. S1ED confirmed the Core Services a Hospice agency was required to provide for their IDG included a MSW. S1ED confirmed the Hospice agency did not have a MSW on staff for their patients and families from 08/28/2024 through 03/03/2025 and the newly hired MSW would not complete orientation to begin seeing patients and families independently until 03/27/2025. S1ED confirmed during the lapse in MSW coverage, the agency admitted 111 patients and 80 patients. S1ED confirmed not having a MSW on staff meant the Hospice agency was not able to perform any of the required updates to the Comprehensive Assessments for this discipline. 2. Failure to maintain employment of a Spiritual Counselor/Chaplain from 12/28/2023 through 05/13/2024 resulting in 0% Comprehensive Assessment updates performed to the Spiritual Assessment during the lapse in coverage.Review of the Hospice agency’s Spiritual Assessment Policy, revised 02/01/2023, revealed, in part, the following: Purpose: To ensure each Hospice patient receives a Spiritual Assessment. Policy: All patients/families admitted to Hospice services will receive a Spiritual Assessment that identifies spiritual needs and goals. A Chaplain or qualified Spiritual Counselor will perform the assessment. Spiritual services will be delivered according to generally accepted standards of practice and in a manner, which is meaningful to the patient/representative. Spiritual care is provided either directly or through coordination with the patient/representative’s designated religious professional, as appropriate. Procedure: 2. The Spiritual Counselor/Chaplain will provide spiritual counseling to meet assessed needs in accordance with the patient/representative’s acceptance of this service and in a manner consistent with the patient/representative’s beliefs and desires. 3. The Spiritual Counselor/Chaplain will continue to visit the patient/representative at intervals designated by the patient’s POC. 4. Each visit or call will be documented in each patient’s medical record. 5. The spiritual POC will be reviewed no less than every 15 days and updated according to patient/representative needs with changes documented and discussed with the IDG. 6. The Spiritual Counselor/Chaplain will coordinate resources and services to meet the patient/representative needs. This will include coordination of services with the patient/representative’s designated local clergy, pastoral counselor or other individual as appropriate. 7. In the event that patient/representative declines spiritual services, the Spiritual Counselor/Chaplain is to inquire if spiritual services are desired form another source and coordinate that care. The Spiritual Counselor/Chaplain will remain available in the event the patient/representative chooses to engage the Spiritual Counselor/Chaplain. Patient #9Review of Patient #9’s Clinical Record revealed he was admitted to the agency and signed his Election of Hospice Benefits Form on 06/12/2024. Further review revealed a current Certification Period of 02/07/2025 through 04/07/2025. Review of Patient #9’s RN Initial Assessment, dated 06/12/2024, revealed, in part, the following: Is the patient accepting to spiritual caregiver services? Yes. Indicate spiritual/existential concerns of patient/caregiver: Referral made to spiritual caregiver/pastoral counselor.Review of Patient #9’s POC and Physician’s Orders, during his Initial Certification Period of 06/12/2024 through 09/09/2024, revealed, in part, Chaplain Visit Frequency: Once monthly. Review of Patient #9’s Visit Calendar, dated 06/12/20024 through 03/19/2025, revealed, in part, no documented evidence of a Chaplain Visit being attempted or conducted.Review of Patient #9’s Chaplain Comprehensive Assessment updates, dated 06/12/20024 through 03/19/2025, was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed the aforementioned information and confirmed Patient #9 did not receive updates to the Chaplain’s Comprehensive Assessment from the time he was admitted on 06/12/2024 until 03/20/2025 when the Chaplain completed his Initial Assessment and should have.Review of the Personnel File for the agency’s Spiritual Counselor/Chaplain employed from 12/28/2023 through 05/13/2024 was attempted with no documented evidence available for review. Review of the Hospice agency’s Written Agreements for the provision of Spiritual Counselor/Chaplain Services from 12/28/2023 through 05/13/2024 was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:45 p.m. with S1ED. S1ED confirmed the Core Services a Hospice agency was required to provide for their IDG included a Spiritual Counselor/Chaplain. S1ED confirmed the Hospice agency did not have a Spiritual Counselor/Chaplain on staff from 12/28/2023 through 05/13/2024, and the newly hired Chaplain did not complete orientation to begin seeing patients and families independently until 06/24/2024. S1ED confirmed during the lapse in Spiritual Counselor/Chaplain coverage, the agency admitted 107 patients and 78 patients expired. S1ED confirmed not having a Spiritual Counselor/Chaplain on staff meant the Hospice agency was not able to perform any of the required updates to the Comprehensive Assessments for this discipline. 3. Failure to maintain employment of a Bereavement Counselor/Chaplain from 12/28/2023 through 05/13/2024 resulting in 0% Comprehensive Assessment updates performed to the Bereavement Assessment during the lapse in coverage.Review of the Hospice agency’s Bereavement Counseling Policy and Procedure, revised on 02/01/2022, revealed, in part, the following: Purpose: To ensure appropriate and coordinated bereavement services are provided to families/caregivers of Hospice patients. Policy: The agency will provide an organized bereavement program supervised by a qualified Bereavement Coordinator for at least 13 months following the death of a patient. The program will provide bereavement services to families/caregivers of Hospice patients both before and after the patient’s death. The purpose of these services will be to facilitate a normal grieving process and to identify and appropriately refer those persons who may be experiencing pathological grief reactions that may interfere with the eventual resolution and integration of their losses. The purpose will also be to prepare the individual to function independently of hospice and to identify a support system with the individual. Procedure: 2. After the Initial Bereavement Risk Assessment is completed, a Bereavement POC can be developed to address anticipatory bereavement/grief issues and implemented as needed. Depending on the patient and family/caregiver needs identified in the Bereavement Risk Assessment, the Bereavement Coordinator may need to contact and/or visit the patient and family/caregiver prior to death. The Bereavement POC will include specific goals and interventions that indicate the kind of bereavement services to be offered and the frequency of service delivery. Patient #3Review of Patient #3’s Clinical Record revealed a Start of Care date of 03/25/2024. Further review revealed he expired at home with his family on 03/30/2024.Review of Patient #3’s Initial Bereavement Risk Assessment upon admission to the Hospice agency revealed it was performed on 03/28/2024. Review of Patient #3’s updated Bereavement Risk Assessment performed within 30 days following his death revealed no documented evidence available for review. Patient #4Review of Patient #4’s Clinical Record revealed a Start of Care date of 05/15/2024. Further review revealed he expired at home with his family on 05/17/2024.Review of Patient #4’s Initial Bereavement Risk Assessment upon admission to the Hospice agency revealed it was performed on 05/16/2024. Review of Patient #4’s updated Bereavement Risk Assessment performed within 30 days following his death revealed no documented evidence available for review. Patient #5Review of Patient #5’s Clinical Record revealed a Start of Care date of 03/19/2024. Further review revealed he expired at home with his family on 04/11/2024.Review of Patient #5’s Initial Bereavement Risk Assessment upon admission to the Hospice agency revealed it was performed on 03/22/2024. Review of Patient #5’s updated Bereavement Risk Assessment performed within 30 days following his death revealed no documented evidence available for review. Review of the Personnel File for the agency’s Bereavement Counselor/Chaplain employed from 12/28/2023 through 05/13/2024 was attempted with no documented evidence available for review. Review of the Hospice agency’s Written Agreements for the provision of Bereavement Counseling/Chaplain Services from 12/28/2023 through 05/13/2024 was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:45 p.m. with S1ED. S1ED reviewed the aforementioned information and confirmed Patient #3, #4, and #5 did not receive updates to the Bereavement section of the Comprehensive Assessment within the required timeframe and should have. S1ED confirmed the Core Services a Hospice agency was required to provide for their IDG included a Bereavement Counselor/Chaplain. S1ED confirmed the Hospice agency did not have a Bereavement Counselor/Chaplain on staff from 12/28/2023 through 05/13/2024 and the newly hired Chaplain did not complete orientation to begin seeing patients and families independently until 06/24/2024. S1ED confirmed during the lapse in Bereavement Counselor/Chaplain coverage, the agency admitted 107 patients and 78 patients expired. S1ED confirmed not having a Bereavement Counselor/Chaplain on staff meant the Hospice agency was not able to perform any of the required updates to the Comprehensive Assessments for this discipline. S1ED confirmed all aspects of care for each discipline should have been updated in the Comprehensive Assessment as needed and no less frequently than every 14 days with any changes communicated, discussed and addressed during IDG meetings to best meet the patient/family needs moving forward and they were not.”

“Based on interviews and record reviews, the Hospice agency failed to ensure the IDG maintained a system of communication, coordination, and integration of services for 2 (#8 and #9) of 14 (#6 - #19) live patients reviewed in the sample. This deficient practice had the potential to affect a current census of 58 patients. Cross Reference: L536, L541, L543, L545, L546, and L552. Review of the Hospice agency’s IDG Membership and Responsibilities Policy, revised on 02/01/2025, revealed, in part, the following: Purpose:To define the roles and responsibilities of the IDG. Policy: The Hospice IDG collaborates with the patient’s attending physician to develop and maintain a patient-directed, individualized POC. The Executive Director coordinates the overall functioning of the IDG. Procedure: 1. The Hospice IDG membership includes, but is not limited to: a) Medical Director or MDb) RNc) MSWd) Pastoral or Spiritual Counselor. e) Volunteer Services.3. In Louisiana, agencies will need to update the POC at least every 14 days. a. Maintaining responsibility for directing, coordinating, and supervising the care and services provided. b. Ensuring care and services are provided in accordance with the POC. c. Ensuring the care and services provided are based on all assessments of the patient and family needs. d. Providing for and ensuring the ongoing sharing of information between all disciplines providing care and services in all settings… . e, Designating a RN to coordinate the implementation of the POC for each patient. f. Participating in the establishment, periodic review and updating of the POC for each family receiving Bereavement Services. Review of the Hospice agency’s Initial and Comprehensive Admission Assessment and POC Policy, revised 04/01/2022, revealed, in part, the following: Purpose: To describe the initial and comprehensive Hospice patient assessment. The comprehensive assessment will be completed no later than 5 calendar days after the date of Election of Hospice Services and includes a thorough assessment of the patient’s physical, psychosocial, emotional and spiritual status related to the terminal illness and related conditions and the caregiver’s and family’s willingness and capability to care for the patient. The information gathered during the comprehensive assessment will be incorporated into an interdisciplinary POC. Procedure: 2. The Initial RN Assessment, including identification of goals and interventions, will include the assessment of: g. The family’s ability and willingness to learn and participate in caregiving; k. Mental/neurological function; l. Need for volunteer support;3. The RN will:a. Discuss desired outcomes with the patient and family using the assessment information gathered;b. Plan the appropriate interventions that will lead to the desired outcomes and review the POC with the patient/family and document their input into the planning process, including their understanding and agreement with the POC; c. Assess whether immediate assessment and intervention is required from another team member and notify that team member;d. Notify the core members of the IDG upon completion of the assessment. e. Review findings of the assessment with the Medical Director or Hospice MD and the Attending Physician, if any, and receive orders, as needed. 4. All treatments, medications, and services provided must be included on the initial POC. The POC will include:a. Goals and interventions agreed upon by the patient/representative and the Attending Physician;b. Documentation of any immediate visit needs, including a visit from a MSW, Chaplain, HA or other team member and appropriate notification of immediate needs; c. Documentation of notification of IDG members;Patient #8Review of Patient #8’s Clinical Record revealed she was admitted to the agency on 02/09/2025 with a terminal diagnosis of Human Immunodeficiency Virus. Further review revealed a current Certification Period of 02/09/2025 through 05/09/2025. Review of Patient #8’s RN Initial Assessment, dated 02/09/2025, revealed, in part, the following:Assessment: Is patient/CG open to volunteer services to meet family support needs? Yes. Indicate POC Compliance Risk Factors: Inadequate finances/resources. Narrative: Patient #8 requires continuous, around the clock supervision, assistance and care. Mother requires a lot of MSW resources. She is living alone with the daughter on a 3rd floor apartment. Appears to be in denial of daughter’s illness/prognosis. Further review revealed no documented evidence of the aforementioned needs being discussed and addressed with the IDG.Review of Patient #8’s MSW Initial Assessment, dated 02/27/2025, revealed, in part, the following:Assessment: Indicate family/relational support findings: Family is overwhelmed at times but is generally able to provide care. Indicate other family/relational support: Mother is primary caregiver. Mother just moved to the area recently and is seeking resources. Indicate caregiver findings: Caregiver is in need of resources due to being new to the area. Community Resource Needs assessed: Yes. Indicate other community resource: Caregiver is new to area and needs resources regarding Snap, Food Stamps, Medicaid, etc. Further review revealed no documented evidence of the aforementioned needs being discussed and addressed with the IDG.Review of Patient #8’s Chaplain Assessment, dated 02/12/2025, revealed, in part, the following:Visit Summary: Caregiver has no support and struggling to accept what was happening. Further review revealed no documented evidence of the aforementioned needs being discussed and addressed with the IDG.Review of Patient #8’s Coordination Notes, dated 02/09/2025 through 03/20/2025, revealed, in part, the following: 02/11/2025 – RN Visit:Patient #8’s mother expressed concerns with difficulty buying food and providing care. 02/14/2025 – RN Visit:Patient #8’s mother refuses Morphine in E-Kit. Mother expressed concerns about not being able to provide meals and not having enough income to suffice for both of them. 02/27/2025 – MSW Visit:Patient #8’s mother stated she applied for food stamps and was awaiting decision letter. Mother stated she received food stamps for herself but it was not enough to feed both her and the patient. Patient #8’s mother is 61 years old and has very little support resources. Stated she tries to maintain her daughter’s care and her own personal doctor’s appointments. 03/02/2025 – Triage Call: Patient #8’s mother report patient fell twice. 03/03/2025 – RN Visit:Patient #8’s mother expressed caregiver burnout stating she does not have anyone to come watch her while she runs errands for groceries or her own medical appointments. Will follow up with Volunteer Services to help with Caregiver Burnout. 03/03/2025 – RN Visit: Patient #8’s mother reported patient fell last night and again this morning. Demonstrated increased weakness and no longer able to feed self. Instructed mother on use of briefs and performing incontinence care in bed. Mother expressed caregiver burnout. Mother reported not having anyone to sit with Patient #8 while she goes for groceries or to her own medical appointments. Follow up needed with Volunteer Services to assist with her caregiver burnout. 03/06/2025 – RN Visit:Patient #8’s mother reports patient has been reliving some traumatic experiences in her dreams then waking up in a panic. 03/10/2025 – RN Visit: Reinforced ways to alleviate caregiver burnout and discussed respite care. Mother stated she would think about it. 03/13/2025 – RN Visit:Reinforced education on how to use pill organizer due to mother voicing confusion with which meds to give in morning and which at night. Patient #8’s mother showed signs of increased anxiety over patient’s condition. Further review revealed no documented evidence of the aforementioned needs and changes in condition being discussed and addressed with the IDG.An interview was conducted on 03/20/2025 at 3:40 p.m. with Patient #8’s mother. She confirmed she didn’t know anyone in the area and had no friends or family to assist her with the care needs of her daughter. She confirmed her daughter required 24/7 supervision and could not be left alone for her to go to the grocery store, pick up medications or go to medical appointments for herself. She confirmed since admission, two of the Hospice nurses told her the agency sometimes found volunteers to come sit with patients and they would check on setting it up, but she never heard anything else about it. She confirmed she had food stamps for herself but it didn’t cover enough food to feed both her and her daughter. An interview was conducted on 03/20/2025 at 4:10 p.m. with S5CH. S5CH confirmed upon admission, he became aware Patient #8’s mother had very little resources and was not sure where to start in terms of finding assistance in order to care for her daughter. S5CH confirmed Patient #8 and her mother did not know anyone in the area and needed emotional and social services support. S5CH confirmed he connected Patient #8’s mother with local churches and food banks in order to receive food for her and the patient, but he didn’t know how long that support would last. S5CH confirmed Patient #8’s mother had voiced signs of caregiver burnout on numerous occasions. S5CH confirmed Patient #8’s mother did not have any natural support to sit with her daughter so she could run to the grocery store, pharmacy and/or other errands. S5CH confirmed Patient #8’s mother was made aware the patient could stay in a respite care setting for a week or so to give her a break, but she did not want her to go for that long, she just needed a break for a couple of hours during the week for errands. Review of Patient #8’s Volunteer Services Notes for her current Certification Period, as of 03/19/2025, revealed, in part, Patient #8’s mother only received “tuck in” phone calls from volunteers. Review of Patient #8’s Comprehensive POC for her current Certification Period, as of 03/19/2025, revealed, in part, no documented evidence of individualized, patient-specific goals and interventions added to the POC for any of the aforementioned needs and changes in condition.Review of Patient #8’s IDG Meeting Notes for her current Certification Period, as of 03/19/2025, revealed, in part, no documented evidence of the aforementioned needs and changes in condition were discussed and addressed with the IDG.Patient #9Review of Patient #9’s Clinical Record revealed he was admitted to the agency on 06/12/2024, and was a resident of a local nursing home, with diagnoses which included Hemiplegia following Intracerebral Hemorrhage affecting Left Non-dominant Side; Paranoid Schizophrenia; Dementia; and Dysphagia. Further review revealed a current Certification Period of 02/07/2025 through 04/07/2025.Review of Patient #9’s Coordination Notes, dated 02/07/2025 through 03/20/2025, revealed, in part, the following: 02/24/2025 - RN Visit: New agitation noted on today as well as coughing while eating03/05/2025 – RN Visit: Patient had outburst of crying and agitation during visit. Further review revealed no documented evidence of the aforementioned changes in condition being discussed and addressed with the IDG.Review of Patient #9’s MARs from the local nursing home, dated 02/01/2025 and 03/20/2025, revealed, in part, documentation indicating Patient #9 demonstrated behaviors most days during both the morning and afternoon shifts from 02/01/2025 and 03/20/2025.Review of Patient #9’s Comprehensive POC, as of 03/20/2025, for his current Certification Period revealed, in part, no documented evidence of individualized, patient-specific goals and interventions added to the POC for any of the aforementioned changes in condition. Review of Patient #9’s IDG Meeting Notes, as of 03/20/2025, for his current Certification Period revealed, in part, no documented evidence of the aforementioned changes in condition were discussed and addressed with the IDG.An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED confirmed when staff identified patient/caregiver needs, the onset of new signs/symptoms, and/or changes in condition, she expected the person identifying it to immediately contact the appropriate member of the IDG to arrange for it to be handled, then discuss the changes with the team during IDG meetings no less frequent than every 14 days. S1ED confirmed all of this should be documented in the patient’s record and in the IDG Meeting Notes so their record would accurately reflect the agency’s efforts to best meet the patient/family needs moving forward. S1ED confirmed if her staff were unable to fulfill the needs of the patient/caregiver, she expected them to make her aware immediately so she could assist with finding a resolution. S1ED reviewed all volunteer services provided for Patient #8 and confirmed the only volunteer services she received since admission were “tuck in” calls to her mother to “check in” and ask if they had any supply or medication needs at the time. S1ED confirmed she was not made aware Patient #8’s mother needed a break a few hours a week and should have been so it could have been addressed appropriately. S1ED reviewed Patient #8’s record and confirmed the social service needs and changes in condition identified by the SN, Chaplain and MSW were not documented as being discussed and addressed with the IDG immediately or during Patient #8’s IDG Meeting and should have been. S1ED reviewed Patient #9’s record and confirmed the changes in condition identified by the nurses were not documented as being discussed and addressed with the MD immediately or with the team during Patient #8’s IDG Meeting and should have been.”

“Based on interviews and record reviews, the Hospice agency failed to maintain a qualified and competent IDG team to fulfill all of the required professional roles. This deficient practice is evidenced by failure to:1. Maintain employment of a MSW from 08/28/2024 through 03/03/2025; and2. Maintain employment of a Counselor/Chaplain from 12/28/2023 through 05/13/2024. This deficient practice had the potential to affect any of the 158 patient deaths and 218 patient admissions during the lapse in IDG coverage, as well as, a current census of 58 patients. Cross Reference: L536, L539, L543, L545, L546, and L552. Review of the Hospice agency’s IDG Membership and Responsibilities Policy, revised on 02/01/2025, revealed, in part, the following: Procedure: 1. The Hospice IDG membership includes, but is not limited to: c. MSW.d. Pastoral or Spiritual Counselor. 1. Failure to maintain employment of a MSW from 08/28/2024 through 03/03/2025.Review of the Personnel File for the agency’s MSW employed from 08/28/2024 through 03/03/2024 was attempted with no documented evidence available for review. Review of the Hospice agency’s Written Agreements for the provision of MSW Services from 08/28/2024 through 03/03/2024 was attempted with no documented evidence available for review. An interview was conducted on 03/25/2025 at 1:00 p.m. with S3MSW. S3MSW confirmed she recently started her role as MSW with the Hospice agency during the first week of March 2025 and would not be released to take patients on her own until 03/27/2025. S3MSW confirmed prior to her being hired, the Hospice agency had not had a MSW on staff since August of 2024. An interview was conducted on 03/27/2025 at 2:45 p.m. with S1ED. S1ED confirmed the required professional roles for a Hospice IDG included a MSW. S1ED confirmed the Hospice agency did not have a MSW on staff from 08/28/2024 through 03/03/2025, and the newly hired MSW would not complete orientation to begin seeing patients and families independently until 03/27/2025. S1ED confirmed during the lapse in MSW coverage, the agency admitted 111 patients and 80 patients expired. 2. Failure to maintain employment of a Counselor/Chaplain from 12/28/2023 through 05/13/2024. Review of the Personnel File for the agency’s Counselor/Chaplain employed from 12/28/2023 through 05/13/2024 was attempted with no documented evidence available for review. Review of the Hospice agency’s Written Agreements for the provision of Counselor/Chaplain Services from 12/28/2023 through 05/13/2024 was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:45 p.m. with S1ED. S1ED confirmed the required professional roles for a Hospice IDG included a Counselor/Chaplain. S1ED confirmed the Hospice agency did not have a Counselor/Chaplain on staff from 12/28/2023 through 05/13/2024, and the current Chaplain did not complete orientation to begin seeing patients and families independently until 06/24/2024. S1ED confirmed during the lapse in Counselor/Chaplain coverage, the agency admitted 107 patients and 78 patients expired.”

“Based on interviews and record reviews, the Hospice agency failed to ensure the care and services provided followed an individualized POC established by the IDG in collaboration with the Attending Physician in accordance with the patient’s needs. The Hospice agency failed to: 1. Ensure SNV were performed as ordered for 1 (#8) of 14 (#6 - #19) live patients in the sample; 2. Ensure HA Visits were performed as ordered for 2 (#8 and #14) of 14 (#6 - #19) live patients in the sample; 3. Ensure MSW Visits were performed as ordered for 2 (#13 and #18) of 14(#6 - #19) live patients in the sample; and4. Ensure Chaplain Visits were performed as ordered for 1 (#12) of 14 (#6 - #19) live patients in the sample. This deficient practice had the potential to affect a current census of 58 patients. Cross Reference: L536, L539, L541, L545, L546, and L552. Review of the Hospice agency’s Interdisciplinary Group (IDG) Membership and Responsibilities Policy, revised on 02/01/2025, revealed, in part, the following: Purpose:To define the roles and responsibilities of the IDG. Policy: The Hospice IDG collaborates with the patient’s attending physician to develop and maintain a patient-directed, individualized POC. The Executive Director coordinates the overall functioning of the IDG. Procedure: 1. The Hospice IDG membership includes, but is not limited to: a) Medical Director or MDb) RNc) MSWd) Pastoral or Spiritual Counselor. e) Volunteer Services.3. In Louisiana, agencies will need to update the POC at least every 14 days. b. Ensuring care and services are provided in accordance with the POC. c. Ensuring the care and services provided are based on all assessments of the patient and family needs. d. Providing for and ensuring the ongoing sharing of information between all disciplines providing care and services in all settings… . f. Participating in the establishment, periodic review and updating of the POC for each family receiving Bereavement Services. Review of the Hospice agency’s Psychosocial Assessment Policy, revised 02/01/2023, revealed, in part, the following: Purpose: To provide guidance for the assessment and reassessment of the psychosocial needs of hospice patients and families/caregivers. Policy: A thorough psychosocial assessment will be initiated at the time of admission and continued throughout the course of care. Psychosocial Assessment will be completed by a qualified Hospice MSW. Procedure: 1. The POC will address identified problems, goals and interventions, and will be approved by the IDG. 4. The MSW will continue to visit the patient/family at intervals designated by the POC. 5. Each visit or call will be documented in the patient’s medical record. 6. The Psychosocial POC will be updated as needed, but at least every 15 days, with changes documented and discussed with the IDG. 7. The MSW will coordinate resources to meet patient/family needs and will document those efforts in the patient’s medical record. Review of the Hospice agency’s Spiritual Assessment Policy, revised 02/01/2023, revealed, in part, the following: Purpose: To ensure each Hospice patient receives a Spiritual Assessment. Policy: All patients/families admitted to Hospice services will receive a Spiritual Assessment that identifies spiritual needs and goals. A Chaplain or qualified Spiritual Counselor will perform the assessment. Spiritual services will be delivered according to generally accepted standards of practice and in a manner, which is meaningful to the patient/representative. Spiritual care is provided either directly or through coordination with the patient/representative’s designated religious professional, as appropriate. Procedure: 1. The POC will address identified spiritual care needs, goals and interventions and will be approved by the IDG. 3. The Spiritual Counselor/Chaplain will continue to visit the patient/representative at intervals designated by the patient’s POC. 4. Each visit or call will be documented in each patient’s medical record. 5. The spiritual POC will be reviewed no less than every 15 days and updated according to patient/representative needs with changes documented and discussed with the IDG. 6. The Spiritual Counselor/Chaplain will coordinate resources and services to meet the patient/representative needs. This will include coordination of services with the patient/representative’s designated local clergy, pastoral counselor or other individual as appropriate. 7. In the event that patient/representative declines spiritual services, the Spiritual Counselor/Chaplain is to inquire if spiritual services are desired from another source and coordinate that care. The Spiritual Counselor/Chaplain will remain available in the event the patient/representative chooses to engage the Spiritual Counselor/Chaplain. 1. Ensure SNV were performed as ordered.Review of Patient #8’s Clinical Record revealed she was admitted to the agency on 02/09/2025 with diagnoses which included Human Immunodeficiency Virus. Further review revealed a current Certification Period of 02/09/2025 through 05/09/2025. Review of Patient #8’s Physician’s Orders and POC for the Certification period of 02/09/2025 through 05/09/2025 revealed a SNV frequency of twice weekly for thirteen weeks. Review of Patient #8’s Visit Calendar for the Certification period of 02/09/2025 through 05/09/2025 revealed the following Missed SNV:03/04/2025 - Patient/Caregiver refused. Further review revealed the aforementioned missed visit was not rescheduled and performed during the week it was missed. An interview was conducted on 03/20/2025 at 3:40 p.m. with Patient #8’s mother. She confirmed she had never refused any SNV for her daughter. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed the aforementioned documentation for Patient #8 and confirmed there was a missed SNV documented as refused by her mother. 2. Ensure HA Visits were performed as ordered.Patient #8Review of Patient #8’s Clinical Record revealed she was admitted to the agency on 02/09/2025 with diagnoses which included Human Immunodeficiency Virus. Further review revealed a current Certification Period of 02/09/2025 through 05/09/2025. Review of Patient #8’s Physician’s Orders and POC for the Certification period of 02/09/2025 through 05/09/2025 revealed a HA Visit frequency of twice weekly for thirteen weeks effective 02/09/2025. Review of Patient #8’s Visit Calendar for the Certification period of 02/09/2025 through 05/09/2025 revealed the following Missed HA Visits:02/11/2025 - Patient/Caregiver refused;02/27/2025 - No answer at the door;03/07/2025 - Patient/Caregiver refused;03/12/2025 - Patient/Caregiver refused;03/14/2025 - Patient/Caregiver refused; and 03/19/2025 - No answer at the door. Further review revealed none of the aforementioned missed visits were rescheduled and performed during the week it was missed. An interview was conducted on 03/20/2025 at 3:40 p.m. with Patient #8’s mother. She confirmed she had never refused any HA Visits for her daughter. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed the aforementioned documentation for Patient #8 and confirmed there were missed HA Visits documented as refused by her mother. Patient #14Review of Patient #14’s Clinical Record revealed he was admitted to the agency on 03/14/2025with diagnoses which included Acute on Chronic Systolic Heart Failure; Intracardiac Thrombosis, COPD, and Pulmonary Embolism. Further review revealed a current Certification Period of 03/14/2025 through 06/11/2025.Review of Patient #14’s Physician’s Orders and POC for the Certification Period of 03/14/2025 through 06/11/2025 revealed a HA Visit frequency of one visit weekly for 13 weeks effective 03/16/2025.Review of Patient #14’s HA’s POC for the Certification Period of 03/14/2025 through 06/11/2025 revealed a HA Visit frequency of one visit weekly for 13 weeks effective 03/16/2025.Review of Patient #14’s Visit Calendar for the Certification Period of 03/14/2025 through 06/11/2025 revealed no documented evidence of a HA Visit being conducted, missed, or attempted from 03/16/2025 through 03/26/2025. Review of Patient #14’s HA Visit Notes for the Certification Period of 03/14/2025 through 06/11/2025 revealed no documented evidence of a HA Visit being conducted, missed, or attempted from 03/16/2025 through 03/26/2025. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed the aforementioned documentation for Patient #14 and confirmed there were no HA Visits performed from 03/16/2025 through 03/26/2025. S1ED confirmed she expected all disciplines to perform their visits as ordered. S1ED stated all Hospice employees were expected to call prior to their visit to ensure the time they planned to go would work for the patient/family. S1ED stated if a Hospice employee showed up to a patient’s home to conduct a visit and could not get anyone to answer the door, they were expected to attempt to call the patient/family and wait 15 minutes then try again. S1ED stated if someone still had not come to the door or answered the phone, they were expected to then contact the office so the office could attempt to make contact with the patient/family while the employee remained at the home. S1ED stated if they still were unable to make contact, she would expect the employee to reschedule during the same week in order to prevent a missed visit from occurring. 3. Ensure MSW Visits were performed as ordered.Patient #13Review of Patient #13’s Clinical Record revealed he was admitted to the agency on 12/04/2024 with diagnoses which included Heart Failure. Further review revealed a current Certification Period of 03/04/2025 through 06/01/2025. Review of Patient #13’s Physician’s Orders and POC for the Certification Period of 12/04/2024 through 03/03/2025 revealed an order written on 01/10/2025 to add a MSW Visit once a month. Review of Patient #13’s MSW Visit Calendar for the Certification Period of 12/04/2024 through 03/03/2025 revealed no documented evidence of a MSW Visit being conducted, missed or canceled from 01/10/2025 through 01/23/2025. Review of Patient #13’s Coordination Notes for the Certification Period of 12/04/2024 through 03/03/2025 revealed no documented evidence of a MSW Visit being attempted, conducted, missed, or canceled from 01/10/2025 through 01/23/2025. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED confirmed a Physician’s Order was written for Patient #13 to receive a MSW Visit on 01/10/2025 and the visit was not conducted until 01/24/2025. S1ED confirmed she expected visits to be conducted as ordered and 14 days was too long. S1ED confirmed Patient #13’s Physician Order for a MSW Visit was not carried out as promptly as it should have been. Patient #18Review of Patient #18’s Clinical Record revealed she was admitted to the agency on 02/10/2025 with a diagnoses of Parkinson’s Disease. Further review revealed a current Certification Period of 02/10/2025 through 05/10/2025.Review of Patient #18’s Physician’s Orders and POC for the Certification Period of 02/10/2025 through 05/10/2025 revealed an order written on 02/26/2025 to add MSW Services. Review of Patient #18’s MSW Visit Calendar for the Certification Period of 02/10/2025 through 05/10/2025 revealed no documented evidence of a MSW Visit being conducted, missed or canceled from 02/26/2025 through 03/18/2025. Review of Patient #18’s Coordination Notes for the Certification Period of 02/10/2025 through 05/10/2025 revealed no documented evidence of a MSW Visit being attempted, conducted, missed or canceled from 02/26/2025 through 03/18/2025. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED confirmed a Physician’s Order was written for Patient #18 to receive a MSW Visit on 02/26/2025 and the visit was not conducted until 03/19/2025. S1ED confirmed she expected visits to be conducted as ordered and 22 days was too long. S1ED confirmed Patient #18’s Physician Order for a MSW Visit was not carried out as promptly as it should have been. 4. Ensure Chaplain Visits were performed as ordered.Review of Patient #12’s Clinical Record revealed he was initially admitted to the agency on 04/09/2024 with diagnoses including Parkinson’s Disease and Anxiety Disorder. Further review revealed he was in his 5th Certification Period from 02/03/2025 through 03/16/2025. Review of Patient #12’s Physician’s Orders and POC for the Certification Period of 02/03/2025 through 03/16/2025 revealed an order written on 03/10/2025 to add Chaplain Services. Review of Patient #12’s Visit Calendar from 03/10/2025 through his discharge on 03/16/2025 revealed, no documented evidence of a Chaplain Visit being conducted, missed or canceled during the aforementioned timeframe.Review of Patient #12’s Coordination Notes from 03/10/2025 through his discharge on 03/16/2025 revealed no documented evidence of a Chaplain Visit being attempted, conducted, missed or canceled during the aforementioned timeframe.An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED confirmed a Physician’s Order was written for Patient #12 to receive a Chaplain Visit on 03/10/2025 and the visit was not conducted as ordered prior to his discharge from the agency on 03/16/2025 and should have been. S1ED confirmed she expected visits to be conducted as ordered and in a timely manner after the order was written.”

“Based on interviews and record reviews, the Hospice agency failed to develop an individualized, patient-centered POC for each patient with goals and interventions for the problems identified during each assessment for 5 (#7, #8, #9, #10, and #11) of 14 (#6 through #19) live patients sampled. This deficient practice had the potential to affect a current census of 58 patients. See findings: L536, L539, L541, L543, L546, and L552. Review of the Hospice agency’s Interdisciplinary Group (IDG) Membership and Responsibilities Policy, revised on 02/01/2025, revealed, in part, the following: Policy: The Hospice IDG collaborates with the patient’s attending physician to develop and maintain a patient-directed, individualized POC. The Executive Director coordinates the overall functioning of the IDG. Procedure: 1. The Hospice IDG membership includes, but is not limited to: a) Medical Director or MDb) RNc) MSWd) Pastoral or Spiritual Counselor. e) Volunteer Services.3. In Louisiana, agencies will need to update the POC At least every 14 days. b. Ensuring care and services are provided in accordance with the POC. c. Ensuring the care and services provided are based on all assessments of the patient and family needs. d. Providing for and ensuring the ongoing sharing of information between all disciplines providing care and services in all settings. f. Participating in the establishment, periodic review and updating of the POC for each family receiving Bereavement Services. Review of the Hospice agency’s Initial and Comprehensive Admission Assessment and POC Policy, revised 04/01/2022, revealed, in part, the following: Purpose: To describe the initial and comprehensive Hospice patient assessment. The comprehensive assessment will be completed no later than 5 calendar days after the date of Election of Hospice Services and includes a thorough assessment if the patient’s physical, psychosocial, emotional and spiritual status related to the terminal illness and related conditions and the caregiver’s and family’s willingness and capability to care for the patient. The information gathered during the comprehensive assessment will be incorporated into an interdisciplinary POC. Procedure: 1. The RN will conduct an Initial Comprehensive Assessment to determine the patient’s immediate care and support needs within 48 hours after the date of EOB, or earlier if requested. This initial assessment will be documented in the patient’s medical record. 2. The Initial RN Assessment, including identification of goals and interventions, will include the assessment of: a. Anxiety/depression;b. Nutrition; c. Coping-Patient and Family;d. Safety Concerns; e. Breathing/respiration; f. Bowel/urinary elimination; g. The family’s ability and willingness to learn and participate in caregiving; h. Physical mobility; i. Integumentary system; j. Cardiac/circulation system; k. Mental/neurological function; l. Need for volunteer support;m. Immediate bereavement needs; n. Pain; o. Need for HA services. 3. The RN will:a. Discuss desired outcomes with the patient and family using the assessment information gathered;b. Plan the appropriate interventions that will lead to the desired outcomes and review the POC with the patient/family and document their input into the planning process, including their understanding and agreement with the POC; c. Assess whether immediate assessment and intervention is required from another team member and notify that team member;d. Notify the core members of the IDG upon completion of the assessment. e. Review findings of the assessment with the Medical Director or Hospice Physician and the Attending Physician, if any, and receive orders, as needed. 4. All treatments, medications, and services provided must be included on the initial POC. The POC will include:a. Goals and interventions agreed upon by the patient/representative and the Attending Physician;b. Documentation of any immediate visit needs, including a visit from a MSW, Chaplain, HA or other team member and appropriate notification of immediate needs; c. Documentation of notification of IDG members;5. The MSW will complete a Psychosocial Evaluation identifying goals and interventions, including the Initial Bereavement Risk Assessment, no later than 5 days after the date of Hospice Election as part of the comprehensive assessment. 6. The Chaplain will complete the spiritual evaluation identifying goals and interventions needed no later than 5 days after the date of hospice election as part of the comprehensive assessment. Patient #7Review of Patient #7’s Clinical Record revealed a Start of Care date of 02/28/2025 with a terminal diagnosis of End Stage Heart Failure Class IV, an EF of 10%, and co-morbidities including;: Chronic Kidney Disease Stage 4; Hepatitis C with Cirrhosis; Atrial Fibrillation and Diabetes Type 2. Further review revealed a current Certification Period of 02/28/2025 through 05/28/2025. Review of Patient #7’s RN Initial Assessment, dated 02/28/2025, revealed, in part, the following: Assessment: Cardiovascular Status: ICD present to left chest. Fall Risk Assessment: At Risk for Falls with a score of 9 due to decreased strength to bilateral upper/lower extremities. Narrative: 2+ pitting edema present to the left lower extremity. Review of Patient #7’s Coordination Notes, dated 02/28/2025 through 03/20/2025, revealed, in part, the following: 03/01/2025:Integumentary issues assessed this visit: Yes, left lower abdomen paracentesis site. Patient and family are having a hard time with his new diagnoses. 03/04/2025: Fall Risk Assessment: At Risk for Falls with a score of 7 due to decreased strength to bilateral lower extremitiesIntegumentary concerns: Poor turgor. Reported concerns with constipation. +1 edema to bilateral lower extremities. Concerns present with patient noncompliance in regards to appropriate use of medications and interventions. 03/06/2025:Patient declined MSW and Chaplain services at this time. 03/16/2025:Patient and family refused Morphine and oxygen. 03/17/2025:Patient and/or family refused Lactulose, Morphine, Ativan and Haldol. Agreeable to Oxycodone. 03/18/2025:Patient and family agreed to Haldol due to continued nausea and vomiting throughout the night. 03/20/2025:Reviewed and discussed his current ordered medications. Reinforced need for medication compliance. 03/21/2025:Noncompliance with medication regimen since visit yesterday. Reinforced need for compliance with medications as ordered. An interview was conducted on 03/24/2025 at 4:15 p.m. with S4RN. S4RN confirmed Patient #7 recently refused Chaplain and Social Work services. S4RN confirmed Patient #7 was identified as an increased fall risk upon admission and each visit his risk continued to increase due to the progression of his generalized weakness. S4RN confirmed Patient #7 was identified as being at risk for skin breakdown upon his admission due to poor skin turgor and his risk continued to increase due to his decreased caloric and oral hydration intake. S4RN confirmed there were on-going concerns with his noncompliance with medication and intervention regimens which further complicated the treatment of his symptoms. S4RN confirmed it was important to monitor and address all of Patient #7’s aforementioned issues during every visit in order to decrease his symptoms and keep him as comfortable as possible. Review of Patient #7’s Comprehensive POC for his current Certification Period, as of 03/20/2025, revealed, in part, no documented evidence of the identification of any of the aforementioned problems with individualized, patient-specific goals and interventions added to the POC. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed Patient #7’s POC and confirmed the aforementioned information was not reflected in his POC and should have been. Patient #8Review of Patient #8’s Clinical Record revealed she was admitted to the agency on 02/09/2025 with diagnoses which included Human Immunodeficiency Virus. Further review revealed a current Certification Period of 02/09/2025 through 05/09/2025. Review of Patient #8’s RN Initial Assessment, dated 02/09/2025, revealed, in part, the following:Assessment: Fall Risk assessment determined “at risk for falls”Is patient/CG open to volunteer services to meet family support needs? Yes. Indicate which volunteer services the patient/family is open to receive: Home Visit; Errands; Emotional Support; and “Tuck in” phone calls.Indicate POC Compliance Risk Factors: Inadequate finances/resources. Narrative: Patient #8 requires continuous, around the clock supervision, assistance and care. Mother requires a lot of MSW resources. She is living alone with the daughter on a 3rd floor apartment. Appears to be in denial of daughter’s illness/prognosis. Review of Patient #8’s MSW Initial Assessment, dated 02/27/2025, revealed, in part, the following:Assessment: Indicate family/relational support findings: Family is overwhelmed at times but is generally able to provide care. Indicate other family/relational support: Mother is primary caregiver. Mother just moved to the area recently and is seeking resources. Indicate caregiver findings: CG is present and willing to care for patient. Caregiver is in need of resources due to being new to the area. Community Resource Needs assessed: Yes. Indicate other community resource: Caregiver is new to area and needs resources regarding snap, food stamps, Medicaid, etc. Review of Patient #8’s Chaplain Assessment, dated 02/12/2025, revealed, in part, the following:Visit Summary: Caregiver has no support and was struggling to accept what was happening. Review of Patient #8’s Coordination Notes, dated 02/09/2025 through 03/20/2025, revealed, in part, the following: 02/11/2025 – RN Visit:Patient #8’s mother expressed concerns with difficulty buying food and providing care. 02/14/2025 – RN Visit:Patient #8’s mother refuses Morphine in E-Kit. Mother expressed concerns about not being able to provide meals and not having enough income to suffice for both of them. 02/27/2025 – MSW Visit:Patient #8’s mother stated she applied for food stamps and was awaiting decision letter. Mother stated she received food stamps for herself but it was not enough to feed both her and the patient. Patient #8’s mother is 61 years old and has very little support resources. Stated she tries to maintain her daughter’s care and her own personal doctor’s appointments. 03/02/2025 – Triage Call: Patient #8’s mother report patient fell twice. 03/03/2025 – RN Visit:Patient #8’s mother expressed caregiver burnout stating she does not have anyone to come watch her while she runs errands for groceries or her own medical appointments. Will follow up with Volunteer Services to help with Caregiver Burnout. Delivered meds and refilled weekly pill organizer. 03/03/2025 – RN Visit: Patient #8’s mother reported patient fell last night and again this morning. Demonstrated increased weakness and no longer able to feed self. Instructed mother on use of briefs and performing incontinence care in bed. Mother expressed caregiver burnout. Mother reported not having anyone to sit with Patient #8 while she goes for groceries or to her own medical appointments. Follow up needed with Volunteer Services to assist with her caregiver burnout. Delivered meds and refilled weekly pill organizer.03/06/2025 – RN Visit:Delivered meds and refilled weekly pill organizer.03/10/2025 – RN Visit: Reinforced ways to alleviate caregiver burnout and discussed respite care. Mother stated she would think about it. 03/13/2025 – RN Visit:Reinforced education on how to use pill organizer due to mother voicing confusion with which meds to give in morning and which at night. Patient #8’s mother showed signs of increased anxiety over patient’s condition. 03/17/2025 – RN Visit: Delivered meds and refilled weekly pill organizer.An interview was conducted on 03/20/2025 at 3:40 p.m. with Patient #8’s mother. She confirmed she didn’t know anyone in the area and had no friends or family to assist her with the care needs of her daughter. She confirmed her daughter required 24/7 supervision and could not be left alone for her to go to the grocery store, pick up medications or go to medical appointments for herself. She confirmed the Hospice nurse has been picking up her daughter’s medications and bringing them to her during visits, as well as refilling the pill organizer each week. She confirmed since admission, two of the Hospice nurses told her the agency sometimes found volunteers to come sit with patients and they would check on setting it up, but she never heard anything else about it. She confirmed she had food stamps for herself but it didn’t cover enough food to feed both her and her daughter. She confirmed the Chaplain gave her phone numbers to local churches to reach out to for assistance, and so far they had been helping out so they hadn’t been without food. An interview was conducted on 03/20/2025 at 4:10 p.m. with S5CH. S5CH confirmed upon admission, he became aware Patient #8’s mother had very little resources and she was not sure where to start in terms of finding assistance in order to care for her daughter. S5CH confirmed Patient #8 and her mother did not know anyone in the area and needed emotional and social services support. S5CH confirmed he connected Patient #8’s mother with local churches and food banks in order to receive enough food to feed both her and the patient. S5CH confirmed Patient #8’s mother had voiced signs of caregiver burnout on numerous occasions. S5CH confirmed Patient #8’s mother did not have any natural support to sit with her daughter so she could run to the grocery store and/or pharmacy or do other errands. S5CH confirmed Patient #8’s mother was made aware of respite possibilities for the patient to stay in a respite care setting for a week or so to give her a break, but she did not want her to go for that long, she just needed a break a couple of hours during the week for errands. Review of Patient #8’s Comprehensive POC for her current Certification Period, as of 03/19/2025, revealed, in part, no documented evidence of the identification of any of the aforementioned problems with individualized, patient-specific goals and interventions added to the POC. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed Patient #8’s POC and confirmed the aforementioned information was not reflected in her POC and should have been. Patient #9Review of Patient #9’s Clinical Record revealed he was admitted to the agency on 06/12/2024, and was a resident of a local nursing home, with diagnoses which included Hemiplegia following Intracerebral Hemorrhage affecting Left Non-dominant Side; Paranoid Schizophrenia; Dementia; and Dysphagia. Further review revealed a current Certification Period of 02/07/2025 through 04/07/2025.Review of Patient #9’s Physician Orders revealed, in part, the following: 01/07/2025 – Apply Nystatin Topical Powder twice daily to affected areas. Reason: Fungal infection to skin folds. An interview was conducted on 03/24/2025 at 8:40 a.m. with S6HA. S6HA confirmed Patient #9 had dysphagia and was paralyzed on one side and weak on the other side. S6HA confirmed he was incontinent and totally dependent on the nursing home staff for his ADLs, required total assistance in order to drink and had to be fed his meals. Review of Patient #9’s Comprehensive POC for his current Certification Period, as of 03/20/2025, revealed, in part, no documented evidence of the identification of any of the aforementioned problems with individualized, patient-specific goals and interventions added to the POC.An interview was conducted on 03/24/2025 at 1:05 p.m. with S1ED. S1ED confirmed Patient #9 resided in a local nursing home. S1ED confirmed the Hospice agency was required to provide the nursing home with the patient’s POC and it should reflect all of the problems identified along with individualized, patient-specific goals and interventions the patient required from nursing home staff. S1ED confirmed the nursing home would be expected to review the POC to determine the patient’s problems and care needs. S1ED reviewed Patient #9’s POC and confirmed the aforementioned information was not reflected in his POC and should have been. Patient #10Review of Patient #10’s Clinical Record revealed he was admitted to the agency on 01/25/2025 and was receiving treatment for Pressure Ulcers to his Sacrum, Right Buttock and Left Buttock. Further review revealed a current Certification Period of 01/25/2025 through 03/21/2025. Review of the Hospice agency’s Wound Log, as of 03/19/2025, revealed, in part, the following: Patient #10 received treatment for a Sacral Pressure Ulcer, a Right Buttock Pressure Ulcer and Left Buttock Pressure Ulcer. Review of Patient #9’s Comprehensive POC for his current Certification Period, as of 03/19/2025, revealed, in part, no documented evidence of the identification of any of the aforementioned problems with individualized, patient-specific goals and interventions added to the POC. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed Patient #8’s POC and confirmed the aforementioned information was not reflected in his POC and should have been. Patient #11Review of Patient #11’s Clinical Record revealed he was admitted to the agency on 02/11/2025 with diagnoses which included Unspecified Severe Protein Deficiency; Human Immunodeficiency Virus; and Bipolar Disorder. Further review revealed a current Certification Period of 02/11/2025 through 05/11/2025. Review of Patient #11’s RN Initial Assessment, dated 02/11/2025, revealed, in part, the following: Is oxygen ordered continuously, intermittent or PRN? Yes. Is there a potential for open flames noted? Yes, family smokes inside of the home. Does patient smoke? Yes. Are there smoking materials in the home? Yes. Indicate smoking materials identified and action taken: Cigarettes. Family informed to get a fire extinguisher and not smoke inside if patient is using oxygen. Narrative: Patient is a current smoker. Nicotine patches ordered. Review of Patient #11’s Physician’s Orders, as of 03/26/2025 for the current Certification Period, revealed, in part, the following:02/11/2025 – Nicotine 21mg/24 hour patch to be applied to skin daily; and 02/12/2025 – Oxygen Gas for inhalation at 2 to 4 liters per minute via nasal cannula as needed.Review of Patient #11’s Comprehensive POC for his current Certification Period, as of 03/26/2025, revealed, in part, no documented evidence of the identification of any of the aforementioned problems with individualized, patient-specific goals and interventions added to the POC. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed Patient #11’s POC and confirmed the aforementioned information was not reflected in his POC and should have been. S1ED confirmed all POC’s should be individualized and patient-centered to reflect their specific situation and current needs, including their goals and interventions.”

“Based on interviews and record reviews, the Hospice agency failed to develop an individualized, patient-centered POC with interventions to promote quality of life and prevent distress through pain and symptom management for 4 (#7, #8, #9, and #10) of 14 (#6 through #19) live patients sampled. This deficient practice had the potential to affect a current census of 58 patients. Cross Reference: L536, L539, L541, L543, L545, and L552. Review of the Hospice agency’s Interdisciplinary Group (IDG) Membership and Responsibilities Policy, revised on 02/01/2025, revealed, in part, the following: Policy: The Hospice IDG collaborates with the patient’s attending physician to develop and maintain a patient-directed, individualized POC. The Executive Director coordinates the overall functioning of the IDG. Procedure: 3. In Louisiana, agencies will need to update the POC at least every 14 days. b. Ensuring care and services are provided in accordance with the POC. c. Ensuring the care and services provided are based on all assessments of the patient and family needs. e, Designating a RN to coordinate the implementation of the POC for each patient. f. Participating in the establishment, periodic review and updating of the POC for each family receiving Bereavement Services. Review of the Hospice agency’s Initial and Comprehensive Admission Assessment and POC Policy, revised 04/01/2022, revealed, in part, the following: Purpose: To describe the initial and comprehensive Hospice patient assessment. The comprehensive assessment will be completed no later than 5 calendar days after the date of Election of Hospice Services and includes a thorough assessment of the patient’s physical, psychosocial, emotional and spiritual status related to the terminal illness and related conditions and the caregiver’s and family’s willingness and capability to care for the patient. The information gathered during the comprehensive assessment will be incorporated into an interdisciplinary POC. Procedure: 1. The RN will conduct an Initial Comprehensive Assessment to determine the patient’s immediate care and support needs within 48 hours after the date of EOB, or earlier if requested. This initial assessment will be documented in the patient’s medical record. 2. The Initial RN Assessment, including identification of goals and interventions, will include the assessment of: a. Anxiety/depression;b. Nutrition; c. Coping-Patient and Family;d. Safety Concerns; e. Breathing/respiration; f. Bowel/urinary elimination; g. The family’s ability and willingness to learn and participate in caregiving; h. Physical mobility; i. Integumentary system; j. Cardiac/circulation system; k. Mental/neurological function; l. Need for volunteer support;m. Immediate bereavement needs; n. Pain; o. Need for HA services. 3. The RN will:a. Discuss desired outcomes with the patient and family using the assessment information gathered;b. Plan the appropriate interventions that will lead to the desired outcomes and review the POC with the patient/family and document their input into the planning process, including their understanding and agreement with the POC; c. Assess whether immediate assessment and intervention is required from another team member and notify that team member;d. Notify the core members of the IDG upon completion of the assessment. e. Review findings of the assessment with the Medical Director or Hospice Physician and the Attending Physician, if any, and receive orders, as needed. 4. All treatments, medications, and services provided must be included on the initial POC. The POC will include:a. Goals and interventions agreed upon by the patient/representative and the Attending Physician;b. Documentation of any immediate visit needs, including a visit from a MSW, Chaplain, HA or other team member and appropriate notification of immediate needs; c. Documentation of notification of IDG members;Patient #7Review of Patient #7’s Clinical Record revealed a Start of Care date of 02/28/2025 with a terminal diagnosis of End Stage Heart Failure Class IV and an EF of 10% and co-morbidities including: Chronic Kidney Disease Stage 4; Hepatitis C with Cirrhosis; Atrial Fibrillation and Diabetes Type 2. Further review revealed a current Certification Period of 02/28/2025 through 05/28/2025. Review of Patient #7’s RN Initial Assessment, dated 02/28/2025, revealed, in part, the following: Assessment: Indicate Patient’s mental status, mood, affect: RestlessNarrative: Patient agitated. Review of Patient #7’s Coordination Notes, dated 02/28/2025 through 03/20/2025, revealed, in part, the following: 03/04/2025: Indicate patient’s emotional status: Anxiety.Reported concerns with constipation. 03/17/2025:Patient reporting nausea, restlessness. Heart rate elevated. Patient and/or family refused Lactulose, Morphine, Ativan and Haldol. Family agreeable to Oxycodone. 03/18/2025:Patient and family agreed to Haldol due to continued nausea and vomiting throughout the night. 03/20/2025:Patient remains restless upon arrival following Ativan administration by spouse earlier in day. Patient reporting stomach upset and only a small bowel movement yesterday. Heart rate elevated. Reviewed and discussed his current medications. Physician contacted, new orders received. Fleets enema administered with results following. Patient continued to report abdominal pain and stated he feels like he needs another bowel movement. Instructed to take Magnesium Citrate and reinforced need for compliance with Miralax and Lactulose as ordered. 03/21/2025:Patient reported continued nausea without abdominal pain and had additional bowel movement since yesterday. Administered prune juice, Miralax and a suppository during visit due to noncompliance with medication regimen since previous visit. No bowel movement during visit but large amounts of gas with active bowel sounds. Reinforced need for compliance with bowel medications as ordered. An interview was conducted on 03/24/2025 at 4:15 p.m. with S4RN. S4RN confirmed Patient #7 had on-going issues with restlessness and his agitation had been increasing since his admission to the agency. S4RN confirmed Patient #7 began having issues with constipation about a week and a half ago and the issues remained current. S4RN confirmed Patient #7 experienced nausea and decreased appetite. S4RN confirmed she spoke with the doctor during each of Patient #7’s visit to update him and obtain new orders. S4RN confirmed it was important to monitor and address all of Patient #7’s aforementioned issues during every visit in order to decrease his symptoms and keep him as comfortable as possible. Review of Patient #7’s Comprehensive POC for his current Certification Period, as of 03/20/2025, revealed, in part, no documented evidence of individualized, patient-specific goals and interventions added to the POC for the management of pain, agitation, hallucinations, nausea or constipation. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed Patient #7’s POC and confirmed his POC did not include individualized, patient-specific goals and interventions for the management of pain, agitation, hallucinations, nausea or constipation and should. Patient #8Review of Patient #8’s Clinical Record revealed she was admitted to the agency on 02/09/2025 with diagnoses which included Human Immunodeficiency Virus. Further review revealed a current Certification Period of 02/09/2025 through 05/09/2025. Review of Patient #8’s RN Initial Assessment, dated 02/09/2025, revealed, in part, the following:Assessment: Mental Status: Confused, Hallucinations Mood/Affect: RestlessReview of Patient #8’s Coordination Notes, dated 02/09/2025 through 03/20/2025, revealed, in part, the following: 02/11/2025 – RN Visit:Mother stated her daughter has been becoming very angry and attempting to physically attack her, resulting in multiple phone calls to the police. 02/14/2025 – RN Visit:Patient #8’s mother refused Morphine in E-Kit. 03/02/2025 – Triage Call: Patient #8’s mother reported patient fell twice. 03/03/2025 – RN Visit: Patient #8’s mother reported patient fell last night and again this morning. MD notified with new orders received for pain medication. 03/06/2025 – RN Visit:Patient #8’s mother reports patient has been reliving some traumatic experiences in her dreams then waking up in a panic. An interview was conducted on 03/202/2025 at 3:40 p.m. with Patient #8’s mother. She confirmed her daughter experienced pain at a level which required medications to relieve it. She confirmed her daughter’s falls were usually related to her being restless or agitated. She confirmed her daughter had on-going issues with agitation and physical aggression since she was admitted to the agency. She confirmed her daughter would become agitated at times when she attempted to provide care. She confirmed she also had night terrors and would wake up hallucinating thinking it was real and someone was in the apartment trying to hurt her. She confirmed at times she had to call local law enforcement because Patient #8 was a danger to them both. Review of Patient #8’s Comprehensive POC for her current Certification Period, as of 03/19/2025, revealed, in part, no documented evidence of individualized, patient-specific goals and interventions added to the POC for the management of pain, agitation, restlessness, anxiety, aggressiveness or hallucinations. An interview was conducted on 03/20/2025 at 4:10 p.m. with S5CH. S5CH confirmed he was aware Patient #8 required medications to treat her pain. S5CH confirmed her mother informed him of issues with Patient #8 being physically combative towards her when trying to provide care and/or when waking up from night terrors and thinking people were there to hurt her. S5CH confirmed Patient #8’s mother made him aware she had to call the police a few times to assist when her daughter was too aggressive and posed a danger to them both. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed Patient #8’s POC and confirmed her POC did not include individualized, patient-specific goals and interventions for the management of pain, restlessness, agitation, hallucinations, or night terrors and should. Patient #9Review of Patient #9’s Clinical Record revealed he was admitted to the agency on 06/12/2024, and was a resident of a local nursing home, with diagnoses which included Hemiplegia following Intracerebral Hemorrhage affecting Left Non-dominant Side; Paranoid Schizophrenia; Dementia; and Dysphagia. Further review revealed a current Certification Period of 02/07/2025 through 04/07/2025.Review of Patient #9’s Coordination Notes, dated 02/07/2025 through 03/20/2025, revealed, in part, the following: 02/24/2025 - RN Visit: New agitation noted today as well as coughing while eating03/05/2025 – RN Visit: Patient had outburst of crying and agitation during visit. Review of Patient #9’s MARs from the local nursing home, dated 02/01/2025 and 03/20/2025, revealed, in part, the following: Patient #9’s nurses documented behaviors most days during both the morning and afternoon shifts through the entire timeframe reviewed. Review of Patient #9’s Comprehensive POC for his current Certification Period, as of 03/20/2025, revealed, in part. no documented evidence of individualized, patient-specific goals and interventions added to the POC for the management of pain, agitation, crying and/or other behaviors. An interview was conducted on 03/24/2025 at 1:05 p.m. with S1ED. S1ED confirmed Patient #9 resided in a local nursing home. S1ED confirmed the Hospice agency was required to provide the nursing home with a patient’s POC with all of their problems including individualized, patient-specific goals and interventions required from nursing home staff. S1ED confirmed the nursing home would be expected to review the POC to determine what interventions a patient required. S1ED reviewed Patient #9’s POC and confirmed his POC did not include individualized, patient-specific goals and interventions for the management of pain, agitation, crying and/or other behaviors and should. Patient #10Review of Patient #10’s Clinical Record revealed he was admitted to the agency on 01/25/2025 and developed 3 stage 3 Pressure Ulcers to his Sacrum, Right Buttock and Left Buttock. Further review revealed a current Certification Period of 01/25/2025 through 03/21/2025. Review of Patient #10’s Comprehensive POC for his current Certification Period, as of 03/19/2025, revealed, in part, no documented evidence of individualized, patient-specific goals and interventions added to the POC for the management of pain. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed Patient #8’s POC and confirmed his POC did not include individualized, patient-specific goals and interventions for the management of pain and should. S1ED confirmed all POC’s should be individualized and patient-specific to reflect their specific situation and current needs. S1ED confirmed all POCs should include individualized, patient-specific goals and interventions for the management of pain.”

“Based on interviews and record reviews, the Hospice agency failed to ensure all required members of the IDG reviewed, revised and updated the POC as frequently as their condition required but no less frequently than 15 calendar days. This deficient practice is evidenced by failure to: 1. Maintain employment of a MSW from 08/28/2024 through 03/03/2025 resulting in 0% POC reviews and documented revisions performed during the lapse in coverage; and2. Maintain employment of a Counselor/Chaplain from 12/28/2023 through 05/13/2024 resulting in 0% POC reviews and documented revisions performed during the lapse in coverage. This deficient practice had the potential to affect any of the 158 patient deaths and 218 patient admissions during the lapse in IDG coverage, as well as, a current census of 58 patients. Cross Reference: L536, L539, L541, L543, L545, L546, and L552. Review of the Hospice agency’s Interdisciplinary Group (IDG) Membership and Responsibilities Policy, revised on 02/01/2025, revealed, in part, the following: Purpose:To define the roles and responsibilities of the IDG. Policy: The Hospice IDG collaborates with the patient’s attending physician to develop and maintain a patient-directed, individualized POC. The Executive Director coordinates the overall functioning of the IDG. Procedure: 1. The Hospice IDG membership includes, but is not limited to: c. MSWd. Pastoral or Spiritual Counselor. 3. In Louisiana, agencies will need to update the POC at least every 14 days. a. Maintaining responsibility for directing, coordinating, and supervising the care and services provided. b. Ensuring care and services are provided in accordance with the POC. c. Ensuring the care and services provided are based on all assessments of the patient and family needs. d. Providing for and ensuring the ongoing sharing of information between all disciplines providing care and services in all settings. f. Participating in the establishment, periodic review and updating of the POC for each family receiving Bereavement Services. 1. Failure to maintain employment of a MSW from 08/28/2024 through 03/03/2025.Review of the Hospice agency’s Psychosocial Assessment Policy, revised 02/01/2023, revealed, in part, the following: Purpose: To provide guidance for the assessment and reassessment of the psychosocial needs of hospice patients and families/caregivers. Policy: A thorough psychosocial assessment will be initiated at the time of admission and continued throughout the course of care. Psychosocial assessment will be completed by a qualified hospice MSW. Procedure: 1. The Psychosocial POC will address identified problems, goals and interventions, and will be approved by the IDG. 6. The Psychosocial POC will be updated as needed, but at least every 15 days, with changes documented and discussed with the IDG. 7. The MSW will coordinate resources to meet patient/family needs and will document those efforts in the patient’s medical record. Review of the Personnel File for the agency’s MSW employed from 08/28/2024 through 03/03/2024 was attempted with no documented evidence available for review. Review of the Hospice agency’s Written Agreements for the provision of MSW Services from 08/28/2024 through 03/03/2024 was attempted with no documented evidence available for review. An interview was conducted on 03/25/2025 at 1:00 p.m. with S3MSW. S3MSW confirmed she recently started her role as MSW with the Hospice agency during the first week of March 2025 and would not be released to take patients on her own until 03/27/2025. S3MSW confirmed prior to her being hired, the Hospice agency had not had a MSW on staff since August of 2024. An interview was conducted on 03/27/2025 at 2:45 p.m. with S1ED. S1ED confirmed the required professional roles for a Hospice IDG included a MSW. S1ED confirmed the Hospice agency did not have a MSW on staff from 08/28/2024 through 03/03/2025, and the newly hired MSW would not complete orientation to begin seeing patients and families independently until 03/27/2025. S1ED confirmed during the lapse in MSW coverage, the agency admitted 111 patients and 80 patients expired. S1ED confirmed not having a MSW on staff meant the Hospice agency was not able to perform any of the required updates to the POC for this discipline. 2. Failure to maintain employment of a Counselor/Chaplain from 12/28/2023 through 05/13/2024.Review of the Hospice agency’s Spiritual Assessment Policy, revised 02/01/2023, revealed, in part, the following: Policy: Spiritual services will be delivered according to generally accepted standards of practice and in a manner, which is meaningful to the patient/representative. Spiritual care is provided either directly or through coordination with the patient/representative’s designated religious professional, as appropriate. Procedure: 1. The Spiritual POC will address identified spiritual care needs, goals and interventions and will be approved by the IDG. 2. The Counselor/Chaplain will provide spiritual counseling to meet assessed needs in accordance with the patient/representative’s acceptance of this service and in a manner consistent with the patient/representative’s beliefs and desires. 3. The Counselor/Chaplain will continue to visit the patient/representative at intervals designated by the patient’s POC. 5. The Spiritual POC will be reviewed no less than every 15 days and updated according to patient/representative needs with changes documented and discussed with the IDG. Review of the Hospice agency’s Bereavement Counseling Policy and Procedure, revised on 02/01/2022, revealed, in part, the following: Purpose: To ensure appropriate and coordinated bereavement services are provided to families/caregivers of Hospice patients. Policy: The agency will provide an organized bereavement program supervised by a qualified Bereavement Coordinator for at least 13 months following the death of a patient. The program will provide bereavement services to families/caregivers of Hospice patients both before and after the patient’s death. Procedure: 2. After the Initial Bereavement Risk Assessment is completed, a Bereavement POC will be developed to address anticipatory bereavement/grief issues and implemented as needed. Depending on the patient and family/caregiver needs identified in the Bereavement Risk Assessment, the Bereavement Coordinator may need to contact and/or visit the patient and family/caregiver prior to death. The Bereavement POC will include specific goals and interventions that indicate the kind of bereavement services to be offered and the frequency of service delivery. 6. A bereavement record will be maintained on each family member/caregiver receiving bereavement services and will include the Bereavement POC, referrals and mailings made as part of the bereavement POC. Review of the Personnel File for the agency’s Counselor/Chaplain employed from 12/28/2023 through 05/13/2024 was attempted with no documented evidence available for review. Review of the Hospice agency’s Written Agreements for the provision of Counselor/Chaplain Services from 12/28/2023 through 05/13/2024 was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:45 p.m. with S1ED. S1ED confirmed the required professional roles for a Hospice IDG included a Counselor/Chaplain. S1ED confirmed the Hospice agency did not have a Counselor/Chaplain on staff from 12/28/2023 through 05/13/2024, and the current Chaplain did not complete orientation until 06/24/2024. S1ED confirmed during the lapse in Counselor/Chaplain coverage, the agency admitted 107 patients and 78 patients expired. S1ED confirmed not having a Counselor/Chaplain on staff meant the Hospice agency was not able to perform any of the required updates to the POC for this discipline.”

“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 7 (#7, #8, #10, #11, #13, #18, and #19) of 14 (#6 through #19) live patients reviewed in the sampleThis deficient practice had the potential to affect any of the 80 patient deaths and 111 patient admissions during the lapse in MSW coverage, as well as, a current census of 58 patients. Review of the Hospice agency’s Interdisciplinary Group (IDG) Membership and Responsibilities Policy, revised on 02/01/2025, revealed, in part, the following: Purpose:To define the roles and responsibilities of the IDG. Policy: The Hospice IDG collaborates with the patient’s attending physician to develop and maintain a patient-directed, individualized Plan of Care (POC). The Executive Director coordinates the overall functioning of the IDG. Procedure: The Hospice IDG membership includes, but is not limited to: c) Social Worker. Review of the Hospice agency’s Initial and Comprehensive Admission Assessment and POC, revised 04/01/2022, revealed, in part, the following: Purpose: To describe the initial and comprehensive Hospice patient assessment. The comprehensive assessment will be completed no later than 5 calendar days after the date of Election of Hospice Services and includes a thorough assessment if the patient’s physical, psychosocial, emotional and spiritual status related to the terminal illness and related conditions and the caregiver’s and family’s willingness and capability to care for the patient. The information gathered during the comprehensive assessment will be incorporated into an interdisciplinary POC. Procedure: 5. The MSW will complete a Psychosocial Evaluation identifying goals and interventions, including the Initial Bereavement Risk Assessment, no later than 5 days after the date of Hospice Election as part of the comprehensive assessment. In the event the patient is imminently dying, the MSW will complete the Initial Psychosocial and Bereavement Assessment as soon as possible but no greater than 72 hours after the date of election. Patient #7Review of Patient #7’s Clinical Record revealed he was admitted to the agency and signed his Election of Hospice Benefits on 02/28/2025. Further review revealed a current Certification Period of 02/28/2025 through 05/28/2025. Review of Patient #7’s RN Initial Assessment, dated 02/28/2025, revealed, in part, the following: Is the patient accepting MSW services? Yes. Review of Patient #7’s POC and Physician’s Orders for the Certification Period of 02/28/2025 through 05/28/2025, revealed, in part, MSW Visit Frequency: Once monthly. Review of Patient #’s Visit Calendar, dated 02/28/2025 through 03/04/2025, revealed, in part, no documented evidence of a MSW Visit being attempted or conducted within the required 5 day window. Review of Patient #7’s MSW Initial Assessment and Initial Psychosocial Assessment, dated 02/28/2025 through 03/04/2025, was attempted with no documented evidence available for review. Patient #8Review of Patient #8’s Clinical Record revealed she was admitted to the agency with the Election of Hospice Benefits Form signed on 02/09/2025. Further review revealed a current Certification Period of 02/09/2025 through 05/09/2025. Review of Patient #8’s RN Initial Assessment, dated 02/09/2025, revealed, in part, the following: Is patient accepting Social Work services? Yes. Review of Patient #8’s POC and Physician’s Orders for the Certification Period of 02/09/2025 through 05/09/2025, revealed, in part, MSW Visit Frequency: Once every two months. Review of Patient #’8s Visit Calendar, dated 02/09/2025 through 02/13/2025, revealed, in part, no documented evidence of a MSW Visit being attempted or conducted within the required 5 day window. Review of Patient #8’s MSW Initial Assessment and Initial Psychosocial Assessment, dated 02/09/2025 through 02/13/2025, was attempted with no documented evidence available for review. Patient #10Review of Patient #10’s Clinical Record revealed he was admitted to the agency with the Election of Hospice Benefits Form signed on 01/25/2025. Further review revealed a current Certification Period of 01/25/2025 through 03/21/2025. Review of Patient #10’s RN Initial Assessment, dated 01/25/2025, revealed, in part, the following: Is patient accepting Social Work services? Yes. Review of Patient #10’s POC and Physician’s Orders for the Certification Period of 01/25/2025 through 03/21/2025, revealed, in part, MSW Visit Frequency: Once monthly. Review of Patient #’10s Visit Calendar, dated 01/25/2025 through 01/29/2025, revealed, in part, no documented evidence of a MSW Visit being attempted or conducted within the required 5 day window. Review of Patient #10’s MSW Initial Assessment and Initial Psychosocial Assessment, 01/25/2025 through 01/29/2025, was attempted with no documented evidence available for review. Patient #11Review of Patient #11’s Clinical Record revealed he was admitted to the agency with his Election of Hospice Benefits Form signed on 02/11/2025. Further review revealed a current Certification Period of 02/11/2025 through 05/11/2025. Review of Patient #11’s RN Initial Assessment, dated 02/11/2025, revealed in part, the following:Is patient accepting Social Work services? Yes. Review of Patient #11’s POC and Physician’s Orders for the Certification Period of 02/11/2025 through 05/11/2025, revealed, in part, no order for MSW Visit frequency. Review of Patient #11’s Visit Calendar, dated 02/11/2025 through 02/15/2025, revealed, in part, no documented evidence of a MSW Visit being attempted or conducted within the required 5 day window. Review of Patient #11’s Initial MSW Assessment and Initial Psychosocial Assessment, dated 02/11/2025 through 02/15/2025, was attempted with no documented evidence available for review. Patient #13Review of Patient #13’s Clinical Record revealed he was admitted to the agency with his Election of Hospice Benefits Form signed on 12/04/2024. Further review revealed a current Certification Period of 03/04/2025 through 06/01/2025. Review of Patient #13’s POC and Physician’s Orders for the Certification Period of 03/04/2025 through 06/01/2025, revealed, in part, no order for MSW Visit frequency upon admission. Review of Patient #13’s Visit Calendar, dated 12/04/2024 through 12/08/2024, revealed, in part, no documented evidence of a MSW Visit being attempted or conducted within the required 5 day window. Review of Patient #13’s Initial MSW Assessment and Initial Psychosocial Assessment, dated 12/04/2024 through 12/08/2024, was attempted with no documented evidence available for review. Patient #18Review of Patient #18’s Clinical Record revealed she was admitted to the agency with her Election of Hospice Benefits Form signed on 02/10/2025. Further review revealed a current Certification Period of 02/10/2025 through 05/10/2025.Review of Patient #18’s RN Initial Assessment, dated 02/10/2025, revealed in part, the following:Is patient accepting Social Work services? Yes. Review of Patient #18’s POC and Physician’s Orders for the Certification Period of 02/10/2025 through 05/10/2025, revealed, in part, MSW Visit Frequency: Once monthly. Review of Patient #18’s Visit Calendar, dated 02/10/2025 through 02/14/2025, revealed, in part, no documented evidence of a MSW Visit being attempted or conducted within the required 5 day window. Review of Patient #18’s Initial MSW Assessment and Initial Psychosocial Assessment, dated 02/10/2025 through 02/14/2025, was attempted with no documented evidence available for review. Patient #19Review of Patient #19’s Clinical Record revealed he was admitted to the agency with his Election of Hospice Benefits Form signed on 08/28/2024. Further review revealed a current Certification Period of 02/24/2025 through 04/24/2025. Review of Patient #19’s Initial RN Visit Assessment, dated 8/28/2024, revealed in part, the following:Is patient accepting Social Work services? Yes. Review of Patient #19’s POC and Physician’s Orders for the Certification Period of 03/04/2025 through 06/01/2025, revealed, in part, MSW Visit Frequency: Once monthly. Review of Patient #18’s Visit Calendar, dated 08/28/2024 through 09/01/2024, revealed, in part, no documented evidence of a MSW Visit being attempted or conducted within the required 5 day window. Review of Patient #19’s Initial MSW Assessment and Initial Psychosocial Assessment, dated 08/28/2024 through 09/01/2024, was attempted with no documented evidence available for review. Review attempted of the Personnel File for the agency’s MSW employed from 08/28/2024 through 03/03/2024 with no documented evidence available for review. Review of the Hospice agency’s Written Agreements for the provision of Bereavement Counseling/Chaplain Services from 08/28/2024 through 03/03/2024 was attempted with no documented evidence available for review. An interview was conducted on 03/25/2025 at 1:00 p.m. with S3MSW. S3MSW confirmed she recently started her role as MSW with the Hospice agency during the first week of March 2025 and would not be released to take patients on her own until 03/27/2025. S3MSW confirmed prior to her being hired, the Hospice agency did not have a MSW on staff since August of 2024. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed the aforementioned information and confirmed Patient #7, #8, #10, #11, #13, #18, and #19 did not receive an Initial MSW Comprehensive Assessment and Initial Psychosocial Assessment within the required 5 day window and should have. S1ED confirmed the Core Services the Hospice agency was required to provide included a MSW. S1ED confirmed the Hospice agency did not have a MSW on staff from 08/28/2024 through 03/03/2025 and the newly hired MSW would not complete orientation to begin seeing patients independently until 03/27/2025. S1ED confirmed during the lapse in MSW coverage, the agency admitted 111 patients and had 80 patients expired. S1ED confirmed during the lapse in MSW coverage, the Hospice agency tried to work with some of their sister agencies to borrow their MSW when they could but it did not provide 100% coverage for all patients. S1ED confirmed there was no written agreement in place for the borrowed services, they just helped if they could. S1ED confirmed not having a MSW on staff meant the Hospice agency was not able to provide the required services and expertise a MSW would have provided to meet the needs of the patients.”

“Based on interviews and record reviews, the Hospice agency failed to meet the Core Service requirement for Bereavement Counseling as evidenced by failure to:1. Provide Bereavement Services under the supervision of a qualified professional; and2. Implement the Bereavement Services program and the Bereavement Plan of Care (POC) for 3 of 3 (#3, #4, and #5) records reviewed for bereavement. This deficient practice had the potential to affect any of the 78 patient deaths and 107 patient admissions during the lapse in Bereavement Counseling/Chaplain coverage, as well as, a current census of 58 patients. Cross Reference: L587, L594, L598. 1. Failure to provide Bereavement Services under the supervision of a qualified professional.Review of the Hospice agency’s Bereavement Counseling Policy and Procedure, revised on 02/01/2022, revealed, in part, the following: Purpose: To ensure appropriate and coordinated Bereavement Services are provided to families/caregivers of Hospice patients. Policy: The agency will provide an organized Bereavement Program supervised by a qualified Bereavement Coordinator for at least 13 months following the death of a patient. Review of Louisiana Administrative Code (LAC) §8217.B.1-3, dated November 2023, revealed, in part, the following: B. Counselor - Bereavement1. Qualifications. Documented evidence of appropriate training, and experience in the care of thebereaved received under the supervision of a qualified professional.2. Responsibilities. Under the supervision of a qualified professional, and as part of an organized program for the provision of Bereavement Services, the counselor shall implement Bereavement Counseling in a manner consistent with standards of practice. Services include, but are not limited to the following:a. assess grief counseling needs;b. provide bereavement information and referral services to the bereaved, as needed, in accordance with the POC;c. provide bereavement support to hospice staff as needed;d. attend hospice IDT meetings; and e. document Bereavement Services provided and progress of bereaved on a clinical progress note to be incorporated into the clinical record.3. Continuing Education. The Bereavement Counselor shall annually obtain two continuing education hours relative to the Bereavement Counselor’s role, including but not limited to the following topics:a. death and dying cultures;b. suicide;c. compassion fatigue;d. anticipatory grief;e. patient survivors;f. grief groups;g. grief;h. loss;i. adjustment;j. ethics; andk. advanced directives and LaPOST.Review of the Personnel File for the agency’s Bereavement Counselor/Chaplain employed from 12/28/2023 through 05/13/2024 was attempted with no documented evidence available for review. Review of the Hospice agency’s Written Agreements for the provision of Bereavement Counseling/Chaplain Services from 12/28/2023 through 05/13/2024 was attempted with no documented evidence available for review. Review of S1ED’s Personnel File, as of 03/27/2025 at 10:30 a.m., revealed no documented evidence of the qualifications and/or continued education requirements necessary to hold the position of Bereavement Coordinator/Counselor during the Hospice agency’s lapse in Chaplain Services. An interview was conducted on 03/27/2025 at 2:45 p.m. with S1ED. S1ED confirmed the Chaplain was responsible for the Hospice agency’s Bereavement Services program and served the role of Bereavement Counselor. S1ED confirmed the Hospice agency did not have a Bereavement Counselor/Chaplain on staff from 12/28/2023 through 05/13/2024 and after the role was filled, he did not complete orientation to begin seeing patients/family/caregivers until after 06/24/2024. S1ED confirmed during the absence of a Bereavement Counselor/Chaplain, she was responsible for carrying out the Bereavement Services program for the Hospice agency. S1ED confirmed she did not meet the requirements for a Bereavement Coordinator/Counselor.2. Failure to implement the Bereavement Services program and the Bereavement Plan of Care.Review of the Hospice agency’s Bereavement Counseling Policy and Procedure, revised on 02/01/2022, revealed, in part, the following: Purpose: To ensure appropriate and coordinated bereavement services are provided to families/caregivers of Hospice patients. Policy: The agency will provide an organized bereavement program supervised by a qualified Bereavement Coordinator for at least 13 months following the death of a patient. The program will provide bereavement services to families/caregivers of Hospice patients both before and after the patient’s death. The purpose of these services will be to facilitate a normal grieving process and to identify and appropriately refer those persons who may be experiencing pathological grief reactions that may interfere with the eventual resolution and integration of their losses. The purpose will also be to prepare the individual to function independently of hospice and to identify a support system with the individual. Procedure: 1. A Bereavement Risk Assessment will be completed at the time of admission as a part of the comprehensive assessment. 2. After the Initial Bereavement Risk Assessment is completed, a Bereavement POC can be developed to address anticipatory bereavement/grief issues and implemented as needed. Depending on the patient and family/caregiver needs identified in the Bereavement Risk Assessment, the Bereavement Coordinator may need to contact and/or visit the patient and family/caregiver prior to death. The Bereavement POC will include specific goals and interventions that indicate the kind of bereavement services to be offered and the frequency of service delivery. 3. Within 30 days after death has occurred, the Initial Bereavement Risk Assessment and POC will be updated. 4. Bereavement interventions will be reflective of the family/caregiver’s choices to participate in the bereavement program. 5. The following mailings will be sent out to the bereaved: a. A condolence card will be sent to the bereaved within 14 days of death. b. Bereavement Newsletters will be sent at 2 weeks, 2 months, 6 months and 13 months after death. c. 1 year anniversary of the death card or letter will be sent within the 12 month after death. d. An invitation to a Memorial Service will be sent within the 13 months after death. e. Other mailings may be sent at the discretion of the Bereavement Coordinator in response to the needs of the bereaved. 6. A bereavement record will be maintained on each family member/caregiver receiving bereavement services and will include the initial and subsequent bereavement risk assessment, bereavement POC, documentation of visits, calls, referrals and mailings made as part of the bereavement POC. 7. Ongoing bereavement contact will normally conclude at the end of the 13 months following death. 8. The Bereavement Coordinator will work with the agency to provide at least an annual Memorial Service for bereaved families/caregivers. The Bereavement Coordinator will facilitate Grief Support Groups as appropriate. A Winter Holiday Grief Event will be offered in November or December. 10. Contracted bereavement services will follow timelines and service details set forth in the individual contract. Patient #3Review of Patient #3’s Clinical Record revealed a Start of Care date of 03/25/2024. Further review revealed he expired at home with his family on 03/30/2024.Review of Patient #3’s Initial Bereavement Risk Assessment upon admission to the Hospice agency revealed it was performed on 03/28/2024. Review of Patient #3’s subsequent Bereavement Risk Assessment performed within 30 days following his death revealed no documented evidence available for review. Review of Patient #3’s Bereavement POC, as of 03/27/2025, revealed, in part, the following: Send initial sympathy card/letter; Make phone call within 14 days following death; Mail changing seasons newsletters; Send cards, letters, and brochures PRN; andInvite to an Annual Memorial Event. Review of Patient #3’s Bereavement Mailings per the Hospice agency’s Bereavement Policy and POC, as of 03/27/2025, revealed, in part, the following: Condolence Card - Within 14 days of death: Sent 07/17/2024;Bereavement Newsletter - 2 weeks after death: Sent 07/17/2024;Bereavement Newsletter - 2 months after death: Sent 07/24/2024;Bereavement Newsletter - 6 months after death: Sent 01/08/2025; Card or Letter - Within 12th month after death: No documented evidence present; andMemorial Service Invitation - 13 months after death: No documented evidence present.Review of Patient #3’s Bereavement Record, as of 03/27/2025, revealed no documented evidence of a phone call within 14 days following death or an invitation to an Annual Memorial Event. Patient #4Review of Patient #4’s Clinical Record revealed a Start of Care date of 05/15/2024. Further review revealed he expired at home with his family on 05/17/2024.Review of Patient #4’s Initial Bereavement Risk Assessment upon admission to the Hospice agency revealed it was performed on 05/16/2024. Review of Patient #4’s subsequent Bereavement Risk Assessment performed within 30 days following his death revealed no documented evidence available for review. Review of Patient #4’s Bereavement POC, as of 03/27/2025, revealed, in part, the following: Send initial sympathy card/letter; Make phone call within 14 days following death; Mail changing seasons newsletters; and Send cards, letters, and brochures PRN.Review of Patient #4’s Bereavement Mailings per the Hospice agency’s Bereavement Policy and POC, as of 03/27/2025, revealed, in part, the following: Condolence Card - Within 14 days of death: Sent 07/17/2024;Bereavement Newsletter - 2 weeks after death: Sent 07/17/2024;Bereavement Newsletter - 2 months after death: Sent 07/24/2024; and Bereavement Newsletter - 6 months after death: Sent 01/08/2025.Review of Patient #4’s Bereavement Record, as of 03/27/2025, revealed no documented evidence of a phone call within 14 days following death. Patient #5Review of Patient #5’s Clinical Record revealed a Start of Care date of 03/19/2024. Further review revealed he expired at home with his family on 04/11/2024.Review of Patient #5’s Initial Bereavement Risk Assessment upon admission to the Hospice agency revealed it was performed on 03/22/2024. Review of Patient #5’s subsequent Bereavement Risk Assessment performed within 30 days following his death revealed no documented evidence available for review. Review of Patient #5’s Bereavement POC, as of 03/27/2025, revealed, in part, the following: Send initial sympathy card/letter; Make phone call within 14 days following death; Mail changing seasons newsletters; Send cards, letters, and brochures PRN; andInvite to an Annual Memorial Event. Review of Patient #5’s Bereavement Mailings per the Hospice agency’s Bereavement Policy and POC, as of 03/27/2025, revealed, in part, the following: Condolence Card - Within 14 days of death: Sent 07/17/2024;Bereavement Newsletter - 2 weeks after death: Sent 07/17/2024;Bereavement Newsletter - 2 months after death: Sent 07/24/2024;Bereavement Newsletter - 6 months after death: Sent 01/08/2025; Card or Letter - Within 12th month after death: No documented evidence present; andMemorial Service Invitation - 13 months after death: No documented evidence present.Review of Patient #5’s Bereavement Record, as of 03/27/2025, revealed no documented evidence of a phone call within 14 days following death or an invitation to an Annual Memorial Event. An interview was conducted on 03/27/2025 at 2:45 p.m. with S1ED. S1ED confirmed the agency’s Bereavement Services program should include mailing cards/letters at specific times following death, hosting weekly Grief Sessions, hosting an Annual Memorial Service, making phone calls to see how family/caregivers are progressing through the grief process then updating each family/caregivers Bereavement POC to reflect their current grief stage and needs. S1ED confirmed the Bereavement Counselor/Chaplain would need to make the phone calls to determine their grief stage, facilitate Grief Sessions, and host an Annual Memorial Service. S1ED confirmed since the Hospice agency did not have a Bereavement Counselor/Chaplain available from 12/28/2023 until after 06/24/2024, these Bereavement Services did not occur. S1ED confirmed the Hospice agency did not hold an Annual Memorial Service during 2024 nor had one been scheduled as of this time for 2025. S1ED stated during the absence of the Bereavement Counselor/Chaplin, volunteers served as “a listening ear” for family/caregivers then confirmed none of the volunteers were trained Grief Counselors, Social Workers or Chaplains. S1ED confirmed during the absence of an agency Bereavement Counselor/Chaplain, cards and letters were not mailed according to the timelines outlined in their Bereavement POC nor did family/caregivers receive phone calls from the Bereavement Counselor/Chaplain per their Bereavement POC. S1ED reviewed and confirmed all of the aforementioned information for Patient #4, #5, and #6 and confirmed their Bereavement Services were not implemented per the agency’s Bereavement Services policy or their POC. S1ED reviewed and confirmed the Bereavement POCs were not individualized or updated based on each family/caregiver’s needs throughout their bereavement process.”

“Based on interview and record reviews, the Hospice agency failed to provide the Core Service of Spiritual Counselor/Chaplain Services through a Hospice employee or contracted staff in order to meet the patient’s and family’s spiritual needs for 5 (#7, #9, #12, #15, and #17) of 14 (#6 through #19) live patients reviewed in the sample. This deficient practice had the potential to affect any of the 78 patient deaths and 107 patient admissions during the lapse in Spiritual Counselor/Chaplain coverage, as well as, a current census of 58 patients. Cross Reference: L587, L594, L596. Review of the Hospice agency’s IDG Membership and Responsibilities Policy, revised on 02/01/2025, revealed, in part, the following: Purpose:To define the roles and responsibilities of the IDG. Policy: The Hospice IDG collaborates with the patient’s attending physician to develop and maintain a patient-directed, individualized POC. The Executive Director coordinates the overall functioning of the IDG. Procedure: The Hospice IDG membership includes, but is not limited to: d) Pastoral or Spiritual Counselor. Review of the Hospice agency’s Initial and Comprehensive Admission Assessment and POC Policy, revised 04/01/2022, revealed, in part, the following: Purpose: To describe the initial and comprehensive Hospice patient assessment. The comprehensive assessment will be completed no later than 5 calendar days after the date of Election of Hospice Services and includes a thorough assessment if the patient’s physical, psychosocial, emotional and spiritual status related to the terminal illness and related conditions and the caregiver’s and family’s willingness and capability to care for the patient. The information gathered during the comprehensive assessment will be incorporated into an interdisciplinary POC. Procedure: 6. The Chaplain will complete the Spiritual Evaluation identifying goals and interventions needed no later than 5 days after the date of Hospice Election as part of the comprehensive assessment. In the event the patient is imminently dying, the Chaplain will complete the Initial Spiritual Assessment as soon as possible but no greater than 72 hours after the date of election. Review of the Hospice agency’s Spiritual Assessment Policy, revised 02/01/2023, revealed, in part, the following: Purpose: To ensure each Hospice patient receives a Spiritual Assessment. Policy: All patients/families admitted to Hospice services will receive a Spiritual Assessment that identifies spiritual needs and goals. A Chaplain or qualified Spiritual Counselor will perform the assessment. Spiritual services will be delivered according to generally accepted standards of practice and in a manner, which is meaningful to the patient/representative. Spiritual care is provided either directly or through coordination with the patient/representative’s designated religious professional, as appropriate. Procedure: 1. The Spiritual Counselor/Chaplain will complete a Spiritual Needs Assessment and POC for each patient and family no later than 5 days after the date of Hospice Election. In the event the patient is imminently dying, the Chaplain will complete the Initial Spiritual Assessment as soon as possible but no greater than 72 hours after the date of election. The POC will address identified spiritual care needs, goals and interventions and will be approved by the IDG. 2. The Spiritual Counselor/Chaplain will provide spiritual counseling to meet assessed needs in accordance with the patient/representative’s acceptance of this service and in a manner consistent with the patient/representative’s beliefs and desires. 3. The Spiritual Counselor/Chaplain will continue to visit the patient/representative at intervals designated by the patient’s POC. 4. Each visit or call will be documented in each patient’s medical record. 5. The spiritual POC will be reviewed no less than every 15 days and updated according to patient/representative needs with changes documented and discussed with the IDG. 6. The Spiritual Counselor/Chaplain will coordinate resources and services to meet the patient/representative needs. This will include coordination of services with the patient/representative’s designated local clergy, pastoral counselor or other individual as appropriate. 7. In the event that patient/representative declines spiritual services, the Spiritual Counselor/Chaplain is to inquire if spiritual services are desired form another source and coordinate that care. The Spiritual Counselor/Chaplain will remain available in the event the patient/representative chooses to engage the Spiritual Counselor/Chaplain. Review of the Personnel File for the agency’s Spiritual Counselor/Chaplain employed from 12/28/2023 through 05/13/2024 was attempted with no documented evidence available for review. Review of the Hospice agency’s Written Agreements for the provision of Spiritual Counselor/Chaplain Services from 12/28/2023 through 05/13/2024 was attempted with no documented evidence available for review. Patient #7Review of Patient #7’s Clinical Record revealed he was admitted to the agency and signed his Election of Hospice Benefits Form on 02/28/2025. Further review revealed a current Certification Period of 02/28/2025 through 05/28/2025. Review of Patient #7’s RN Initial Assessment, dated 02/28/2025, revealed, in part, the following: Is the patient accepting to spiritual caregiver services? Yes. Indicate spiritual/existential concerns of patient/caregiver: Referral made to spiritual caregiver/pastoral counselor.Review of Patient #7’s POC and Physician’s Orders for the Certification Period of 02/28/2025 through 05/28/2025, revealed, in part, Chaplain Visit Frequency: Once monthly.Review of Patient #’s Visit Calendar, dated 02/28/2025 through 03/04/2025, revealed, in part, no documented evidence of a Chaplain Visit being attempted or conducted within the required 5 day window. Review of Patient #7’s Chaplain Initial Assessment and Initial Spiritual Assessment, dated 02/28/2025 through 03/04/2025, was attempted with no documented evidence available for review. Patient #9Review of Patient #9’s Clinical Record revealed he was admitted to the agency and signed his Election of Hospice Benefits Form on 06/12/2024. Further review revealed a current Certification Period of 02/07/2025 through 04/07/2025. Review of Patient #9’s RN Initial Assessment, dated 06/12/2024, revealed, in part, the following: Is the patient accepting to spiritual caregiver services? Yes. Indicate spiritual/existential concerns of patient/caregiver: Referral made to spiritual caregiver/pastoral counselor.Review of Patient #9’s POC and Physician’s Orders, during his Initial Certification Period of 06/12/2024 through 09/09/2024, revealed, in part, Chaplain Visit Frequency: Once monthly. Review of Patient #9’s Visit Calendar, dated 06/12/20024 through 06/16/2024, revealed, in part, no documented evidence of a Chaplain Visit being attempted or conducted within the required 5 day window. Review of Patient #9’s Chaplain Initial Assessment and Initial Spiritual Assessment, dated 06/12/20024 through 06/16/2024, was attempted with no documented evidence available for review. Patient #12Review of Patient #12’s Clinical Record revealed he was admitted to the agency and signed his Election of Hospice Benefits Form on 04/09/2024. Further review revealed a current Certification Period of 02/03/2025 through 03/16/2025.Review of Patient #12’s RN Initial Assessment, dated 04/09/2024, revealed, in part, the following: Is patient accepting Chaplain Services? Yes. Indicate spiritual/existential concerns of patient and/or caregivers: Referral made to spiritual caregiver/pastoral counselor. Review of Patient #12’s POC and Physician’s Orders, during his Initial Certification Period of 04/09/2024 through 07/07/2024, revealed, in part, Chaplain Visit Frequency: Once monthly. Review of Patient #12’s Visit Calendar from 04/09/2024 through 04/13/2024, revealed, in part, no documented evidence of a Chaplain Visit being attempted or conducted within the required 5 day window. Review of Patient #12’s Chaplain Initial Assessment and Initial Spiritual Assessment, dated 04/09/2024 through 04/13/2024, was attempted with no documented evidence available for review. Patient #15Review of Patient #15’s Clinical Record revealed he was admitted to the agency with his Election of Hospice Benefits Form signed on 05/02/2024. Further review revealed a current Certification Period of 02/06/2025 through 04/06/2025. Review of Patient #15’s RN Initial Assessment, dated 05/02/2024, revealed in part, the following:Is patient accepting Chaplain services? Yes. Review of Patient #15’s POC and Physician’s Orders, during his Initial Certification Period of 05/02/2024 through 06/10/2024, revealed, in part, Chaplain Visit Frequency: Once monthly. Review of Patient #15’s Visit Calendar from 05/02/2024 through 05/06/2024, revealed, in part, no documented evidence of a Chaplain Visit being attempted or conducted within the required 5 day window. Review of Patient #15’s Chaplain Initial Assessment and Initial Spiritual Assessment, dated 05/02/2024 through 05/06/2024, was attempted with no documented evidence available for review. Patient #17Review of Patient #17’s Clinical Record revealed she was admitted to the agency with her Election of Hospice Benefits Form signed on 05/08/2024. Further review revealed a current Certification Period of 03/04/2025 through 05/02/2025. Review of Patient #17’s RN Initial Assessment, dated 05/08/2024, revealed in part, the following:Is patient accepting Chaplain services? Yes. Review of Patient #17’s Visit Calendar from 05/08/2024 through 05/12/2024, revealed, in part, no documented evidence of a Chaplain Visit being attempted or conducted within the required 5 day window. Review of Patient #17’s Chaplain Initial Assessment and Initial Spiritual Assessment, dated 05/08/2024 through 05/12/2024, was attempted with no documented evidence available for review. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed the aforementioned information and confirmed Patient #7, #9, #12, #15, and #17 did not receive an Initial Chaplain Comprehensive Assessment and Initial Spiritual Assessment within the required 5 day window and should have. S1ED confirmed the Core Services the Hospice agency was required to provide included a Spiritual Counselor/Chaplain. S1ED confirmed the Hospice agency did not have a Spiritual Counselor/Chaplain on staff from 12/28/2023 through 05/13/2024 and the newly hired Chaplain did not complete orientation to begin seeing patients independently until 06/24/2024. S1ED confirmed during the lapse in Spiritual Counselor/Chaplain coverage, the agency admitted 107 patients and had 78 patients expired. S1ED confirmed during the lapse in Spiritual Counselor/Chaplain coverage, the Hospice agency tried to work with some of their sister agencies to borrow their Chaplain when they could but it did not provide 100% coverage for all patients and families. S1ED confirmed there was no written agreement in place for the borrowed services, they just helped if they could. S1ED confirmed not having a Spiritual Counselor/Chaplain on staff meant the Hospice agency was not able to provide the required services and expertise a Chaplain would have provided to meet the needs of their patients and families.”

“Based on interviews and record reviews, the Hospice agency failed to ensure the Registered Nurse (RN) conducted an on-site Hospice Aide (HA) Supervisory Visit at least every 14 days to assess the quality of care and services provided by the HA for 2 (#9 and #15) of 14 (#6 through #19) living patients reviewed. This deficient practice had the potential to affect a current census of 58 patients who received HA services. Patient #9Review of Patient #9’s Clinical Record revealed he was admitted to the agency on 06/12/2024. Further review revealed a current Certification Period of 02/07/2025 through 04/07/2025. Review of Patient #9’s Plan of Care and Physician’s Orders during the Certification Period of 12/09/2024 through 02/06/2025, revealed, in part, the following: Skilled Nurse (SN) Visit Frequency: Twice weekly; and HA Visit Frequency: Twice weekly. Review of Patient #9’s Visit Calendar for the Certification Period of 12/09/2024 through 02/06/2025 revealed, in part, the following: 12/10/2024 - HA Visit conducted;12/12/2024 - HA Visit conducted; 12/17/2024 - HA Visit conducted; 12/19/2024 - HA Visit conducted; and 12/24/2024 - HA Visit conducted. Further review revealed no documented evidence of a RN Supervisory Visit conducted from 12/05/2024 through 12/25/2024. Review of Patient #9’s RN Supervisory Visits for the Certification Period of 12/09/2024 through 02/06/2025 revealed in part, no documented evidence of a RN Supervisory Visit conducted from 12/05/2024 through 12/25/2024. An interview was conducted on 03/24/2025 at 1:05 p.m. with S1ED. S1ED reviewed Patient #9’s Visit Calendar and confirmed there was no documented evidence of an RN Supervisory Visit being conducted from 12/05/2024 through 12/25/2024 and there should have been. Patient #15Review of Patient #15’s Clinical Record revealed she was admitted to the agency on 05/02/2024. Further review revealed a current Certification Period of 02/06/2025 through 04/06/2025. Review of Patient #15’s Plan of Care and Physician’s Orders for the Certification Period of 02/06/2025 through 04/06/2025 revealed, in part, the following: SN Visit Frequency: Once weekly; and HA Visit Frequency: Once weekly for one week then twice weekly for 8 weeks. Review of Patient #15’s Visit Calendar for the Certification Period of 02/06/2025 through 04/06/2025 revealed, in part, the following: 03/04/2025 – HA Visit conducted; 03/06/2025 – HA Visit conducted;03/11/2025 – HA Visit conducted;03/13/2025 – HA Visit conducted;03/18/2025 – HA Visit conducted; and03/20/2025 – HA Visit conducted. Further review revealed no documented evidence of a RN Supervisory Visit conducted from 03/04/2025 through 03/20/2025. Review of Patient #15’s RN Supervisory Visits for the Certification Period of 02/06/2025 through 04/06/2025 revealed, in part, no documented evidence of a RN Supervisory Visit conducted from 03/04/2025 through 03/20/2025. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed Patient #15’s Visit Calendar and confirmed there was no documented evidence of an RN Supervisory Visit being conducted from 03/04/2025 through 03/20/2025 and there should have been.”

“Based on interviews and record reviews, the Hospice agency failed to be primarily engaged in providing care and services consistent with accepted standards of practice for Medical Social Services (MSW) and Counseling/Chaplain Services. This deficient practice was evidenced by: Medical Social Services:1. Failure to maintain employment of a MSW from 08/28/2024 through 03/03/2025 which resulted in: a. An incomplete IDG during the lapse in coverage from 08/28/2024 through 03/03/2025; b. MSW Services not being provided to meet the patient’s and family’s psychosocial needs for 7 (#7, #8, #10, #11, #13, #18, and #19) of 14 (#6 through #19) live patients reviewed in the sample.; c. 0% Comprehensive Assessment updates performed to the Psychosocial Assessment during the lapse in coverage for 6 (#8, #10, #11, #13, #18, and #19) of 14 (#6 - #19) live patients reviewed in the sample.; d. 0% POC reviews and documented revisions for Medical Social Services were performed during the lapse in coverage from 08/28/2024 through 03/03/2025.; and e. MSW Services (Initial Visit, Assessment or Psychosocial Assessment) were not provided within the required 5 day window, to meet the patients’ and families’ psychosocial needs. Counseling/Chaplain Services: 1. Failure to maintain employment of a Spiritual Counselor/Chaplain from 12/28/2023 through 05/13/2024 resulted in: a. Absence of a Counselor/Chaplain from 12/28/2023 through 05/13/2024 resulted in an incomplete IDG during the lapse in coverage.;b. Bereavement Services not being provided by or under the supervision of a qualified professional;c. Failure to ensure the completion of the Chaplain’s Initial Comprehensive Assessment and Spiritual Assessment within 5 days after the Election of Hospice Benefits for 5 (#7, #9, #12, #15, and #17) of 14 (#6 - #19) live patients reviewed in the sample.; d. Failure to implement the Bereavement Services program and the Bereavement Plan of Care (POC) for 3 of 3 (#3, #4, and #5) records reviewed for bereavement.; and e. Failure to meet the patients’ and families’ spiritual needs due to lack of Spiritual Counseling/Chaplain Services for 5 (#7, #9, #12, #15, and #17) of 14 (#6 through #19) live patients reviewed in the sample.These deficient practices had the potential to affect any of the 158 patient who expired and 218 patient admitted during the lapse in coverage of Core Services, as well as, a current census of 58 patients. Review of the Hospice agency’s Interdisciplinary Group (IDG) Membership and Responsibilities Policy, revised on 02/01/2025, revealed, in part, the following: Policy: The Hospice IDG collaborates with the patient’s attending physician to develop and maintain a patient-directed, individualized POC. The Executive Director coordinates the overall functioning of the IDG. Procedure: 1. The Hospice IDG membership includes, but is not limited to: a)MSWb)Pastoral or Spiritual Counselor. c)Volunteer Services.3. In Louisiana, agencies will need to update the POC At least every 14 days. a. Maintaining responsibility for directing, coordinating, and supervising the care and services provided. b. Ensuring care and services are provided in accordance with the POC. c. Ensuring the care and services provided are based on all assessments of the patient and family needs. f. Participating in the establishment, periodic review and updating of the POC for each family receiving Bereavement Services. Review of the Hospice agency’s Initial and Comprehensive Admission Assessment and POC Policy, revised 04/01/2022, revealed, in part, the following: Purpose: The comprehensive assessment will be completed no later than 5 calendar days after the date of Election of Hospice Services and includes a thorough assessment if the patient’s physical, psychosocial, emotional and spiritual status related to the terminal illness and related conditions and the caregiver’s and family’s willingness and capability to care for the patient. The information gathered during the comprehensive assessment will be incorporated into an interdisciplinary POC. Procedure: 5. The MSW will complete a Psychosocial Evaluation identifying goals and interventions, including the Initial Bereavement Risk Assessment, no later than 5 days after the date of Hospice Election as part of the comprehensive assessment. In the event the patient is imminently dying, the MSW will complete the Initial Psychosocial and Bereavement Assessment as soon as possible but no greater than 72 hours after the date of election. 6. The Chaplain will complete the spiritual evaluation identifying goals and interventions needed no later than 5 days after the date of hospice election as part of the comprehensive assessment. In the event the patient is imminently dying, the Chaplain will complete the initial spiritual assessment as soon as possible but no greater than 72 hours after the date of election. Review of the Hospice agency’s Psychosocial Assessment Policy, revised 02/01/2023, revealed, in part, the following: Policy: A thorough psychosocial assessment will be initiated at the time of admission and continued throughout the course of care. Psychosocial assessment will be completed by a qualified hospice MSW. Procedure: 1. The MSW will complete a psychosocial assessment and POC for each patient no later than 5 days after the date of Hospice Election. In the event the patient is imminently dying, no later than 72 hours after the date of election. The POC will address identified problems, goals and interventions, and will be approved by the IDG. 2. The psychosocial assessment will be performed at the initial meeting of the patient and family/caregiver in the patient’s place of residence or in the hospital if the patient is hospitalized at the time of intake. 3. The initial psychosocial assessment will include, but not limited to: grief, coping skills, patient’s response to terminal illness, identification of drug or alcohol abuse, assessment of the support system, financial assessment, bereavement risk assessment, need for volunteer services, and assessment of patient/family end of life preparation. 6. The psychosocial POC will be updated as needed, but at least every 15 days, with changes documented and discussed with the IDG. 7. The MSW will coordinate resources to meet patient/family needs and will document those efforts in the patient’s medical record. Review of the Hospice agency’s Spiritual Assessment Policy, revised 02/01/2023, revealed, in part, the following: Purpose: To ensure each Hospice patient receives a Spiritual Assessment. Policy: All patients/families admitted to Hospice services will receive a Spiritual Assessment that identifies spiritual needs and goals. A Chaplain or qualified Spiritual Counselor will perform the assessment. Spiritual services will be delivered according to generally accepted standards of practice and in a manner, which is meaningful to the patient/representative. Spiritual care is provided either directly or through coordination with the patient/representative’s designated religious professional, as appropriate. Procedure: 1. The Spiritual Counselor/Chaplain will complete a Spiritual Needs Assessment and POC for each patient and family no later than 5 days after the date of Hospice Election. In the event the patient is imminently dying, the Chaplain will complete the Initial Spiritual Assessment as soon as possible but no greater than 72 hours after the date of election. The POC will address identified spiritual care needs, goals and interventions and will be approved by the IDG. 2. The Spiritual Counselor/Chaplain will provide spiritual counseling to meet assessed needs in accordance with the patient/representative’s acceptance of this service and in a manner consistent with the patient/representative’s beliefs and desires. 3. The Spiritual Counselor/Chaplain will continue to visit the patient/representative at intervals designated by the patient’s POC. 4. Each visit or call will be documented in each patient’s medical record. 5. The spiritual POC will be reviewed no less than every 15 days and updated according to patient/representative needs with changes documented and discussed with the IDG. 6. The Spiritual Counselor/Chaplain will coordinate resources and services to meet the patient/representative needs. Review of the Hospice agency’s Bereavement Counseling Policy and Procedure, revised on 02/01/2022, revealed, in part, the following: Purpose: To ensure appropriate and coordinated bereavement services are provided to families/caregivers of Hospice patients. Policy: The agency will provide an organized bereavement program supervised by a qualified Bereavement Coordinator for at least 13 months following the death of a patient. The program will provide bereavement services to families/caregivers of Hospice patients both before and after the patient’s death… . The purpose of these services will be to facilitate a normal grieving process and to identify and appropriately refer those persons who may be experiencing pathological grief reactions that may interfere with the eventual resolution and integration of their losses. Procedure: 1. A Bereavement Risk Assessment will be completed at the time of admission as a part of the comprehensive assessment. 2. After the Initial Bereavement Risk Assessment is completed, a Bereavement POC can be developed to address anticipatory bereavement/grief issues and implemented as needed. Depending on the patient and family/caregiver needs identified in the Bereavement Risk Assessment, the Bereavement Coordinator may need to contact and/or visit the patient and family/caregiver prior to death. The Bereavement POC will include specific goals and interventions that indicate the kind of bereavement services to be offered and the frequency of service delivery. 3. Within 30 days after death has occurred, the Initial Bereavement Risk Assessment and POC will be updated. 7. Ongoing bereavement contact will normally conclude at the end of the 13 months following death. Medical Social Services:a.Lack of a MSW resulted in an incomplete IDG during the lapse in coverage from 08/28/2024 through 03/03/2025. Review of the Personnel File for the agency’s MSW revealed no documented evidence of Written Agreements for the provision of MSW Services from 08/28/2024 through 03/03/2024. An interview was conducted on 03/25/2025 at 1:00 p.m. with S3MSW. S3MSW confirmed she started her role as MSW with the Hospice agency during the first week of March 2025 and would not be released to take patients on her own until 03/27/2025. S3MSW confirmed prior to her being hired, the Hospice agency had not had a MSW on staff since August of 2024. An interview was conducted on 03/27/2025 at 2:45 p.m. with S1ED. S1ED confirmed the required professional roles for a Hospice IDG included a MSW. S1ED confirmed the Hospice agency did not have a MSW on staff from 08/28/2024 through 03/03/2025, and the newly hired MSW would not complete orientation to begin seeing patients and families independently until 03/27/2025. S1ED confirmed during the lapse in MSW coverage, the agency admitted 111 patients and 80 patients expired. b. MSW Services not being provided to meet the patient’s and family’s psychosocial needs.Review of clinical records for Patent #7 (election of hospice benefit 02/28/2025), Patient #8 (election of hospice benefit 02/09/2025), Patient #10 (election of hospice benefit 01/25/2025), Patient #11 (election of hospice benefit 02/11/2025), Patient #13 (election of hospice benefit 12/04/2024), Patient #18 (election of hospice benefit 02/10/2025), and Patient #19 (election of hospice benefit 08/24/2024), revealed the MSW did not complete an Initial Assessment or Psychosocial Assessment within 5 days of Election of Hospice Benefits. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed the aforementioned information and confirmed the Hospice agency did not have a system in place to ensure Patient #7, #8, #10, #11, #13, #18, and #19 received the MSW’s Initial Comprehensive Assessment and Psychosocial Assessment within the required 5 day window and should have. S1ED confirmed the Core Services the Hospice agency was required to provide in their IDG included a MSW. S1ED confirmed the Hospice agency did not have a MSW on staff from 08/28/2024 through 03/03/2025 and the newly hired MSW would not complete orientation to begin seeing patients independently until 03/27/2025. S1ED confirmed the Hospice agency did not contact the state licensing office to inform them or seek assistance upon their difficulty in fulfilling this core service. S1ED confirmed while the Hospice agency did not have a MSW on staff, they were not able to perform the required initial assessments to determine what services their patients and families required to meet their needs. c.0% Comprehensive Assessment updates performed to the Psychosocial Assessment during the lapse in MSW coverage. Review of clinical records for Patient #8 (election of hospice benefit 02/09/2025), Patient #10 (election of hospice benefit 01/25/2025), Patient #11 (election of hospice benefit 02/11/2025), Patient #13 (election of hospice benefit 12/04/2024), Patient #18 (election of hospice benefit 02/10/2025), and Patient #19 (election of hospice benefit 08/24/2024), revealed none of the required Comprehensive Assessment updates were performed by the MSW. Review of agency’s personnel files revealed no documented evidence of a MSW employed from 08/28/2024 through 03/03/2025. Review of the Hospice agency’s Written Agreements for the provision of MSW Services revealed there was no documented evidence of employment of a MSW from 08/28/2024 through 03/03/2025. An interview was conducted on 03/25/2025 at 1:00 p.m. with S3MSW. S3MSW confirmed she started her role as MSW with the Hospice agency during the first week of March 2025, and would not be released to take patients on her own until 03/27/2025. S3MSW confirmed prior to her being hired, the Hospice agency did not have a MSW available on staff since August of 2024. An interview was conducted on 03/27/2025 at 2:45 p.m. with S1ED. S1ED reviewed the aforementioned information and confirmed the Hospice agency did not have a system in place to ensure Patient #8, #10, #11, #13, #18, and #19 received updates to the MSW Comprehensive Assessment within the required timeframe and should have. S1ED confirmed during the lapse in MSW coverage, the Hospice agency was not able to perform any of the required updates to the Comprehensive Assessments for this discipline to ensure patient and family needs were being met. d. 0% POC reviews and documented revisions performed during the lapse in MSW coverage from 08/28/2024 through 03/03/2025.Review of the Personnel File for the agency’s MSW employed from 08/28/2024 through 03/03/2024 was attempted with no documented evidence available for review. Further review revealed no documented evidence of Written Agreements for the provision of MSW Services from 08/28/2024 through 03/03/2024. An interview was conducted on 03/25/2025 at 1:00 p.m. with S3MSW. S3MSW confirmed she started her role as MSW with the Hospice agency during the first week of March 2025 and would not be released to take patients on her own until 03/27/2025. S3MSW confirmed prior to her being hired, the Hospice agency had not had a MSW on staff since August of 2024. An interview was conducted on 03/27/2025 at 2:45 p.m. with S1ED. S1ED confirmed the required professional roles for a Hospice IDG included a MSW. S1ED confirmed the Hospice agency did not have a MSW on staff from 08/28/2024 through 03/03/2025, and the newly hired MSW would not complete orientation to begin seeing patients and families independently until 03/27/2025. S1ED confirmed during the lapse in MSW coverage, the agency admitted 111 patients and 80 patients expired. S1ED confirmed the Hospice agency did not contact the state licensing office to inform them or seek assistance due to their difficulty in fulfilling this core service. S1ED confirmed the Hospice agency did not have a system in place to ensure the continual employment of all Core Services in order to revise the POC. e. MSW Services (Initial Visit, Assessment or Psychosocial Assessment) were not provided within the 5 day window, to meet the patient’s and family’s psychosocial needs.Review of the clinical records for Patient #7 (Election of Hospice Benefits Form signed on 02/28/2025), Patient #8 (Election of Hospice Benefits Form signed on 02/09/2025), Patient #10 (Election of Hospice Benefits Form signed on 01/25/2025), Patient #11 (Election of Hospice Benefits Form signed on 02/11/2025), Patient #13 (Election of Hospice Benefits Form signed on 12/04/2024), Patient #18 (Election of Hospice Benefits Form signed on 02/10/2025), and Patient #19 (Election of Hospice Benefits Form signed on 08/28/2024) revealed the patients/families were accepting of MSW services and did not receive MSW Initial Visits, Assessments or Psychosocial Assessments within the required 5 day windowAn interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed the aforementioned information and confirmed the Hospice agency did not have a system in place to ensure the completion of Patient #7, #8, #10, #11, #13, #18, and #19’s Initial MSW Comprehensive Assessment, Initial Psychosocial Assessment within the required 5 day window, or the MSW visits as ordered and should have. S1ED confirmed the Core Services the Hospice agency was required to provide included a MSW. S1ED confirmed the Hospice agency did not have a MSW on staff from 08/28/2024 through 03/03/2025 and the newly hired MSW would not complete orientation to begin seeing patients independently until 03/27/2025. S1ED confirmed the Hospice agency did not contact the state licensing office to inform them or seek assistance due to their difficulty in fulfilling this core service. S1ED confirmed while the Hospice agency did not have a MSW on staff, they were not able provide the required services to meet the psychosocial needs of their patients and families.Counseling/Chaplain Services a. Absence of a Counselor/Chaplain from 12/28/2023 through 05/13/2024 resulted in an incomplete IDG during the lapse in coverage.Review of the Personnel File for the agency’s Counselor/Chaplain employed from 12/28/2023 through 05/13/2024 was attempted with no documented evidence available for review. Further review revealed no documented evidence of Written Agreements for the provision of Counselor/Chaplain Services from 12/28/2023 through 05/13/2024 available for review. An interview was conducted on 03/27/2025 at 2:45 p.m. with S1ED. S1ED confirmed the required professional roles for a Hospice IDG included a Counselor/Chaplain. S1ED confirmed the Hospice agency did not have a Counselor/Chaplain on staff from 12/28/2023 through 05/13/2024, and the current Chaplain did not complete orientation to begin seeing patients and families independently until 06/24/2024. S1ED confirmed during the lapse in Counselor/Chaplain coverage, the agency admitted 107 patients and 78 patients expired. b. Bereavement Services not being provided by or under the supervision of a qualified professional. Review of the Personnel File for the agency’s Bereavement Counselor/Chaplain employed from 12/28/2023 through 05/13/2024 was attempted with no documented evidence available for review. Further review revealed no documented Written Agreements for the provision of Bereavement Counseling/Chaplain Services from 12/28/2023 through 05/13/2024.Review of S1ED’s Personnel File, as of 03/27/2025 at 10:30 a.m., revealed no documented evidence of the qualifications and/or continued education requirements necessary to hold the position of Bereavement Coordinator/Counselor during the Hospice agency’s lapse in Chaplain Services. An interview was conducted on 03/27/2025 at 2:45 p.m. with S1ED. S1ED confirmed the Hospice agency did not have a Bereavement Counselor/Chaplain on staff from 12/28/2023 through 05/13/2024, and after the role was filled, he did not complete orientation to begin seeing patients/family/caregivers until after 06/24/2024. S1ED confirmed the Hospice agency did not contact the state licensing office to inform them or seek assistance due to their difficulty in fulfilling this core service. S1ED confirmed during the absence of a Bereavement Counselor/Chaplain, she was responsible for carrying out the Bereavement Services program for the Hospice agency. S1ED confirmed she did not meet the requirements for a Bereavement Counselor/Chaplain, and the Hospice agency was responsible for having a system in place to provide Bereavement Services by or under the supervision of a qualified professional. c. Failure to ensure the completion of the Chaplain’s Initial Comprehensive Assessment and Spiritual Assessment within 5 days after the Election of Hospice Benefits. Review of the clinical records for Patient #7 (Election of Hospice Benefits Form on 02/28/2025), Patient #9 (Election of Hospice Benefits Form on 06/12/2024), Patient #12 (Election of Hospice Benefits Form on 04/09/2024), Patient #15 (Election of Hospice Benefits Form on 05/02/2024), and Patient #17 (Election of Hospice Benefits Form on 05/08/2024) revealed the Spiritual Counselor/Chaplain did not complete an Initial Assessment or Spiritual Assessment within 5 days of the Election of Hospice Benefits. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed the aforementioned information and confirmed the Hospice agency did not have a system in place to ensure Patient #7, #9, #12, #15, and #17 received an Initial Chaplain Comprehensive and Spiritual Assessment within the required 5 day window and should have. S1ED confirmed the Core Services the Hospice agency was required to provide in their IDG included a Spiritual Counselor/Chaplain. S1ED confirmed the Hospice agency did not have a Chaplain on staff from 12/28/2023 through 05/13/2024 and the newly hired Chaplain did not complete orientation to begin seeing patients independently until 06/24/2024. S1ED confirmed the Hospice agency did not contact the state licensing office to inform them or seek assistance upon their difficulty in fulfilling this core service. S1ED confirmed while the Hospice agency did not have a Chaplain on staff, they were not able to perform the required initial assessments to determine what services their patients and families required to meet their needs. d. Failure to implement the Bereavement Services program and the Bereavement Plan of Care (POC)Patient #3Review of Patient #3’s Clinical Record revealed he was admitted on 03/25/2024 and expired at home with his family on 03/30/2024. Further review revealed no updated Bereavement Assessments were performed within 30 days following the patient’s death per the Bereavement Services Policy, and the Bereavement POC was not followed. Review of Patient #3’s Bereavement Mailings per the Hospice agency’s Bereavement Policy and Bereavement POC, as of 03/27/2025, revealed, in part, the following: Condolence Card – due within 14 days of death: Sent 07/17/2024;Bereavement Newsletter – due 2 weeks after death: Sent 07/17/2024;Bereavement Newsletter – due 2 months after death: Sent 07/24/2024;Bereavement Newsletter – due 6 months after death: Sent 01/08/2025; Card or Letter – due within 12th month after death: No documented evidence present; andMemorial Service Invitation – due 13 months after death: No documented evidence present.Review of Patient #3’s Bereavement Record, as of 03/27/2025, revealed no documented evidence of a phone call within 14 days following death or an invitation to an Annual Memorial Event. Patient #4Review of Patient #4’s Clinical Record revealed he was admitted to the agency on 05/15/2024 and expired at home with his family on 05/17/2024. Further review revealed no updated Bereavement Assessments were performed within 30 days following the patient’s death per the Bereavement Services Policy, and the Bereavement POC was not followed. Review of Patient #4’s Bereavement Mailings per the Hospice agency’s Bereavement Policy and Bereavement POC, as of 03/27/2025, revealed, in part, the following: Condolence Card – due within 14 days of death: Sent 07/17/2024;Bereavement Newsletter – due 2 weeks after death: Sent 07/17/2024;Bereavement Newsletter – due 2 months after death: Sent 07/24/2024; and Bereavement Newsletter – due 6 months after death: Sent 01/08/2025.Review of Patient #4’s Bereavement Record, as of 03/27/2025, revealed no documented evidence of a phone call within 14 days following death. Patient #5Review of Patient #5’s Clinical Record revealed he was admitted to the agency on 03/19/2024 and expired at home with his family on 04/11/2024. Further review revealed no updated Bereavement Assessments were performed within 30 days following the patient’s death per the Bereavement Services Policy, and the Bereavement POC was not followed. Review of Patient #5’s Bereavement Mailings per the Hospice agency’s Bereavement Policy and POC, as of 03/27/2025, revealed, in part, the following: Condolence Card – due within 14 days of death: Sent 07/17/2024;Bereavement Newsletter – due 2 weeks after death: Sent 07/17/2024;Bereavement Newsletter – due 2 months after death: Sent 07/24/2024;Bereavement Newsletter – due 6 months after death: Sent 01/08/2025; Card or Letter – due within 12th month after death: No documented evidence present; andMemorial Service Invitation – due 13 months after death: No documented evidence present.Review of Patient #5’s Bereavement Record, as of 03/27/2025, revealed no documented evidence of a phone call within 14 days following death or an invitation to an Annual Memorial Event. An interview was conducted on 03/27/2025 at 2:45 p.m. with S1ED. S1ED confirmed the Hospice agency was responsible for providing patients and families with a Bereavement Services program. S1ED confirmed since the Hospice agency did not have a Bereavement Counselor/Chaplain available from 12/28/2023 until after 06/24/2024, and their Bereavement Services were not provided per their policy and procedures. S1ED confirmed the Hospice agency did not contact the state licensing office to inform them or seek assistance due to their difficulty in fulfilling this core service. S1ED reviewed the aforementioned information and confirmed the Hospice agency had not had a system in place to ensure Patient #3, #4, and #5 received Bereavement Services per the agency’s Bereavement Services policy and their POC, and should have. S1ED confirmed the Hospice agency did not have a system in place to ensure Bereavement POCs were individualized, updated or implemented based on each family/caregiver’s needs throughout their bereavement process and should have. e. Failure to meet the patients’ and families’ spiritual needs due to lack of Spiritual Counseling/Chaplain Services. Review of the clinical records for Patient #7 (Election of Hospice Benefits Form signed on 02/28/2025), Patient #9 (Election of Hospice Benefits Form signed on 06/12/2024), Patient #12 (Election of Hospice Benefits Form signed on 04/09/2024), Patient #15 (Election of Hospice Benefits Form signed on 05/02/2024), and Patient #17 (Election of Hospice Benefits Form signed on 05/08/2024) revealed the patients/families were accepting of Chaplain services and did not receive an Initial Visit, Assessment or Spiritual Assessment within the 5 day window. Review of the Personnel File for the agency’s Spiritual Counselor/Chaplain employed from 12/28/2023 through 05/13/2024 was attempted with no documented evidence available for review. Further review revealed no documented Written Agreements for the provision of Spiritual Counselor/Chaplain Services from 12/28/2023 through 05/13/2024.An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED reviewed the aforementioned information and confirmed the Hospice agency did not have a system in place to ensure Patient #7, #9, #12, #15, and #17 received an Initial Chaplain Comprehensive Assessment and Initial Spiritual Assessment within the required 5 day window and should have. S1ED confirmed the Core Services the Hospice agency was required to provide included a Spiritual Counselor/Chaplain. S1ED confirmed the Hospice agency did not have a Spiritual Counselor/Chaplain on staff from 12/28/2023 through 05/13/2024 and the newly hired Chaplain did not complete orientation to begin seeing patients independently until 06/24/2024. S1ED confirmed during the lapse in Spiritual Counselor/Chaplain coverage, the agency admitted 107 patients and had 78 patients expired. S1ED confirmed the Hospice agency did not contact the state licensing office to inform them or seek assistance due to their difficulty in fulfilling this core service. S1ED confirmed while the Hospice agency did not have a Spiritual Counselor/Chaplain on staff, they were not able to provide the required services to meet the needs of their patients and families.”

“Based on record review and interview, the Hospice agency failed to ensure drugs and biologicals were disposed of properly, in accordance with all applicable laws and regulations, after a patient’s death. 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 a hospice nurse at the time of a patient’s death; 2. Ensure the hospice nurse, in the presence of a witness, documented the name and remaining counts of controlled drugs in the patient’s death note for 3 (#3, #5, and #10) of 4 (#3, #4, #5, and #10) death records reviewed; and 3. Ensure the hospice nurse, in the presence of a witness, performed the disposal of, documented the name of the witness and disposal method of controlled drugs in the patient’s death note for 3 (#3, #5, and #10) of 4 (#3, #4, #5, and #10) death records reviewedThis deficient practice had the potential to affect any of the 145 patient deaths during the past 12 months and a current census of 58 patients. Review of the memo issued by the Louisiana Department of Health (LDH) - Health Standards Section, 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 LDH Health Standards Section is issuing this notice to all licensed hospice providers. Effective 08/01/2018, Act 23 amends and reenacts Louisiana (LA) Revised Statute (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 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.1. Review of the Hospice agency’s policy titled “Medication Disposal”, last revised 12/01/2024, revealed, in part, the following: Purpose: To outline the process for disposal of controlled drugs in the home setting. Policy:Hospice agency staff will destroy or dispose of patient controlled substance medications, or will facilitate the destruction or disposal of patient controlled substance medications, according to the guidelines outlined in section 3222 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (“SUPPORT Act”), or according to State regulatory guidelines. Procedure: A. Education on Disposal of Controlled Substances1. The nurse will instruct the patient/caregiver on the proper disposal of controlled drugs and importance of disposing of all unused medications. Patients/caregivers re provided with education on safe drug disposal and hospice medication disposal policy upon admission to Hospice services. Education will include safe methods of disposal and ties in which the Hospice agency may assist with the disposal of controlled drugs. Education regarding the destruction or disposal of controlled substances will be documented in the patient record. 2. … In the event that the patient/caregiver decline to destroy medications immediately, the Hospice nurse will provide education to the patient/caregiver regarding Drug Enforcement Agency (DEA) safe medication destruction methods… .B. Disposal of Patient Controlled Substances by the Hospice Agency1. The patient, caregiver and care environment will be assessed by the admitting nurse for risk factors of diversion. 2. The nurse will inform the patient/caregiver upon admission that they will provide assistance with proper disposal of controlled substances… . 3. The nurse will document in the medical record if the patient/caregiver accepts or refuses the Hospice agency to assist with the disposal of the controlled substance(s). 5. When Hospice medications are disposed of in the presence of a Hospice nurse, the disposal must be witnessed by the nurse, the patient/caregiver, and/or another employee of the hospice or facility. 6. The Hospice nurse will document in the patient’s medical record the medication name, dosage, route, quantity, method of disposal, date and time of disposal, who disposed of the controlled substance(s), and who witnessed the disposal. C. Additional State Specific Guidelines. Further review revealed no documented evidence of State Specific Guidelines for Louisiana to reflect all of the requirements established in LA RS 40:2191. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED confirmed the Hospice agency was not aware of LA RS 40:2191 and the statute was not reflected in the agency’s policy and procedure for the disposal of medications. 2. and 3. Patient #3Review of Patient #3’s Clinical Record revealed a Start of Care date of 03/25/2024. Further review revealed he expired at home on 03/30/2024.Review of Patient #3’s Plan of Care and Physician Orders at the time of his death on 03/30/2024 revealed, in part, the following orders:Lorazepam 0.5mg tablet. 1 tablet by mouth every 6 hours as needed; and Morphine Concentrate 100mg/5mL Oral Solution. 0.25mL by mouth every 3 hours as needed. Review of Patient #3’s Death Visit Note written on 03/30/2024 at 8:47 a.m. revealed, in part, the following: Medications: Does patient have comfort pack? Yes. Is pack present and intact? Yes. Indicate if agency staff provided education regarding safe medication disposal? Yes. Provide specifics of education provided: Nurse educated family on safe medication disposal bins at local pharmacy. Further review revealed no documented evidence of the name of the medications with their final count and the name of the witness or the method of disposal with the name of the witness.Review of Patient #3’s Coordination Notes, dated 03/30/2024, revealed in part, the following: No documented evidence of the name of medications with their final count and the name of the witness or the method of disposal with the name of the disposal witness following Patient #3’s death.Patient #5Review of Patient #5’s Clinical Record revealed a Start of Care date of 03/19/2024. Further review revealed he expired at home on 04/11/2024.Review of Patient #5’s Plan of Care and Physician Orders at the time of his death on 04/11/2024 revealed, in part, the following orders: Hydrocodone 5mg-Acetaminophen 325mg tablet. 1 tablet by mouth every 6 hours as needed;Tramadol 50mg tablet. 1 tablet by mouth every 6 hours as needed; Lorazepam 0.5mg tablet. 1 tablet by mouth every 6 hours as needed; and Morphine Concentrate 100mg/5mL Oral Solution. 0.25mL by mouth every 3 hours as needed. Review of Patient #5’s Death Visit Note written on 04/11/2024 at 2:12 p.m. revealed, in part, the following: Medications: Does patient have comfort pack? Yes. Is pack present and intact? Yes. Indicate if agency staff provided education regarding safe medication disposal? Yes. Provide specifics of education provided: Mix with medication inactivator and dispose in Ziploc. Further review revealed no documented evidence of the name of the medications with their final count and the name of the witness or the method of disposal with the name of the witness.Review of Patient #5’s Coordination Notes, dated 04/11/2024, revealed in part, the following: No documented evidence of the name of medications with their final count and the name of the witness or the method of disposal with the name of the disposal witness following Patient #5’s death.Patient #10Review of Patient #10’s Clinical Record revealed a Start of Care date of 01/25/2025. Further review revealed he expired at home on 03/21/2025.Review of Patient #10’s Plan of Care and Physician Orders at the time of his death on 03/21/2025 revealed, in part, the following orders: Lorazepam 0.5mg tablet. 1 tablet by mouth every 6 hours as needed; and Morphine Concentrate 100mg/5mL Oral Solution. 0.25mL by mouth every 3 hours as needed. Review of Patient #10’s Death Visit Note written on 03/21/2025 at 2:39 p.m. revealed, in part, the following: Medications: Does patient have comfort pack? Yes. Is pack present and intact? Yes. Indicate if agency staff provided education regarding safe medication disposal? Yes. Provide specifics of education provided. “staff disposed of”Further review revealed no documented evidence of the name of the medications with their final count and the name of the witness or the method of disposal with the name of the witness.Review of Patient #10’s Coordination Notes, dated 03/21/2025, revealed in part, the following: No documented evidence of the name of medications with their final count and the name of the witness or the method of disposal with the name of the disposal witness following Patient #10’s death.An interview was conducted on 03/25/2025 at 1:20 p.m. with S2DCO. S2DCO confirmed narcotic counts and/or the destruction of narcotics following a patient’s death were not documented in a paper record. S2DCO confirmed only place this information would be documented was within the electronic Death Visit Note. An interview was conducted on 03/27/2025 at 2:00 p.m. with S1ED. S1ED confirmed the Hospice agency allowed a patient’s family to maintain ownership of narcotic medications following the patient’s death. S1ED confirmed the Hospice agency allowed family/caregivers to be in charge of the destruction of controlled substances without the presence of the Hospice nurse following the patient’s death. S1ED confirmed upon a patient’s death, she would expect the RN to perform a final medication count with a witness then document the information in the Death Visit Note. S1ED confirmed now that she was aware of LA RS 40:2191, she would also expect all medications to be destroyed immediately following the count and for the method of destruction and name of the witness to be documented in the Death Visit Note and it had not been for Patient #3, #5, and #10.”