Traditions Health

“Based on record reviews and interviews, the Hospice agency failed to ensure licensed professionals actively participated in all aspects of the patient’s Hospice care in accordance with current professional standards, including all applicable state laws. The Hospice agency failed to ensure a patient’s medical pronouncement of death by a coroner was based on personal observation or information and statements obtained from a qualified professional for 1 (#3) of 3 (#1, #2 and #3) sampled patients. This deficient practice had the potential to affect any of the Hospice agency’s patient deaths since 07/01/2010, a current census of 20 patients, and any future patients admitted to the Hospice agency. Cross Reference: L651. Review of LA RS 9:111, effective 07/01/2010, revealed, in part, the following: A. A person will be considered dead if in the announced opinion of a physician, duly licensed in the state of Louisiana based on ordinary standards of approved medical practice, the person has experienced an irreversible cessation of spontaneous respiratory and circulatory functions….B. The medical pronouncement of death by a coroner may also be based on personal observation, information, or statements obtained from coroner investigators, Registered Nurses, physician assistants, or emergency medical technicians at the scene who are reporting from firsthand observation of the physical condition of the deceased. …Review of the Hospice agency’s Expected Patient Death Policy and Procedure, last reviewed 09/01/2024, as of 05/28/2025, revealed the policy did not meet the requirements established in LA RS 9:111. Further review revealed, in part, the following: Policy: I. The Hospice will observe applicable federal, state and local rules and regulations of a patient’s death in the home. Procedure: I. The Hospice will be aware of the state and local regulations related to death in the home including:A. Who may pronounce and/or certify a patient’s death;III. Interventions by the Hospice are specific according to the following factors:C. In the event there is a valid Do Not Resuscitate (DNR) and the Licensed Practical Nurse (LPN) is present: 2. The LPN: a. Confirms the absence of vital signs, only as allowed per state regulations and licensure; b. Contacts the physician, who pronounces death; c. Contacts community authority and funeral home; andD. In the event there is a valid DNR and the LPN is not present: 3. LPN Notification: a. The LPN comes to the home and confirms absence of vital signs, only as allowed by state regulations and licensure; calls physician who pronounces death.IV. Post mortem care will be provided with attention and respect given to: A. Pronouncement of death according to local, state and federal;V. Documentation and communication of the patient’s death to appropriate personnel, attending physician, and legal entities, as appropriate. Review of Patient #3’s Clinical Record revealed he was admitted to the Hospice agency on 06/02/2023 for a Certification Period of 06/02/2023 through 08/30/2023. Further review revealed he expired on 06/07/2023. Review of Patient #3’s Death Visit performed by S2LPN on 06/07/2023 revealed no documented evidence of a Registered Nurse (RN) being present during this visit. Review of Patient #3’s Client Coordination Note written by S2LPN on 06/07/2023, revealed in part, the following: SN Performing Visit: S2LPNNote: Nurse arrived for death visit at 10:30 a.m. No respirations or pulse noted. Nurse listened for heart beat for a full 2 minutes. Coroner called and pronounced time of death as 11:35 a.m. An interview was conducted on 05/28/2025 at 11:45 a.m. with S1DIR. S1DIR confirmed the agency’s policy and procedure allowed for a nurse, either LPN or RN, to perform a death assessment to ensure the absence of vital signs then contact the coroner or the patient’s physician by phone to receive pronouncement of death and release of the body. S1DIR confirmed according to LA RS 9:111, the performance of this assessment was not within an LPN’s Scope of Practice within the State of Louisiana. S1DIR reviewed Patient #3’s Clinical Records and confirmed an LPN performed his death assessment and should not have.”

“Based on record reviews and interview, the Hospice agency’s Governing Body and Administrator failed to assume full legal authority and responsibility for the management and provision of all Hospice services in accordance with all applicable laws and regulations. This deficient practice was evidenced by failure to establish a written policy and procedure which reflected all applicable laws to ensure:1. Compliance with LA RS 40:2191 for the safe disposal of unused controlled substances by a Hospice nurse following a patient’s death for 3 of 3 (#1, #2, and #3) patients sampled; and 2. Compliance with LA RS 9:111 for the patient’s medical pronouncement of death by a coroner and/or physician was based on the personal observation or information and statements obtained from a qualified professional for 1 (#3) of 3 (#1, #2 and #3) sampled patients.This deficient practice had the potential to affect a current census of 20 patients and any future patients admitted to the Hospice agency. Cross Reference: L585 and L694. 1. Review of the memo issued by the state regulatory agency, dated 06/25/2018, revealed the following, in part: In accordance with Act 23 of the 2018 Regular Legislative Session, regarding the 2018 Regular Legislative Session, the state regulatory agency is issuing this notice to all licensed Hospice providers. Effective 08/01/2018, Act 23 amends and reenacts Louisiana Revised Statute (LA RS) 40:2191 relative to disposal of controlled substances by Hospice providers; to provide for ownership; to provide for written procedures; to provide for patient records; to provide for disposal; to provide for patient notification; and to provide for related matters. Review of LA RS 40:2191 revealed the following, in part: Disposal of deceased patient’s unused controlled substances:A. Upon death of a patient receiving Hospice services, ownership of the patient’s unused Schedule II, III, IV, or V controlled substances under 21 CFR 1308 may transfer to the Hospice for immediate disposal pursuant to the following provisions:(1) Each Hospice shall establish a written procedure to ensure safe disposal of unused controlled substances by a Hospice nurse at the time of a patient’s death.(2) Upon the death of a patient receiving Hospice services, in the presence of a witness, the Hospice nurse shall record in the medical record the name and quantity of each unused controlled substance.(3)(a) The Hospice nurse shall conduct immediate disposal of the controlled substance at the site of care … (b) … the Hospice nurse shall perform the disposal in the presence of a witness, who shall sign a document indicating their witnessing the disposal. (5) The Hospice nurse shall record the method of disposal in the medical record.Review of the Hospice agency’s Medication Disposal Policy and Procedure, last reviewed 09/01/2024, as of 05/28/2025, revealed the policy did not meet the requirements established in LA RS 40:2191. Further review revealed, in part, the following: Purpose: To establish a procedure for appropriately handling and disposing of home medications to ensure patient, family, staff and community safety. Policy:1. This policy applies to management and disposal of all medications. 2. The Hospice supports the responsible management of and disposal of all medications in accordance with state and federal laws. 3. The Hospice recognizes and respects that the medications in the home are the property of the patient. 4. The Hospice will not remove medications from the patient’s home or dispose of patient’s medications. Procedure: I. On admission to the Hospice program, the Hospice nurse will provide the patient and/or authorized representative with a copy of the Hospice’s policy for managing the safe use and disposal of medications. III. Disposal ProcessA. In accordance with FDA recommendations, options for disposing of expired, unwanted, or unused medications are: 1. Medication take-back options; 2. Disposal in the household trash; 3. Flushing certain potentially dangerous medicines in the toilet. B. In the event of medications that are no longer needed, the Hospice staff will instruct the patient and/or caregiver on disposal options in accordance with disposing per package instructions, federal and state law. C. If disposal assistance is requested by family or authorized representative. The Hospice nurse will observe and provide verbal assistance for proper disposal medications. D. If Hospice staff provides verbal assistance with disposal, the staff will document in the patient’s clinical record the medications, dosage, route of administration, quantity disposed and the time, date and the way that occurred. IV. When the Hospice has provided medications to Hospice patients in contracted facilities, such as hospitals, or nursing facilities, the Hospice will abide by that contracted facility’s policy on disposal of medications. V. The Hospice staff will provide disposal information to patient.Patient #1Review of Patient #1’s Clinical Record revealed he was admitted to the Hospice agency on 02/26/2025 for a Certification Period of 02/26/2025 through 03/03/2025 with a terminal diagnosis of Unspecified Systolic Congestive Heart Failure. Further review revealed he expired on 03/03/2025.Review of Patient #1’s Plan of Care and Physician’s Orders for the Certification Period at the time of his death, revealed, in part, the following active orders: Hydrocodone 5mg/Acetaminophen 325mg: Give 1 tablet every 6 hours by mouth as needed for pain rating of 4-6 out of 10;Lorazepam 0.5mg Tablet: Give 1 tablet every 4 hours by mouth as needed for anxiety; andMorphine Concentrate 100mg/5mL: Give 0.5mL every 2 hours by mouth as needed for shortness of breath and/or severe pain rating of 7-10 out of 10. Review of Patient #1’s Death Visit, dated 03/03/2025, revealed, in part, no documented evidence of the final count of controlled drugs and/or the method of destruction with the name and signature of the witness. Review of Patient #1’s Client Coordination Note, dated 03/03/2025, revealed, in part, no documented evidence of the final count of controlled drugs and/or the method of destruction with the name and signature of the witness. Patient #2Review of Patient #2’s Clinical Record revealed she was admitted to the Hospice agency on 04/22/2025 for a Certification Period of 04/22/2025 through 07/20/2025 with a terminal diagnosis of Senile Degeneration of the Brain. Further review revealed she expired on 05/01/2025.Review of Patient #2’s Plan of Care and Physician’s Orders for the Certification Period at the time of her death, revealed, in part, the following active orders: Dilaudid Oral Liquid 1mg/mL: Give 0.5 mL every 2 hours by mouth as needed for pain rating of 5-10 out of 10; andFentanyl Transdermal Patch 25mcg/hr: Apply 1 patch transdermal every 72 hours for pain. Review of Patient #1’s Death Visit, dated 05/01/2025, revealed, in part, no documented evidence of a witness to the final count of controlled drugs and/or the method of destruction with the name and signature of the witness. Further review revealed, in part, the following: Disposition of Medications: Family requested drugs be destroyed by Nurse per use of Hospice agency protocol. Who destroyed medications: S1DIRNurse who witnessed medication disposal: S1DIRMedications at time of death: Lorazepam: 27 tablets; Dilaudid: 13-0.25mL prefilled syringes and Dilaudid: approximately 3mL remaining in bottle.Review of Patient #2’s Client Coordination Note, dated 05/01/2025, revealed, in part, no documented evidence of a witness to the final count of controlled drugs and/or the method of destruction with the name and signature of the witness. Patient #3Review of Patient #3’s Clinical Record revealed he was admitted to the Hospice agency on 06/02/2023 for a Certification Period of 06/02/2023 through 08/30/2023 with a terminal diagnosis of Malignant Neoplasm of Left Bronchus or Lung. Further review revealed he expired on 06/07/2023.Review of Patient #3’s Plan of Care and Physician’s Orders for the Certification Period at the time of his death, revealed, in part, the following active orders: Lorazepam 0.5mg tablet: Give 1 tablet every 6 hours by mouth as needed for anxiety/agitation; Lorazepam Oral Concentrate 2mg/mL: Give 0.25mL every 6 hours by mouth as needed for anxiety and agitation when patient can’t swallow tablets;Morphine Concentrate 100mg/5mL: Give 0.5mL every 4 hours by mouth for pain and/or shortness of breath; andMorphine Concentrate 100mg/5mL: Give 0.5mL every 2 hours by mouth as needed for breakthrough pain and/or shortness of breath.Review of Patient #3’s Death Visit, dated 06/07/2023, revealed, in part, no documented evidence of a witness to the final count of controlled drugs and/or the method of destruction with the name and signature of the witness. Further review revealed, in part, the following: Disposition of Medications: Family requested drugs be destroyed by Nurse per use of Hospice agency protocol. Who destroyed medications: S2LPNNurse who witnessed medication disposal: S2LPNMedications at time of death: Lorazepam: 28 mL; Lorazepam: 8 pre-filled syringes; Lorazepam: 14 tablets; Morphine Concentrate: 26 syringes. Review of Patient #3’s Client Coordination Note, dated 06/07/2023, revealed, in part, no documented evidence of a witness to the final count of controlled drugs and/or the method of destruction with the name and signature of the witness. An interview was conducted on 05/28/2025 at 11:45 a.m. with S1DIR. S1DIR reviewed Patient #1, #2 and #3’s Clinical Records and confirmed the there was no documented evidence of a controlled drug count with a witness and/or the destruction of the controlled drugs with a witness and their signature. S1DIR confirmed she was aware of LA RS 40:2191 and its requirements for Hospice agencies following a patient’s death. S1DIR confirmed following a patient’s death, she expected nurses to document controlled drug counts with the name of the witness and the method of destruction with the name of the witness. S1DIR confirmed the Hospice agency’s current policy and procedure did not reflect her expectation nor did it reflect LA RS 40:2191. S1DIR confirmed the agency did not utilize handwritten, paper documentation to allow for the signature of the witness.2. Review of LA RS 9:111 revealed, in part, the following: A. A person will be considered dead if in the announced opinion of a physician, duly licensed in the state of Louisiana based on ordinary standards of approved medical practice, the person has experienced an irreversible cessation of spontaneous respiratory and circulatory functions….B. The medical pronouncement of death by a coroner may also be based on personal observation, information, or statements obtained from coroner investigators, Registered Nurses, physician assistants, or emergency medical technicians at the scene who are reporting from firsthand observation of the physical condition of the deceased. …Review of the Hospice agency’s Expected Patient Death Policy and Procedure, last reviewed 09/01/2024, as of 05/28/2025, revealed, in part, the following:Policy: I. The Hospice will observe applicable federal, state and local rules and regulations of a patient’s death in the home. Procedure: I. The Hospice will be aware of the state and local regulations related to death in the home including:A. Who may pronounce and/or certify a patient’s death;III. Interventions by the Hospice are specific according to the following factors:C. In the event there is a valid Do Not Resuscitate (DNR) and the Licensed Practical Nurse (LPN) is present: 2. The LPN: a. Confirms the absence of vital signs, only as allowed per state regulations and licensure; b. Contacts the physician, who pronounces death; c. Contacts community authority and funeral home; andD. In the event there is a valid DNR and the LPN is not present: 3. LPN Notification: a. The LPN comes to the home and confirms absence of vital signs, only as allowed by state regulations and licensure; calls physician who pronounces death.IV. Post mortem care will be provided with attention and respect given to: A. Pronouncement of death according to local, state and federal;V. Documentation and communication of the patient’s death to appropriate personnel, attending physician, and legal entities, as appropriate. Patient #3Review of Patient #3’s Clinical Record revealed he was admitted to the Hospice agency on 06/02/2023 for a Certification Period of 06/02/2023 through 08/30/2023. Further review revealed he expired on 06/07/2023. Review of Patient #3’s Death Visit performed by S2LPN on 06/07/2023 revealed no documented evidence of an RN being present during this visit. Review of Patient #3’s Client Coordination Note written by S2LPN on 06/07/2023, revealed in part, the following: SN Performing Visit: S2LPNNote: Nurse arrived for death visit at 10:30 a.m. No respirations or pulse noted. Nurse listened for heart best for a full 2 minutes. Coroner called and pronounced time of death as 11:35 a.m. Further review revealed, in part, no documented evidence of an RN being present during this visit.An interview was conducted on 05/28/2025 at 11:45 a.m. with S1DIR. S1DIR reviewed Patient #3’s Clinical Records and confirmed an LPN performed his death assessment. S1DIR confirmed she was aware of LA RS 9:11 and its requirements for Hospice agencies following a patient’s death. S1DIR confirmed according to LA RS 9:111, the performance of this assessment was not within an LPN’s Scope of Practice in the State of Louisiana. S1DIR confirmed the agency’s current policy and procedure allowed for a nurse, either LPN or RN, to perform a death assessment to ensure the absence of vital signs then contact the coroner or the patient’s physician by phone to receive pronouncement of death and release of the body which did not accurately reflect the requirements of LA RS 9:111 and should. S1DIR stated the Hospice agency was corporately owned and the only one located in Louisiana so their policies and procedures were not inclusive of laws specific to Louisiana. S1DIR confirmed she made her corporate office aware of both LA RS 40:2191 and LA RS 9:111 in the past and no changes were made to the policies to reflect the requirements. An interview was conducted on 05/28/2025 at 11:50 a.m. with S3CORP. S3CORP reviewed the Hospice agency’s aforementioned policies and confirmed they did not accurately reflect the requirements of LA RS 40:2191 and/or LA RS 9:111 and should have.”

“Based on record reviews and interview, the Hospice agency failed to ensure drugs and biologicals were handled in accordance with all applicable laws and regulations. This deficient practice was evidenced by failure to:1. Establish a written procedure compliant with all applicable laws to ensure the safe disposal of unused controlled substances by a Hospice nurse following a patient’s death;2. Ensure the Hospice nurse, in the presence of a witness, documented the name and remaining counts of controlled drugs for 3 of 3 (#1, #2, and #3) patients sampled; and 3. Ensure the Hospice nurse, in the presence of a witness, performed the disposal of, documented the name of the witness, along with their signature, and the method of disposal of controlled drugs for 3 of 3 (#1, #2, and #3) patients sampled. This deficient practice had the potential to affect any of the Hospice agency’s patients who have expired since 07/01/2010, a current census of 20 patients, and any future patients admitted to the Hospice agency. Cross Reference: L651. Review of the memo issued by the state regulatory agency, dated 06/25/2018, revealed the following, in part: In accordance with Act 23 of the 2018 Regular Legislative Session, regarding the 2018 Regular Legislative Session, the state regulatory agency is issuing this notice to all licensed Hospice providers. Effective 08/01/2018, Act 23 amends and reenacts Louisiana Revised Statute (LA RS) 40:2191 relative to disposal of controlled substances by Hospice providers; to provide for ownership; to provide for written procedures; to provide for patient records; to provide for disposal; to provide for patient notification; and to provide for related matters. Review of LA RS 40:2191, effective 08/01/2018, 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 Medication Disposal Policy and Procedure, last reviewed 09/01/2024, as of 05/28/2025, revealed the policy did not meet the requirements established in LA RS 40:2191. Further review revealed, in part, the following: Purpose: To establish a procedure for appropriately handling and disposing of home medications to ensure patient, family, staff and community safety. Policy:1. This policy applies to management and disposal of all medications. 2. The Hospice supports the responsible management of and disposal of all medications in accordance with state and federal laws. 3. The Hospice recognizes and respects that the medications in the home are the property of the patient. 4. The Hospice will not remove medications from the patient’s home or dispose of patient’s medications. Procedure: I. On admission to the Hospice program, the Hospice nurse will provide the patient and/or authorized representative with a copy of the Hospice’s policy for managing the safe use and disposal of medications. III. Disposal ProcessA. In accordance with FDA recommendations, options for disposing of expired, unwanted, or unused medications are: 1. Medication take-back options; 2. Disposal in the household trash; 3. Flushing certain potentially dangerous medicines in the toilet. B. In the event of medications that are no longer needed, the Hospice staff will instruct the patient and/or caregiver on disposal options in accordance with disposing per package instructions, federal and state law. C. If disposal assistance is requested by family or authorized representative. The Hospice nurse will observe and provide verbal assistance for proper disposal medications. D. If Hospice staff provides verbal assistance with disposal, the staff will document in the patient’s clinical record the medications, dosage, route of administration, quantity disposed and the time, date and the way that occurred. IV. When the Hospice has provided medications to Hospice patients in contracted facilities, such as hospitals, or nursing facilities, the Hospice will abide by that contracted facility’s policy on disposal of medications. V. The Hospice staff will provide disposal information to patient.An interview was conducted on 05/28/2025 at 11:45 a.m. with S1DIR. S1DIR confirmed she was aware of LA RS 40:2191 and its requirements for a Hospice agency following patient death. S1DIR reviewed the Hospice agency’s aforementioned policy and confirmed it did not accurately reflect the requirements of LA RS 40:2191 and should have. 2. and 3. Patient #1Review of Patient #1’s Clinical Record revealed he was admitted to the Hospice agency on 02/26/2025 for a Certification Period of 02/26/2025 through 03/03/2025 with a terminal diagnosis of Unspecified Systolic Congestive Heart Failure. Further review revealed he expired on 03/03/2025.Review of Patient #1’s Plan of Care and Physician’s Orders for the Certification Period at the time of his death, revealed, in part, the following active orders: Hydrocodone 5mg/Acetaminophen 325mg: Give 1 tablet every 6 hours by mouth as needed for pain rating of 4-6 out of 10;Lorazepam 0.5mg Tablet: Give 1 tablet every 4 hours by mouth as needed for anxiety; andMorphine Concentrate 100mg/5mL: Give 0.5mL every 2 hours by mouth as needed for shortness of breath and/or severe pain rating of 7-10 out of 10. Review of Patient #1’s Death Visit, dated 03/03/2025, revealed, in part, no documented evidence of the final count of controlled drugs and/or the method of destruction with the name and signature of the witness. Review of Patient #1’s Client Coordination Note, dated 03/03/2025, revealed, in part, no documented evidence of the final count of controlled drugs and/or the method of destruction with the name and signature of the witness. Patient #2Review of Patient #2’s Clinical Record revealed she was admitted to the Hospice agency on 04/22/2025 for a Certification Period of 04/22/2025 through 03/07/20/2025 with a terminal diagnosis of Senile Degeneration of the Brain. Further review revealed she expired on 05/01/2025.Review of Patient #2’s Plan of Care and Physician’s Orders for the Certification Period at the time of her death, revealed, in part, the following active orders: Dilaudid Oral Liquid 1mg/mL: Give 0.5 mL every 2 hours by mouth as needed for pain rating of 5-10 out of 10; andFentanyl Transdermal Patch 25mcg/hr: Apply 1 patch transdermal every 72 hours for pain. Review of Patient #1’s Death Visit, dated 05/01/2025, revealed, in part, no documented evidence of a witness to the final count of controlled drugs and/or the method of destruction with the name and signature of the witness. Further review revealed, in part, the following: Disposition of Medications: Family requested drugs be destroyed by Nurse per use of Hospice agency protocol. Who destroyed medications: S1DIRNurse who witnessed medication disposal: S1DIRMedications at time of death: Lorazepam: 27 tablets; Dilaudid: 13-0.25mL prefilled syringes and Dilaudid: approximately 3mL remaining in bottle.Review of Patient #2’s Client Coordination Note, dated 05/01/2025, revealed, in part, no documented evidence of a witness to the final count of controlled drugs and/or the method of destruction with the name and signature of the witness. Patient #3Review of Patient #3’s Clinical Record revealed he was admitted to the Hospice agency on 06/02/2023 for a Certification Period of 06/02/2023 through 08/30/2023 with a terminal diagnosis of Malignant Neoplasm of Left Bronchus or Lung. Further review revealed he expired on 06/07/2023.Review of Patient #3’s Plan of Care and Physician’s Orders for the Certification Period at the time of his death, revealed, in part, the following active orders: Lorazepam 0.5mg tablet: Give 1 tablet every 6 hours by mouth as needed for anxiety/agitation; Lorazepam Oral Concentrate 2mg/mL: Give 0.25mL every 6 hours by mouth as needed for anxiety and agitation when patient can’t swallow tablets;Morphine Concentrate 100mg/5mL: Give 0.5mL every 4 hours by mouth for pain and/or shortness of breath; andMorphine Concentrate 100mg/5mL: Give 0.5mL every 2 hours by mouth as needed for breakthrough pain and/or shortness of breath.Review of Patient #3’s Death Visit, dated 06/07/2023, revealed, in part, no documented evidence of a witness to the final count of controlled drugs and/or the method of destruction with the name and signature of the witness. Further review revealed, in part, the following: Disposition of Medications: Family requested drugs be destroyed by Nurse per use of Hospice agency protocol. Who destroyed medications: S2LPNNurse who witnessed medication disposal: S2LPNMedications at time of death: Lorazepam: 28 mL; Lorazepam: 8 pre-filled syringes; Lorazepam: 14 tablets; Morphine Concentrate: 26 syringes. Review of Patient #3’s Client Coordination Note, dated 06/07/2023, revealed, in part, no documented evidence of a witness to the final count of controlled drugs and/or the method of destruction with the name and signature of the witness. An interview was conducted on 05/28/2025 at 11:45 a.m. with S1DIR. S1DIR confirmed following a patient’s death, she expected nurses to document controlled drug counts with the name of the witness and the method of destruction with the name of the witness. S1DIR confirmed this information would be documented in the patient’s Death Visit or Client Coordination Note. S1DIR confirmed the agency did not utilize handwritten, paper documentation to allow for the signature of the witness; only a Visit Note and/or Client Coordination Note. S1DIR reviewed Patient #1, #2 and #3’s Clinical Records and confirmed the required information was not present and should have been.”

“Observed in Record Review. In 2 of 3 patient records reviewed admitted after last survey, During RR# 1 and RR# 2’s patient records review it was noted the organization had not ensured the plan of care included individualized measurable goals and time frames to meet those goals. For example: review of RR# 1’s plan of care revealed a Chaplain goal Patient/Caregiver will feel relief from Spiritual Concerns with no time frame. Review of RR# 1’s initial Spiritual assessment revealed documentation that RR# 1 had no spiritual concerns. Further review of RR# 1’s plan of care revealed a MSW goal Patient/Caregiver will have decreased fear/anxiety regarding death and dying process with no time frame. Review of RR# 1’s initial Psychosocial assessment revealed documentation that RR# 1 had no fear or anxiety related to the death and dying process. Review of RR# 2’s plan of care revealed a MSW goal Patient/Caregiver will have decreased fear/anxiety regarding death and dying process with no time frame. Review of RR# 2’s initial Psychosocial assessment revealed documentation that RR# 2 had no fear or anxiety related to death and dying process. Further review of RR# 2’s plan of care revealed a Chaplain goal Caregivers will experience a sense of accomplishment at having supported the dying person with no time frame. This was reviewed, discussed, and validated with the Administrator.”

“Observed in Record Review. In 1 of 3 patient records reviewed admitted after last survey, During RR# 2’s patient record it was noted the organization had not ensured the plan of care included all services needed for the palliation and management of the terminal illness and related conditions to include medications and treatment necessary to meet the patient’s needs. For example: review of RR# 2’s RN comprehensive assessment revealed RR# 2 had a terminal diagnosis of lung cancer with metastases to brain and liver, had an indwelling foley catheter and was on medications for seizures. Review of RR# 2’s plan of care revealed no interventions related to the foley catheter or seizure precautions. This was reviewed, discussed, and validated with the Administrator.”

“Observed in Record Review. In 6 of 14 patient records reviewed, all services for the palliation and management of the terminal illness and related conditions were not included. For example, during home visit RRHV#1 the surveyor observed that the patient had dressings on the left forearm and elbow for wounds that the nurse said were new in the last few weeks. In RRNHV#1 a volunteer made two patient visits. In RRNHV#4 it was noted that the patient had a wound and cried out during dressing changes. In RRNHV#5 there was no advance directive; the patient was incontinent of bowel and bladder; and was at risk for falls. In RRNHV#6 the patient had dyspnea on exertion and was using oxygen; was incontinent; and was at risk for falls. In RRNHV#7 the patient had a wound; was incontinent of bowel and bladder; and was at risk for falls. Plans of care were not revised to include these identified problems or provided treatments. This RFI was reviewed with the Regional Administrator, Administrator, and Clinical Team Leader.”

“Observed in Record Review. In 14 of 14 patient records reviewed, patient goals were generic, few were specific, and most were not measurable. Some were to be met by the end of the benefit period, but most had no identified completion target. Additionally, many goals were not revised during the benefit period. Examples included: pain will be managed at a level acceptable to the patient by end of certification period; patient will receive appropriate and safe wound care; patient will verbalize understanding of the pain scale; patient will verbalize understanding of hospice Medicare benefit. This RFI was reviewed with the Regional Administrator, Administrator, and Clinical Team Leader.”

“Observed in Tracer Activities. In 1 of 1 patient records reviewed, for patients receiving volunteer services and during discussion with the volunteer coordinator, it was learned that visit volunteers did not document their activity in patient records. The coordinator stated that she did not know this was required. This RFI was verified by the Regional Administrator, Administrator, and Clinical Team Leader. Observed in Record Review. In 2 of 14 patient records reviewed, documentation was not accurate. In the records of RRHV#1 and RRHV#3 interdisciplinary meeting notes written after the public health emergency ended on May 11, 2023 included the following statement: Some visits of the IDG team members may be completed using telemedicine if the visits cannot safely be performed in person due to the COVID-19 pandemic. This RFI was verified by the Regional Administrator, Administrator, and Clinical Team Leader. Observed in Record Review. In 1 of 14 patient records reviewed, the organization did not ensure that patient records were complete and accurate. For example, in the record of RRHV#1 a registered nurse repeatedly documented that the patient had a deep tissue injury to the right elbow, which eventually closed. In later notes she again documented a wound to the right elbow in some notes, and the left elbow in other notes. However, on the body diagram, the location of the wound was consistently the right elbow. In that same record, she also documented that a patient had bilateral new unstageable deep tissue injuries but did not include measurements at that time. This RFI was reviewed with the Regional Administrator, Administrator, and Clinical Team Leader.”