Notre Dame Hospice of Greater Baton Rouge

“Based on interviews and record reviews, the Hospice agency failed to meet the Condition of Participation for Initial and Comprehensive Assessments of the Patient. This deficient practice is evidenced by failure to have a system in place to: 1. Ensure the Chaplain’s Initial Comprehensive Assessment was performed within 5 days of a patient’s Election of Hospice Benefits for 1 (#6) of 10 (#5 through #14) live patients reviewed in the final sample (See findings in L523);2. Ensure an Initial Spiritual Assessment was performed within 5 days after the Election of Hospice Benefits for 1 (#6) of 10 (#5 through #14) live patients reviewed in the final sample(See findings in L524);3. Ensure a patient’s Comprehensive Assessment accurately reflected a newly written Physician’s Order to Refer to Physical Therapy for further evaluation for 1 of 1 (#11) live patients reviewed for referrals (See findings in L532);4. Ensure a patient’s Comprehensive Assessment was updated following the identification of a new pressure wound for 1 (#6) of 3 (#5, #6, and #8) patients reviewed for wounds (See findings in L533); and 5. Ensure a patient’s Comprehensive Assessment was updated to reflect the status of a Physician’s Order to refer to Physical Therapy for Evaluation for 1 of 1 (#11) live patients reviewed for referrals (See findings in L533). This deficient practice had the potential to affect any of the 39 admissions during the past 12 months, a current census of 18 patients and any future admissions to the agency. See findings in L523, L524, L532, and L533. See findings in L523, L524, L532, and L533.”

“Based on observations, interviews and record reviews, the Hospice agency failed to meet the Condition of Participation for Interdisciplinary Group (IDG), Care Planning (POC) and Coordination of Services. This deficient practice is evidenced by failure to have a system in place to: 1. Ensure the IDG maintained a system of communication, coordination, and integration of services when a patient had a change in status and/or newly identified concern for 3 (#5, #6, #11) of 10 (#5 through #14) live patients reviewed in the final sample (See Findings: L539); 2. Maintain a qualified and competent IDG, specifically a qualified Social Worker (MSW), from 08/11/2023 through 06/13/2025 (See Findings: L541);3. Ensure the individualized POC established by the IDG in collaboration with the attending physician was implemented as ordered for 2 (#5, #11) of 10 (#5 through #14) live patients reviewed in the sample (See Findings: L543); 4. Develop an individualized POC which accurately reflected medical devices in use for urinary and stool output for 1 (#8) of 10 (#5 through #14) live patients in the sample (See Findings: L545); 5. Ensure a patient’s individualized POC included the identification of interventions to manage pain and symptoms for 3 (#8, #9, and #11) of 10 (#5 through #14) live patients in the sample (See Findings: L546);6. Ensure the individualized POC included orders for all drugs and treatments necessary to meet the needs of the patient for 2 (#6 and #8) of 10 (#5 through #14) live patients in the sample (See Findings: L549); 7. Ensure the IDG updated the POC as frequently as necessary and no less than every 15 calendar days to maintain an individualized POC for 3 (#5, #6 and #11) of 10 (#5 through #14) live patients reviewed in the sample (See Findings: L552). This deficient practice had the potential to affect any of the 39 admissions during the past 12 months, a current census of 18 patients and any future admissions to the agency. See findings in L539, L541, L543, L545, L546, L549, and L552. See findings in L539, L541, L543, L545, L546, L549, and L552.”

“Based on interviews and record reviews, the Hospice agency failed to meet the Condition of Participation for Core Services as evidenced by failure to have a system in place to ensure Medical Social Work (MSW) Services were provided by a qualified Social Worker. This deficient practice was evidenced by having S4SW, a RSW, as the only social worker for the Hospice agency providing medical social worker services for 10 of 10 (#5 through #14) live patients reviewed in the final sample. Per interview with a representative of the state’s licensing board for Social Workers, RSWs are not allowed to work in a Hospice agency independently and they required the direct supervision of a LMSW if providing clinical services. This deficient practice had the potential to affect any of the 39 admissions during the past 12 months, a current census of 18 patients and any future admissions to the agency. See findings in L594. See findings in L594.”

“Based on interviews and record reviews, the Hospice agency failed to meet the Condition of Participation for the Organization and Administration of Services. This deficient practice is evidenced by failure to have a system in place to ensure the Hospice agency: 1. Met the Condition of Participation (COP) for Initial and Comprehensive Assessments in regards to the performance of all required aspects for Initial Assessments and the performance of updates to the Comprehensive Assessments following new orders and/or status changes for 2 (#6 and #11) of 10 (#5 through #14) live patients in the sample (See findings in L520, L523, L533); 2. Met the COP for Interdisciplinary Group (IDG), Care Planning (POC) and Coordination of Services in regards to maintaining a qualified IDG, maintaining a system of communication between the IDG, the provision of care per the POC, and the creation of and making updates to the POC following new orders and/or status changes for 5 (#5, #6, #8, #9, and #11) of 10 (#5 through #14) live patients in the sample (See findings in L536, L539, L541, L543, L545, L546, L549, L552); 3. Met the COP for Core Services in regards to ensuring Medical Social Work (MSW) Services were provided by a qualified Social Worker for 10 of 10 (#5 through #14) live patients reviewed in the final sample (See findings in L587 and L594); and 4. Met the COP for the Organization and Administration of Services in regards to the provision of Physical Therapy services and the provision of controlled substances per accepted standards of practice for 7 (#5, #6, #7, #8, #9, #11, and #12) of 10 (#5 through #14) live patients in the sample (See findings in L652).This deficient practice had the potential to affect any of the 39 admissions during the past 12 months, a current census of 18 patients and any future admissions to the agency. See Findings L520, L523, L533, L536, L539, L541, L543, L545, L546, L549, L552, L587, L594, L648 and L652. See Findings in L520, L523, L524, L533, L536, L539, L541, L543, L545, L546, L549, L552, L587, L594, L648 and L652.”

“Based on interviews and record review, the Hospice agency failed to ensure all members of the Interdisciplinary Group (IDG) completed the Initial Comprehensive Assessment within 5 days of a patient’s Election of Hospice Benefits (EOB). This deficient practice is evidenced by the Chaplain’s failure to perform an Initial Assessment within 5 days of EOB for 1 (#6) of 10 (#5 through #14) live patients reviewed in the final sample. This deficient practice had the potential to affect any of the 39 admissions during the past 12 months, a current census of 18 patients and any future admissions to the agency. Cross Reference: L520. Review of Patient #6’s Clinical Record revealed she was admitted to the Hospice agency on 01/09/2024 with her EOB signed on 01/09/2024. Further review revealed a current Certification Period of 05/03/2025 through 07/01/2025. Review of Patient #6’s Physician’s Orders and Plan of Care revealed, in part, a Chaplain Visit frequency of twice monthly. Review of Patient #6’s Chaplain’s Initial Assessment, dated 01/09/2024 through 01/13/2024, was attempted with no documented evidence available for review. Review of Patient #6’s Visit Calendar, dated 01/09/2024 through 01/13/2024, revealed, in part, no documented evidence of a Chaplain Visit being attempted or conducted within the required 5 day window. An interview was conducted on 06/13/2025 at 2:30 p.m. with S3DON. S3DON confirmed Patient #6 did not receive a Chaplain’s Initial Assessment during the required 5 day window and should have.”

“Based on interview and record review, the Hospice agency failed to ensure the completion of all components of the Comprehensive Assessment as evidenced by failure to Complete the Spiritual Assessment to identify needs to be addressed related to the terminal illness within 5 days after the Election of Hospice Benefits (EOB) for 1 (#6) of 10 (#5 through #14) live patients reviewed in the final sample. This deficient practice had the potential to affect any of the 39 admissions during the past 12 months, a current census of 18 patients and any future admissions to the agency. Cross Reference: L520. Review of Patient #6’s Clinical Record revealed she was admitted to the Hospice agency on 01/09/2024 with her EOB signed on 01/09/2024. Further review revealed a current Certification Period of 05/03/2025 through 07/01/2025. Review of Patient #6’s Initial Spiritual Assessment, dated 01/09/2024 through 01/13/2024, was attempted with no documented evidence available for review. An interview was conducted on 06/13/2025 at 2:30 p.m. with S3DON. S3DON confirmed Patient #6 did not receive an Initial Spiritual Assessment within the required 5 day window and should have.”

“Based on interview and record review, the Hospice agency failed to ensure Patient #11’s Comprehensive Assessment accurately reflected a Physician’s Order to refer to Physical Therapy (PT) for further evaluation for 1 of 1 (#11) live patients reviewed for referrals. This deficient practice had the potential to affect any of the 39 admissions during the past 12 months, a current census of 18 patients and any future admissions to the agency. Cross Reference: L520. Review of Patient #11’s Clinical Record revealed she was admitted to the Hospice agency on 04/28/2025 with a terminal diagnosis of Primary Central Nervous System Lymphoma. Further review revealed a current Certification Period of 06/06/2025 through 06/10/2025. Review of Patient #11’s Physician’s Orders revealed, in part, an order written by S5MD on 05/07/2025 for a Physical Therapy (PT) Evaluation. Review of Patient #11’s Comprehensive Assessments for all disciplines, dated 05/07/2025 through 06/10/2025, revealed, in part, no documented evidence of the Physician’s Order written on 05/07/2025 for PT Evaluation. Review of Patient #11’s IDG Meetings, dated 05/07/2025 through 06/10/2025, revealed, in part, the following: 05/13/2025 - No documented evidence of the Physician’s Order written on 05/07/2025 for PT Evaluation;05/27/2025 - No documented evidence of the Physician’s Order written on 05/07/2025 for PT Evaluation; and 06/04/2025 - No documented evidence of the Physician’s Order written on 05/07/2025 for PT Evaluation. An interview was conducted on 06/12/2025 at 11:35 a.m. with S1ADM. S1ADM confirmed Physical Therapy was included in the services a Hospice agency was required to provide patients when ordered. S1ADM confirmed Patient #11’s terminal diagnosis of Primary Central Nervous System Lymphoma would be a qualifying diagnosis for PT Services. S1ADM confirmed Patient #11 received a Physician’s Order for a PT Evaluation. S1ADM confirmed when a referral order was written for PT Evaluation, the patient’s Comprehensive Assessment should reflect the order. An interview was conducted on 06/13/2025 at 2:30 p.m. with S3DON. S3DON confirmed Physical Therapy was included in the services a Hospice agency was required to provide patients when ordered. S3DON confirmed Patient #11’s terminal diagnosis of Primary Central Nervous System Lymphoma would be a qualifying diagnosis for PT Services. S3DON confirmed Patient #11 received a Physician’s Order for a PT Evaluation. S3DON confirmed when a referral order was written for PT Evaluation, the patient’s Comprehensive Assessment should reflect the order and it was not for Patient #11.”

“Based on interviews and record review, the Hospice agency failed to ensure the Comprehensive Assessment was updated every 15 days and as needed to accurately reflect the patient’s condition. This deficient practice is evidenced by failure to: 1. Ensure Patient #6’s Comprehensive Assessment was updated following the identification of a new pressure wound for 1 (#6) of 3 (#5, #6, and #8) patients reviewed for wounds; and 2. Ensure Patient #11’s Comprehensive Assessment was updated to reflect the status of a Physician’s Order to refer to Physical Therapy (PT) for Evaluation for 1 of 1 (#11) live patients reviewed for referrals. This deficient practice had the potential to affect any of the 39 admissions during the past 12 months, a current census of 18 patients and any future admissions to the agency. Cross Reference: L520. 1. Identification of a new pressure wound. Patient #6Review of Patient #6’s Clinical Record revealed she was admitted to the Hospice agency on 01/09/2024 and in a current Certification Period of 05/03/2025 through 07/01/2025. Further review revealed she resided at a local nursing home (NH) and the NH nurse identified a Stage 2 Pressure Ulcer to the Sacral Region on 06/02/2025. Review of Patient #6’s active Physician Orders present in the EMR at her NH, as of 06/10/2025 at 9:30 a.m., revealed, in part, a wound treatment order written by the NH on 06/07/2025 for a Stage 2 Pressure Ulcer of the Sacral Region. An interview was conducted on 06/10/2025 at 9:40 a.m. with Patient #6’s nurse at the local NH where she resided. She confirmed she was Patient #6’s regularly assigned nurse and was very familiar with her condition and care. She confirmed Patient #6 was currently receiving treatment for a Stage 2 Pressure Ulcer to the Sacral Region identified by her on 06/02/2025. She confirmed she informed S3DON as soon as the wound was identified. She confirmed the orders for Patient #6’s wound care were written by the NH’s physician.Review of the Hospice agency’s Wound Log of all patients currently receiving treatment, as of 06/10/2025 at 11:45 a.m., revealed Patient #6 was not on the list.An interview was conducted on 06/10/2025 at 11:45 a.m. with S2DON when he provided the aforementioned Wound Log. S2DON confirmed the information on the Wound Log was accurate and only 2 patients (#5 and #8) were currently receiving treatment for wounds. Review of Patient #6’s Comprehensive Assessments, dated 06/03/2025 through 06/10/2025, revealed, in part, no documented evidence of her Stage 2 Pressure Ulcer to the Sacral Region. An interview was conducted on 06/13/2025 at 2:30 p.m. with S3DON. S3DON confirmed Patient #6’s NH nurse made her aware of Patient #6’s newly identified pressure wound at the beginning of June 2025. S3DON confirmed she did not update Patient #6’s Comprehensive Assessments to reflect the presence of the newly identified wound and/or any wound status updates and should have. 2. Physician’s Order to refer to PT for Evaluation. Patient #11Review of Patient #11’s Clinical Record revealed she was admitted to the Hospice agency on 04/28/2025 with a terminal diagnosis of Primary Central Nervous System Lymphoma. Further review revealed a current Certification Period of 06/06/2025 through 06/10/2025. Review of Patient #11’s Physician’s Orders revealed, in part, an order written by S5MD on 05/07/2025 for a Physical Therapy (PT) Evaluation. Review of Patient #11’s Comprehensive Assessments for all disciplines, dated 05/07/2025 through 06/10/2025, revealed, in part, no documented evidence of status of the Physician’s Order written on 05/07/2025 for PT consult and evaluation. Review of Patient #11’s IDG Meetings, dated 05/07/2025 through 06/102/2025, revealed, in part, no documented evidence of the status of the Physician’s Order written on 05/07/2025 for PT consult and evaluation.An interview was conducted on 06/12/2025 at 11:35 a.m. with S1ADM. S1ADM confirmed Physical Therapy was included in the services a Hospice agency was required to provide patients when ordered. S1ADM confirmed Patient #11’s terminal diagnosis of Primary Central Nervous System Lymphoma would be a qualifying diagnosis for PT Services. S1ADM confirmed Patient #11 received a Physician’s Order for a PT Evaluation. S1ADM confirmed the status of referrals should be reflected in the patient’s Comprehensive Assessment and it was not for Patient #11. An interview was conducted on 06/13/2025 at 2:30 p.m. with S3DON. S3DON confirmed Physical Therapy was included in the services a Hospice agency was required to provide patients when ordered. S3DON confirmed Patient #11’s terminal diagnosis of Primary Central Nervous System Lymphoma would be a qualifying diagnosis for PT Services. S3DON confirmed Patient #11 received a Physician’s Order for a PT Evaluation. S3DON confirmed she did not update Patient #11’s Comprehensive Assessment to reflect the status of the referral and should have.”

“Based on interviews and record reviews, the Hospice agency failed to ensure the Interdisciplinary Group (IDG) maintained a system of communication, coordination, and integration of services. This deficient practice was evidenced by failure to inform and involve the patient’s prescribing physician and other members of the IDG when: 1. The Social Worker (MSW) identified psychosocial concerns involving Patient #5 which required increased MSW and Hospice Aide (HA) Visit Frequency for 1 (#5) of 10 (#5 through #14) live patients reviewed in the final sample; 2. A newly identified pressure wound was identified for 1 (#6) of 3 (#5, #6, and #8) patients reviewed for wounds; and 3. A Physician’s Order was written to Refer Patient #11 for Evaluation by Physical Therapy (PT) for 1 of 1 (#11) patients reviewed for referrals.This deficient practice had the potential to affect any of the 39 admissions during the past 12 months, a current census of 18 patients and any future admissions to the agency. Cross Reference: L536. 1. Newly identified Psychosocial Concerns.Patient #5Review of Patient #5’s Clinical Record revealed he was admitted to the agency on 04/23/2025 and was in a current Certification Period of 04/23/2025 through 07/21/2025. Review of Patient #5’s MSW Visit Notes written by S4SW, dated 04/23/2025 through 06/11/2025, revealed, in part, the following: 04/23/2025 - MSW to visit weekly until wife feels comfortable and has a routine in place. 05/01/2025 - MSW to continue ongoing support weekly and monitor for needs and changes. 05/08/2025 - MSW to monitor for changes on an ongoing basis. 05/14/2025 - Patient continues to express guilt regarding wife having to care for him and his needs. MSW will meet with patient and wife weekly to assess and monitor for any changes or needs. 05/22/2025 - MSW to monitor on a weekly basis to ensure caregiver/patient are coping well. 05/29/2025 - Patient continues to express guilt and feelings of being burden on wife. MSW to monitor patient/caregiver weekly. 06/04/2025 - Patient continues to express guilt and feelings of being burden on wife. 06/09/2025 - MSW to monitor patient once a week. Review of Patient #5’s MSW Visit Calendar, dated 05/01/2025 through 06/11/2025, revealed, in part, the following visits conducted weekly by S4SW: 05/01/2025; 05/08/2025;05/14/2025; 05/22/2025; 05/29/2025; 06/04/2025; and 06/09/2025.Further review revealed S4SW had weekly visits scheduled throughout the remainder of Patient #5’s current Certification Period. Review of Patient #5’s HA Visit Calendar, dated 05/01/2025 through 06/11/2025, revealed, in part, the following visits conducted four times weekly by S6HA:05/05/2025, 05/06/2025; 05/07/2025; 05/09/2025; 05/12/2025; 05/13/2025; 05/14/2025; 05/16/2025;05/19/2025; 05/20/2025; 05/21/2025; 05/23/2025; and 05/26/2025; 05/27/2025; 05/28/2025; 05/30/2025. Review of Patient #5’s Physician’s Orders for the current Certification Period revealed, in part, the following: MSW Visit Frequency (effective 04/27/2025): Twice monthly for two months then once monthly for one month; andHA Visit Frequency (effective 04/27/2025): Three visits weekly for twelve weeks.Review of Patient #5’s IDG Meeting Notes, dated 04/23/2025 through 06/11/2025, revealed, in part, the following: No documented evidence of the IDG being informed of and/or discussing the psychosocial concerns S4SW identified for Patient #5 and his spouse;No documented evidence of the IDG being informed of and/or discussing Patient #5 requiring weekly MSW Visits in order to meet his psychosocial needs; and No documented evidence of the IDG being informed of and/or discussing Patient #5 requiring an additional HA Visit every week in order to meet his care needs.An interview was conducted on 06/12/2025 at 11:35 a.m. with S1ADM. S1ADM confirmed any newly identified issues and/or concerns should be discussed and documented during IDG Meetings (sooner, if necessary) with the Plan of Care (POC) and Physician’s Orders updated to ensure the patient/family’s needs were met. S1ADM confirmed if psychosocial concerns were identified and those concerns required an increased frequency of MSW Visits, this should be discussed and documented during IDG to determine if a frequency change was necessary to ensure needs were being met. S1ADM confirmed if a patient/family required more HA Visits than ordered, the reasoning should be discussed and documented during IDG to determine if a frequency change was necessary to ensure needs were being met. S1ADM confirmed during subsequent IDG Meetings, the status of all identified issues, concerns, and/or ordered visit frequencies should be discussed to determine if any progress was being made and/or if any additional changes were required and this discussion should be documented in the IDG Meeting Notes. An interview was conducted on 06/13/2025 at 2:30 p.m. with S3DON. S3DON confirmed S4SW saw Patient #5 more frequently than ordered due to his identified psychosocial concerns related to grief, coping, guilt, and feelings of being a burden on his spouse and sole caregiver. S3DON confirmed S6HA saw Patient #5 more frequently than ordered to alleviate some of the psychosocial concerns identified by S4SW. S3DON confirmed there was no documentation to indicate Patient #5’s identified psychosocial concerns and need for increased SW and HA Visits were discussed during IDG Meetings and there should be. 2. Newly identified Pressure Wound. Patient #6Review of Patient #6’s Clinical Record revealed she was admitted to the Hospice agency on 01/09/2024 and in a current Certification Period of 05/03/2025 through 07/01/2025. Further review revealed the local nursing home (NH) where she resided identified a Stage 2 Pressure Ulcer to the Sacral Region on 06/02/2025.An interview was conducted on 06/10/2025 at 9:40 a.m. with Patient #6’s nurse at her NH. She confirmed she was Patient #6’s regularly assigned nurse and was very familiar with her condition and care. She confirmed Patient #6 was currently receiving treatment for a Stage 2 Pressure Ulcer to the Sacral Region identified by her on 06/02/2025. She confirmed she informed S3DON as soon as she identified the wound. Review of Patient #6’s IDG Meeting Notes, dated 06/02/2025 through 06/10/2025, revealed, in part, the following: No documented evidence of the IDG being informed of and/or discussing her Stage 2 Pressure Ulcer to the Sacral Region after it was identified by the NH on 06/02/2025. An interview was conducted on 06/12/2025 at 11:35 a.m. with S1ADM. S1ADM confirmed a newly identified wound would require immediate notification to the patient’s physician with the communication documented in their record, as well as, the Plan of Care (POC) and Physician’s Orders updated to ensure the patient’s needs were met. An interview was conducted on 06/13/2025 at 2:30 p.m. with S3DON. S3DON confirmed Patient #6’s NH nurse made her aware of Patient #6’s newly identified pressure wound at the beginning of June 2025. S3DON confirmed there was no documented evidence of Patient #6’s Hospice Physician and other members of the IDG being informed immediately upon the identification of her Stage 2 Pressure Ulcer to the Sacral Region and there should be. 3. Referral for evaluation by Physical Therapy. Patient #11Review of Patient #11’s Clinical Record revealed she was admitted to the Hospice agency on 04/28/2025 with a terminal diagnosis of Primary Central Nervous System Lymphoma. Further review revealed a current Certification Period of 06/06/2025 through 06/10/2025. Review of Patient #11’s Physician’s Orders revealed, in part, the following: 05/07/2025 - Refer to Physical Therapy (PT) for Evaluation. Review of Patient #11’s IDG Meeting Notes, dated 05/07/2025 through 06/10/2025, revealed, in part, the following: No documented evidence of the IDG being informed of and/or discussing the status of her Physician’s Order for PT Evaluation after it was written on 05/07/2025. An interview was conducted on 06/12/2025 at 11:35 a.m. with S1ADM. S1ADM confirmed Patient #11 received a Physician’s Order to be Referred to PT for Evaluation on 05/07/2025. S1ADM confirmed the status of all referrals for further evaluation should be discussed and documented during IDG Meetings and it was not for Patient #11. An interview was conducted on 06/13/2025 at 2:30 p.m. with S3DON. S3DON confirmed Patient #11 received a Physician’s Order to be Referred to PT for Evaluation on 05/07/2025. S3DON confirmed the status of all referrals for further evaluation should be discussed and documented immediately with the ordering provider and during IDG Meetings and it was not for Patient #11.”

“Based on interviews and record review, 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 employ a qualified MSW from 08/11/2023 through 06/13/2025. This deficient practice had the potential to affect any of the 39 admissions during the past 12 months, a current census of 18 patients and any future admissions to the agency. Cross Reference: L536, L587 and L594. Review of S4SW’s Personnel File, as of 06/13/2025, revealed, in part, she was hired on 08/11/2023 and did not meet the job requirements to hold her position. Further review revealed she was a RSW, not a LMSW. Review of S4SW’s License through the Louisiana State Board of Social Work Examiners, as of 06/13/2025, revealed, in part, she was a RSW, not a LMSW. Review of the Hospice agency’s Organizational Chart and List of Current Staff Members, as of 06/13/2024, revealed, in part, the following: S4SW.Further review revealed no documented evidence of a LMSW being employed by the Hospice agency. Review of the RSW’s Scope of Practice according to the state’s licensing board for Social Workers, as of 06/13/2025, revealed, in part, the following: A RSW cannot work independently and must work under the direct supervision of a LMSW. An interview was conducted on 06/13/2025 at 11:25 a.m. with a representative of the state’s licensing board for Social Workers. She confirmed a RSW was not allowed to work in a Hospice agency independently and also required the direct supervision of a LMSW if providing clinical services. Review of the National Association of Social Workers (NASW), as of 06/13/2025 at 11:35 a.m., revealed, in part, the following in regards to what is considered Clinical Social Work: “Clinical social work is a specialty practice area of social work which focuses on the assessment, diagnosis, treatment, and prevention of mental illness, emotional, and other behavioral disturbances. Individual, group and family therapy are common treatment modalities. Social workers who provide these services are required to be licensed or certified at the clinical level in their state of practice. Clinical social workers perform services in a variety of settings including private practice, hospitals, community mental health, primary care, and agencies. NASW advocates for clinical social workers through the legislative and regulatory process.”An interview was conducted on 06/13/2025 at 11:10 a.m. with S1ADM. S1ADM confirmed S4SW was hired on 08/11/2023 and was the Hospice agency’s only Social Worker at this time. S1ADM confirmed S4SW was a RSW, not a LMSW and did not work under the supervision of a LMSW. S1ADM confirmed S4SW was not qualified and competent to serve on the agency’s IDG and should.”

“Based on observation, interviews and record reviews, the Hospice agency failed to ensure the care and services provided followed an individualized Plan of Care (POC) established by the Interdisciplinary Group (IDG) in collaboration with the Attending Physician in accordance with the patient’s needs. The Hospice agency failed to: 1. Ensure Wound Care was performed as ordered for 1 (#5) of 3 (#5, #6, and #8) patients reviewed for wounds; and2. Ensure a Physical Therapy (PT) Evaluation was performed as ordered for 1 of 1 (#11) patients reviewed for referrals. This deficient practice had the potential to affect any of the 39 admissions during the past 12 months, a current census of 18 patients and any future admissions to the agency. Cross Reference: L536. 1. Wound Care. Review of the Louisiana State Board of Nursing Declaratory Statement Scope of Practice for Registered Nurses - Wound Care Management adapted 02/1999 revealed the following in part: Registered nurses render care that is directed towards the prevention and treatment of wounds. Wounds are a common health care challenge that often occur with or result from chronic disorders such as impaired circulation and malnutrition. Nursing care of skin/wound conditions involves the identification, assessment, management, and ongoing evaluation of patients with alterations in skin/tissue integrity that includes but is not limited to draining wounds, pressure ulcers, and vascular ulcers, and conditions resulting from incontinence, surgical procedures, and/or trauma.Scope of Practice - The Louisiana State Board of Nursing recognizes that assessment, planning, intervention, teaching, evaluation, and supervision are the major responsibilities of the registered nurse in the practice setting. The registered nurse is responsible for performing a nursing assessment and physical examination for preventative and restorative nursing and for providing patient/family teaching. Recognizing that the physician must always prescribe wound care, the following roles are defined to delineate the scope of practice for each member of the nursing team members. The registered nurse initiates appropriate wound preventative measures, stages wounds and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by an authorized prescriber.Patient #5Review of Patient #5’s Clinical Record revealed he was admitted to the Hospice agency on 04/23/2025 and was in a current Certification Period of 04/23/2025 through 07/21/2025. Further review revealed he was currently receiving treatment for an active Pressure Wound to the Right Heel. Review of Patient #5’s Ordered Visit Frequencies for the current Certification Period, as of 06/09/2025, revealed, in part, two skilled nurse visits weekly. Review of Patient #5’s POC for the current Certification Period, as of 06/09/2025, revealed, in part, the followingWound #1: Right Heel - Pressure InjuryIdentified: 04/23/2025. Progress: Resolved.Intervention: Clean with wound cleanser, pat dry, paint with betadine, cover with telfa and wrap with kerlix. An observation was conducted during home visit on 06/10/2025 at 8:40 a.m. of S3DON performing Patient #5’s wound care on the active pressure wound to the right heel. S3DON was observed to cleanse the wound with wound cleanser, patted the wound dry, then painted the area with betadine and left the wound open to air. An interview was conducted on 06/10/2025 at 8:55 a.m. with S3DON. S3DON confirmed Patient #5’s Pressure Wound to the Right Heel was not resolved and was still actively receiving treatment. S3DON confirmed after she painted the wound with betadine she left the wound open to air and did not cover it with a telfa pad then wrap the area with a kerlix. S3DON confirmed Patient #5’s current Wound Care order was to cleanse with wound cleanser, pat dry, paint with betadine, apply a telfa pad then wrap the foot with kerlix. 2. Physical Therapy Evaluation.Patient #11Review of Patient #11’s Clinical Record revealed she was admitted to the Hospice agency on 04/28/2025 with a terminal diagnosis of Primary Central Nervous System Lymphoma. Further review revealed a current Certification Period of 06/06/2025 through 06/10/2025 and a Revocation of Hospice Benefits on 06/10/2025. Review of Patient #11’s Physician’s Orders, dated 05/07/2025 through 06/10/2025, revealed, in part, the following: 05/07/2025 - Refer to PT for Evaluation. Further review revealed no documented evidence of an order written to cancel the aforementioned referral for services. Review of Patient #11’s PT Evaluation, dated 05/07/2025 through 06/10/2025, was attempted throughout the course of the survey with no documented evidence available for review. Review of Patient #11’s Assessment Notes, dated 05/07/2025 through 06/10/2025, revealed, in part, the following: 05/09/2025 through 05/16/2025: Patient received Respite Care at a local skilled nursing facility.Further review revealed no documented evidence of Patient #11 receiving the ordered PT Evaluation during her Respite stay. An interview was conducted on 06/12/2025 at 11:35 a.m. with S1ADM. S1ADM confirmed PT was one of the services Hospice agencies were required to provide. S1ADM confirmed PT services were not curative and were aimed at pain and symptom management when their ordering physician felt it was appropriate. S1ADM confirmed Patient #11 received a Physician’s Order for a PT Evaluation on 05/07/2025 but the agency’s contracted PT would not perform house calls where the patient lived. S1ADM stated they contacted Patient #11’s family and asked the family to transport the patient to the PT’s office in order to receive her ordered evaluation. S1ADM stated the family informed the agency they could not transport her and needed PT to come to their home to perform the evaluation. S1ADM confirmed a couple of days after the PT order was written, Patient #11 received 7 days of respite care in a local skilled nursing facility and confirmed the facility provided PT services Monday through Friday. S1ADM confirmed she did not know why the PT evaluation was not completed while she was in respite care but it should have. S1ADM confirmed when Patient #11’s hospice benefits were revoked on 06/10/2025, she had not received her PT Evaluation as ordered and should have. S1ADM stated “the ball was dropped on this one”.An interview was conducted on 06/13/2025 at 2:30 p.m. with S3DON. S3DON confirmed Physical Therapy was included in the services a Hospice agency was required to provide patients when ordered. S3DON confirmed Patient #11 received a Physician’s Order for a PT Evaluation on 05/07/2025. S3DON confirmed Patient #11’s terminal diagnosis would be appropriate for and order for PT Services aimed at helping manage pain and symptoms. S3DON confirmed when Patient #11’s hospice benefits were revoked on 06/10/2025, she had not received her PT Evaluation as ordered and should have.”

“Based on interviews and record reviews, the Hospice agency failed to develop an individualized, written Plan of Care (POC) reflective of patient/family goals and interventions, as well as, problems identified during assessment. This deficient practice was evidenced by failure to develop a POC which accurately reflected medical devices in use for urinary and stool output for 1 (#8) of 10 (#5 through #14) live patients in the sample.This deficient practice had the potential to affect any of the 39 admissions during the past 12 months, a current census of 18 patients and any future admissions to the agency. Cross Reference: L536. Review of Patient #8’s Clinical Record revealed she was admitted to the Hospice agency on 05/29/2025 with a terminal diagnosis of Parkinson’s Disease and Comorbidities including; Rectal Abscess, Fournier Gangrene, status post Colostomy. Further review revealed she was in a current Certification Period of 05/29/2025 through 08/26/2025. Review of Patient #8’s Initial RN Assessment, dated 05/29/2025, revealed, in part, the following: Date new Foley Catheter placed: 05/29/2025; Foley in place, draining clear, yellow urine. Patient status post Colostomy placement. Colostomy intact. Review of Patient #8’s POC for the current Certification Period, as of 06/13/2025, revealed, in part, no documented evidence of the identification of or interventions for her Foley Catheter or Colostomy. An interview was conducted on 06/13/2025 at 2:30 p.m. with S3DON. S3DON confirmed Patient #8’s POC should reflect the presence of and interventions for her Foley Catheter and Colostomy and it did not.”

“Based on interviews and record reviews, the Hospice agency failed to ensure a Patient’s Plan of Care (POC) included the identification of interventions to manage pain and symptoms for 3 (#8, #9, and #11) of 10 (#5 through #14) live patients in the sample. This deficient practice had the potential to affect any of the 39 admissions during the past 12 months, a current census of 18 patients and any future admissions to the agency. Cross Reference: L536. Patient #8Review of Patient #8’s Clinical Record revealed she was admitted to the Hospice agency on 05/29/2025 with a terminal diagnosis of Parkinson’s Disease and Comorbidities including; Rectal Abscess, Fournier Gangrene, status post Colostomy. Further review revealed she was in a current Certification Period of 05/29/2025 through 08/26/2025. Review of Patient #8’s POC for the current Certification Period, as of 06/13/2025, revealed, in part, no interventions for the management of pain and symptoms. Patient #9Review of Patient #9’s Clinical Record revealed he was admitted to the Hospice agency on 05/02/2025 with a terminal diagnosis of Alzheimer’s Disease and Comorbidities including Arthritis. Further review revealed a current Certification Period of 05/02/2025 through 07/30/20205. Review of Patient #9’s POC for the current Certification Period, as of 06/13/2025, revealed, in part, no interventions for the management of pain and symptoms. Patient #11Review of Patient #11’s Clinical Record revealed she was admitted to the Hospice agency on 04/28/2025 with a terminal diagnosis of Primary Central Nervous System Lymphoma. Further review revealed a current Certification Period of 06/06/2025 through 06/10/2025. Review of Patient #11’s POC for the current Certification Period, as of 06/13/2025, revealed, in part, no interventions for the management of pain and symptoms. An interview was conducted on 06/13/2025 at 2:30 p.m. with S3DON. S3DON confirmed every Hospice patient’s POC should include interventions for the management of pain and symptoms and Patient #8, #9 and #11’s POCs did not address management of pain and symptoms. .”

“Based on interviews and record reviews, the Hospice agency failed to ensure a Patient’s Plan of Care (POC) included orders for treatments necessary to meet the needs of the patient for 2 (#6 and #8) of 10 (#5 through #14) live patients in the sample. This deficient practice had the potential to affect any of the 39 admissions during the past 12 months, a current census of 18 patients and any future admissions to the agency. Cross Reference: L536. Patient #6Review of Patient #6’s Clinical Record revealed she was admitted to the Hospice agency on 01/09/2024 and in a current Certification Period of 05/03/2025 through 07/01/2025. Further review revealed the local nursing home (NH) where she resided identified a Stage 2 Pressure Ulcer to the Sacral Region on 06/02/2025. An interview was conducted on 06/10/2025 at 9:40 a.m. with Patient #6’s nurse at her NH. She confirmed she was Patient #6’s regularly assigned nurse and was very familiar with her condition and care. She confirmed Patient #6 was currently receiving treatment for a Stage 2 Pressure Ulcer to the Sacral Region identified by her on 06/02/2025. She confirmed she informed S3DON as soon as she identified the wound. Review of Patient #6’s Nurse Visit conducted on 06/02/2025 by S3DON, revealed, in part, the following: Wounds addressed on this visit: Wound #1: Sacrum. Status: Open. Onset Date: 06/02/2025. Type: Pressure Injury. Review of Patient #6’s IDG Meeting Notes, dated 06/02/2025 through 06/10/2025, revealed, in part, the following: No documented evidence of the IDG being informed of and/or discussing her Stage 2 Pressure Ulcer to obtain an order for Wound Care after it was identified on 06/02/2025. Review of Patient #6’s POC and Physician’s Orders, dated 06/02/2025 through 06/10/2025, revealed, in part, no documented evidence of the presence of her Stage 2 Pressure Ulcer to the Sacral Region with no Wound Care Orders present for its care following identification on 06/02/2025. An interview was conducted on 06/12/2025 at 11:35 a.m. with S1ADM. S1ADM confirmed a newly identified wound would require a written Wound Care order to ensure the patient’s needs were met. An interview was conducted on 06/13/2025 at 2:30 p.m. with S3DON. S3DON confirmed Patient #6’s NH nurse made her aware of Patient #6’s newly identified pressure wound at the beginning of June 2025. S3DON confirmed Patient #6’s Clinical Record did not include orders for Wound Care. S3DON confirmed the Hospice agency should have obtained wound care orders for the newly identified Stage 2 pressure wound. Patient #8Review of Patient #8’s Clinical Record revealed she was admitted to the Hospice agency on 05/29/2025 with a terminal diagnosis of Parkinson’s Disease and Comorbidities including; Rectal Abscess, Fournier Gangrene, status post Colostomy. Further review revealed she was in a current Certification Period of 05/29/2025 through 08/26/2025. Review of Patient #8’s Initial RN Assessment, dated 05/29/2025, revealed, in part, the following: Patient status post colostomy placement with Colostomy intact. Review of Patient #8’s POC and Physician’s Orders for the current Certification Period, as of 06/13/2025, revealed, in part, no documented evidence of orders for the care and maintenance of Patient #8’s Colostomy. An interview was conducted on 06/13/2025 at 2:30 p.m. with S3DON. S3DON confirmed Patient #8 had a colostomy in place upon admission and it remained present. S3DON confirmed Patient #6’s Clinical Record did not include orders for the care and maintenance of her Colostomy. S3DON confirmed the Hospice agency should have obtained orders for the care and maintenance of Patient #8’s Colostomy.”

“Based on interviews and record reviews, the Hospice agency’s Interdisciplinary Group (IDG) failed to review and revise the Plan of Care (POC) as frequently as the condition required and no less frequently than every 15 calendar days. This deficient practice was evidenced by failure to update the POC to reflect: 1. Psychosocial concerns identified during Social Worker (MSW) Visits for 1 (#5) of 10 (#5 through #14) live patients in the sample; 2. A newly identified Pressure Ulcer for 1 (#6) of 3 (#5, #6, and #8) patients reviewed for wounds; and3. A Physician’s Order written to Refer to Physical Therapy (PT) for Evaluation for 1 of 1 (#11) patients reviewed for referral. This deficient practice had the potential to affect any of the 39 admissions during the past 12 months, a current census of 18 patients and any future admissions to the agency. Cross Reference: L536. 1. Psychosocial Concerns.Patient #5Review of Patient #5’s Clinical Record revealed he was admitted to the agency on 04/23/2025 and was in a current Certification Period of 04/23/2025 through 07/21/2025. Review of Patient #5’s MSW Visit Notes written by S4SW, dated 04/23/2025 through 06/11/2025, revealed, in part, the following: 04/23/2025 - MSW to visit weekly until wife feels comfortable and has a routine in place. 05/01/2025 - MSW to continue ongoing support weekly and monitor for needs and changes. 05/08/2025 - MSW to monitor for changes on an ongoing basis. 05/14/2025 - Patient continues to express guilt regarding wife having to care for him and his needs. MSW will meet with patient and wife weekly to assess and monitor for any changes or needs. 05/22/2025 - MSW to monitor on a weekly basis to ensure caregiver/patient are coping well. 05/29/2025 - Patient continues to express guilt and feelings of being burden on wife. MSW to monitor patient/caregiver weekly. 06/04/2025 - Patient continues to express guilt and feelings of being burden on wife. 06/09/2025 - MSW to monitor patient once a week. Review of Patient #5’s MSW Visit Calendar, dated 05/01/2025 through 06/11/2025, revealed, in part, the following visits conducted weekly by S4SW: 05/01/2025; 05/08/2025;05/14/2025; 05/22/2025; 05/29/2025; 06/04/2025; and 06/09/2025.Further review revealed S4SW had weekly visits scheduled throughout the remainder of Patient #5’s current Certification Period. Review of Patient #5’s HA Visit Calendar, dated 05/01/2025 through 06/11/2025, revealed, in part, the following visits conducted four times weekly by S6HA:05/05/2025, 05/06/2025; 05/07/2025; 05/09/2025; 05/12/2025; 05/13/2025; 05/14/2025; 05/16/2025;05/19/2025; 05/20/2025; 05/21/2025; 05/23/2025; and 05/26/2025; 05/27/2025; 05/28/2025; 05/30/2025. Review of Patient #5’s Physician’s Orders for the current Certification Period revealed, in part, the following: MSW Visit Frequency (effective 04/27/2025): Twice monthly for two months then once monthly for one month; andHA Visit Frequency (effective 04/27/2025): Three visits weekly for twelve weeks.Further review revealed no documented evidence of a change in the aforementioned ordered frequency for MSW or HA services in order to meet patient needs.Review of Patient #5’s POC for the current Certification Period revealed, in part, the following: No documented evidence in the POC of the aforementioned psychosocial concerns;No documented evidence in the POC of an update to MSW Visit Frequency due to Patient #5 requiring weekly MSW Visits in order to meet his psychosocial needs; and No documented evidence in the POC of an update to HA Visit Frequency due to Patient #5 requiring an additional HA Visit each week in order to meet his needs.An interview was conducted on 06/12/2025 at 11:35 a.m. with S1ADM. S1ADM confirmed any newly identified issues and/or concerns should be updated in the patient’s POC along with their Physician’s Orders updated to ensure the patient/family needs were met. S1ADM confirmed if psychosocial concerns were identified and those concerns required an increased frequency of MSW Visits, this should be reflected in the POC and should include appropriate interventions to ensure needs were met. S1ADM confirmed if a patient/family required more HA Visits than ordered, the reasoning should be reflected in the POC to ensure needs were met. S1ADM confirmed the addition of new concerns in the POC, as well as, status updates should be updated as needed and no less frequently than every 15 days. An interview was conducted on 06/13/2025 at 2:30 p.m. with S3DON. S3DON confirmed S4SW saw Patient #5 more frequently than ordered due to his identified psychosocial concerns related to grief, coping, guilt, and feelings of being a burden on his spouse and sole caregiver. S3DON confirmed S6HA saw Patient #5 more frequently than ordered to alleviate some of the psychosocial concerns identified by S4SW. S3DON confirmed Patient #5’s POC was not updated to reflect this information and it should have been. 2. Pressure Ulcer. Patient #6Review of Patient #6’s Clinical Record revealed she was admitted to the Hospice agency on 01/09/2024 and in a current Certification Period of 05/03/2025 through 07/01/2025. Further review revealed the local nursing home (NH) where she resided identified a Stage 2 Pressure Ulcer to the Sacral Region on 06/02/2025.An interview was conducted on 06/10/2025 at 9:40 a.m. with Patient #6’s nurse at her NH. She confirmed she was Patient #6’s regularly assigned nurse and was very familiar with her condition and care. She confirmed Patient #6 was currently receiving treatment for a Stage 2 Pressure Ulcer to the Sacral Region identified by her on 06/02/2025. She confirmed she informed S3DON as soon as she identified the wound. Review of Patient #6’s POC, dated 06/02/2025 through 06/10/2025, revealed, in part, the following: No documented evidence in the POC of her Stage 2 Pressure Ulcer to the Sacral Region identified on 06/02/2025. An interview was conducted on 06/12/2025 at 11:35 a.m. with S1ADM. S1ADM confirmed a newly identified wound would require the POC and Physician’s Orders to be updated to ensure the patient’s needs were met. An interview was conducted on 06/13/2025 at 2:30 p.m. with S3DON. S3DON confirmed Patient #6’s NH nurse made her aware of Patient #6’s newly identified pressure wound at the beginning of June 2025. S3DON confirmed Patient #6’s POC was not updated to reflect this information and it should have been. 3. Referral for evaluation by Physical Therapy. Patient #11Review of Patient #11’s Clinical Record revealed she was admitted to the Hospice agency on 04/28/2025 with a terminal diagnosis of Primary Central Nervous System Lymphoma. Further review revealed a current Certification Period of 06/06/2025 through 06/10/2025. Review of Patient #11’s Physician’s Orders revealed, in part, the following: 05/07/2025 - Refer to Physical Therapy (PT) for Evaluation. Review of Patient #11’s POC, dated 05/07/2025 through 06/10/2025, revealed, in part, the following: No documented evidence in the POC of her Physician’s Order for PT Evaluation after it was written on 05/07/2025. An interview was conducted on 06/12/2025 at 11:35 a.m. with S1ADM. S1ADM confirmed Patient #11 received a Physician’s Order to be Referred to PT for Evaluation on 05/07/2025. S1ADM confirmed her POC should have been updated to reflect the referral and should have been updated with status updates on scheduling and it was not. An interview was conducted on 06/13/2025 at 2:30 p.m. with S3DON. S3DON confirmed Patient #11 received a Physician’s Order to Refer to PT for Evaluation on 05/07/2025. S3DON confirmed Patient #11’s POC was not updated to reflect her referral and it should have been.”

“Based on interviews and record reviews, the Hospice agency failed to provide Medical Social Services by a qualified Social Worker (SW) in a manner consistent with acceptable standards of practice for (10) of 10 (#5 through #14) live patients reviewed in the final sample. This deficient practice had the potential to affect any of the 39 admissions during the past 12 months, a current census of 18 patients and any future admissions to the agency. Cross Reference: L587. Review of the Hospice agency’s undated Policy Number PC.S20 - Social Work Services, as of 06/12/2025, revealed, in part, the following: Procedures: 1. The Hospice agency ensures there are an adequate number of qualified social workers to meet the needs of the patients and their families. 2. A SW is assigned to each patient/family and participates as a member of the Hospice IDG in the development and implementation of the POC. 3. The Comprehensive Assessment includes a Psychosocial Assessment conducted by the SW to evaluate the patient/family’s emotional, social, financial, and environmental resources and identify appropriate psychosocial problems, interventions and goals for the patient’s POC. 5. Social Work services and interventions may include but are not limited to: a. identifying the patient/family psychosocial needs;b. assisting the patient/family with advanced directives; c. assessing and enhancing the responsiveness of the environment with connecting the patient/family with community resources as needed;d. providing interventions for specific symptom relief; e. screening for psychopathology and providing education and interventions accordingly; h. assessing and referring for bereavement services;k. documenting problems, assessment findings, goals, care provided, interventions and patient/family response to care; o. consulting and collaborating with the IDG.6. The social worker reassess the patient/family needs every 15 days and, with the IDG, updates the patient’s POC as needed. Review of the Hospice agency’s Social Worker Job Description, revised 08/14/2023, revealed, in part, the following: IV. Minimum Qualifications: The SW shall hold a current, valid license as a LMSW issued by the Louisiana State Board of Social Work Examiners.Patient #5Review of Patient #5’s Clinical Record revealed he was admitted to the agency on 04/23/2025 and was in a current Certification Period of 04/23/2025 through 07/21/2025. Review of Patient #5’s POC and Physician’s Orders for the current Certification Period revealed, in part, a MSW Visit Frequency of twice monthly for two months then once monthly for one month. Review of Patient #5’s MSW Initial Assessment and Initial Psychosocial Assessment was performed by S4SW. Patient #6Review of Patient #6’s Clinical Record revealed she was admitted to the agency on 01/09/2024 and was in a current Certification Period of 05/03/2025 through 07/01/2025.Review of Patient #6’s POC and Physician’s Orders for the current Certification Period revealed, in part, a MSW Visit Frequency of twice monthly for two months as of 05/04/2025 then twice weekly as of 06/10/2025. Review of Patient #6’s MSW Initial Assessment and Initial Psychosocial Assessment was performed by S4SW. Patient #7Review of Patient #7’s Clinical Record revealed she was admitted to the agency on 02/07/2024 and was in a current Certification Period of 06/01/2025 through 07/30/2025.Review of Patient #7’s POC and Physician’s Orders for the current Certification Period revealed, in part, a MSW Visit Frequency of three times monthly for two months as of 05/27/2025. Review of Patient #7’s MSW Initial Assessment and Initial Psychosocial Assessment was performed by S4SW. Patient #8Review of Patient #8’s Clinical Record revealed she was admitted to the agency on 05/09/2025 and was in a current Certification Period of 05/29/2025 through 08/26/2025.Review of Patient #8’s POC and Physician’s Orders for the current Certification Period revealed, in part, a MSW Visit Frequency of once monthly for one month then twice monthly for two months. Review of Patient #8’s MSW Initial Assessment and Initial Psychosocial Assessment was performed by S4SW. Patient #9Review of Patient #9’s Clinical Record revealed she was admitted to the agency on 05/02/2025 and was in a current Certification Period of 05/02/2025 through 07/30/2025.Review of Patient #9’s POC and Physician’s Orders for the current Certification Period revealed, in part, a MSW Visit Frequency of once monthly for one month then twice monthly for two months. Review of Patient #9’s MSW Initial Assessment and Initial Psychosocial Assessment was performed by S4SW. Patient #10Review of Patient #10’s Clinical Record revealed she was admitted to the agency on 08/30/2023 and was in a current Certification Period of 04/21/2025 through 06/19/2025. Review of Patient #10’s POC and Physician’s Orders for the current Certification Period revealed, in part, a MSW Visit Frequency of twice monthly for one visit per month and 2 PRN as of 04/25/2025. Review of Patient #10’s MSW Initial Assessment and Initial Psychosocial Assessment was performed by S4SW. Patient #11Review of Patient #11’s Clinical Record revealed she was admitted to the agency on 04/28/2025 and was in a current Certification Period of 06/06/2025 through 06/10/2025.Review of Patient #11’s POC and Physician’s Orders for the current Certification Period revealed, in part, a MSW Visit Frequency of three times monthly for one month then twice monthly for two months. Review of Patient #11’s MSW Initial Assessment and Initial Psychosocial Assessment was performed by S4SW. Patient #12Review of Patient #12’s Clinical Record revealed he was admitted to the agency on 06/06/2025 and was in a current Certification Period of 06/06/2025 through 09/03/2025.Review of Patient #12’s POC and Physician’s Orders for the current Certification Period revealed, in part, a MSW Visit Frequency of one monthly for one months as of 06/11/2025. Review of Patient #12’s MSW Initial Assessment and Initial Psychosocial Assessment was performed by S4SW. Patient #13Review of Patient #13’s Clinical Record revealed he was admitted to the agency on 02/06/2025 and was in a current Certification Period of 05/07/2025 through 08/04/2025.Review of Patient #13’s POC and Physician’s Orders for the current Certification Period revealed, in part, a MSW Visit Frequency of once monthly for one month and then twice monthly for 2 months as of 05/13/2025. Review of Patient #13’s MSW Initial Assessment and Initial Psychosocial Assessment was performed on by S4SW. Patient #14Review of Patient #14’s Clinical Record revealed she was admitted to the agency on 11/27/2024 and was in a current Certification Period of 05/13/2025 through 07/11/2025.Review of Patient #14’s POC and Physician’s Orders for the current Certification Period revealed, in part, a MSW Visit Frequency of once monthly for one months, twice monthly for two months, and once monthly for one month as of 05/19/2025. Review of Patient #14’s MSW Initial Assessment and Initial Psychosocial Assessment was performed by S4SW. Review of S4SW’s Personnel File, as of 06/13/2025, revealed, in part, she was hired on 08/11/2023 and did not meet the job requirements to hold her position. Further review revealed she was a RSW, not a LMSW. Review of S4SW’s License through the Louisiana State Board of Social Work Examiners, as of 06/13/2025, revealed, in part, she was a RSW, not a LMSW. Review of the Hospice agency’s Organizational Chart and List of Current Staff Members, as of 06/13/2024, revealed, in part, S4SW was the only Social Worker employed by the Hospice agency. Review of the RSW’s Scope of Practice according to the state’s licensing board for Social Workers, as of 06/13/2025, revealed, in part, a RSW cannot work independently and must work under the direct supervision of a LMSW. An interview was conducted on 06/13/2025 at 11:25 a.m. with a representative of the state’s licensing board for Social Workers. She confirmed a RSW was not allowed to work in a Hospice agency independently and also required the direct supervision of a LMSW if providing clinical services. Review of the National Association of Social Workers (NASW), as of 06/13/2025 at 11:35 a.m., revealed, in part, the following in regards to what is considered Clinical Social Work: “Clinical social work is a specialty practice area of social work which focuses on the assessment, diagnosis, treatment, and prevention of mental illness, emotional, and other behavioral disturbances. Individual, group and family therapy are common treatment modalities. Social workers who provide these services are required to be licensed or certified at the clinical level in their state of practice. Clinical social workers perform services in a variety of settings including private practice, hospitals, community mental health, primary care, and agencies. NASW advocates for clinical social workers through the legislative and regulatory process.”An interview was conducted on 06/13/2025 at 11:10 a.m. with S1ADM. S1ADM confirmed S4SW was hired on 08/11/2023 and remained employed as the Hospice agency’s only Social Worker at this time. S1ADM confirmed S4SW was a RSW, not a LMSW and did not work under the supervision of a LMSW. S1ADM confirmed S4SW did not meet the requirements to hold her position and should.”

“Based on interview and record reviews, the Hospice agency’s Registered Nurse failed to ensure a patient’s written patient care instructions (POC) for the Hospice Aide (HA) were reflective of the patient’s status and care needs for 1 (#8) of 10 (#5 through #14) live patients in the sample. This deficient practice had the potential to affect any of the 39 admissions during the past 12 months, a current census of 18 patients and any future admissions to the agency. Review of Patient #8’s Clinical Record revealed she was admitted to the Hospice agency on 05/29/2025 and was in a current Certification Period of 05/29/2025 through 08/26/2025. Further review revealed Patient #8 was admitted to the Hospice agency with a Foley Catheter and a Colostomy in place. Review of Patient #8’s Visit Frequency Order for the current Certification Period, as of 06/13/2025, revealed, in part, HA Visits to be performed twice weekly. Review of Patient #8’s Initial RN Assessment, dated 05/29/2025, revealed, in part, the following: Patient status post colostomy placement with Colostomy intact; and Foley Catheter in place, draining clear, yellow urine. Review of Patient #8’s HA POC for the current Certification Period, as of 06/13/2025, revealed, in part, HA to deliver briefs and provide incontinence care with each visit. Further review revealed no documented evidence of the presence of and/or written care instructions and supplies necessary for the care and maintenance of her Foley Catheter and Colostomy. An interview was conducted on 06/13/2025 at 2:30 p.m. with S3DON. S3DON confirmed Patient #8 had a Foley Catheter and Colostomy in place upon admission and they remained present. S3DON confirmed the HA would be responsible for bringing the necessary supplies with them to a patient’s visit in order to change the Colostomy bag. S3DON confirmed Patient #8’s HA POC did not reflect the presence of and/or written care instructions and supplies necessary for the care and maintenance of her Foley Catheter and Colostomy and should.”

“Based on record review and interview, the Hospice Agency failed to ensure volunteers provided day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equaled 5% of the total patient care hours of all paid hospice employees. Review of the Hospice agency’s Annual Volunteer Services Cost Savings Report for the past 12 months, as of 06/13/2025, revealed the total volunteer hours did not meet 5% of the total patient care hours during the timeframe reviewed.An interview was conducted on 06/13/2025 at 11:10 a.m. with S1ADM. S1ADM confirmed she was aware the Hospice agency’s Volunteer Program was not where it should be. S1ADM confirmed the Hospice agency did not meet the volunteer requirements and should have.”

“Based on interviews and record reviews, the Hospice agency failed to provide care and services in a matter which was consistent with accepted standards of practice. This deficient practice was evidenced by failure to ensure: 1. Physical Therapy consults were provided per Physician’s Order for 1 of 1 (#11) patients reviewed for therapy services; and 2. Current and accurate records were maintained of the disposition of all controlled substances provided by the Hospice agency to the patient for 7 of 7 (#5, #6, #7, #8, #9, #11, and #12) live patients reviewed for controlled substances. This deficient practice had the potential to affect any of the 39 admissions during the past 12 months, a current census of 18 patients and any future admissions to the agency. Cross Reference: L648. 1. Provision of Physical Therapy services. Review of Patient #11’s Clinical Record revealed she was admitted to the Hospice agency on 04/28/2025 with a terminal diagnosis of Primary Central Nervous System Lymphoma. Further review revealed a current Certification Period of 06/06/2025 through 06/10/2025. Review of Patient #11’s Physician’s Orders revealed, in part, an order on 05/07/2025 for a Physical Therapy (PT) Evaluation. Review of Patient #11’s Physical Therapy Evaluation, dated 05/07/2025 through her revocation on 06/10/2025 was attempted throughout the course of the survey process with no documented evidence available for review. Review of Patient #11’s Assessment Notes, dated 05/07/2025 through 06/10/2025, revealed, in part, the following: 05/09/2025 – Patient currently in respite care at a local skilled nursing facility; 05/12/2025 – Patient currently in respite care at a local skilled nursing facility; and 05/16/2025 – Patient returned home from respite care at a local skilled nursing facility.Further review revealed no documented evidence to indicate an attempt was made for Patient #11 to receive the ordered PT Evaluation during her respite stay. Review of the aforementioned local skilled nursing facility’s webpage, as of 06/12/2025 at 11:55 a.m., revealed, in part, PT services were provided at this facility Monday through Friday. Review of Patient #11’s Communication Notes, dated 05/07/2025 through 06/10/2025, revealed, in part, the following: 05/19/2025 by S4MSW - Patient’s daughter called requesting update on when her mother’s PT Consult would be scheduled. Explained it was in progress and she will be informed when it gets scheduled. Further review revealed no additional documented evidence regarding the status of Patient #11’s PT Evaluation. Review of Patient #11’s POC, dated 05/07/2025 through 06/10/2025, revealed, in part, no documented evidence of the Physician’s Order written on 05/07/2025 for PT Evaluation. Review of Patient #11’s IDG Meetings, dated 05/07/2025 through 06/102/2025, revealed, in part, the following: 05/13/2025 - No documented evidence of a discussion regarding her PT Evaluation status; 05/27/2025 - No documented evidence of a discussion regarding her PT Evaluation status; and06/04/2025 - No documented evidence of a discussion regarding her PT Evaluation status.An interview was conducted on 06/12/2025 at 11:35 a.m. with S1ADM. S1ADM confirmed Physical Therapy was included in the services a Hospice agency was required to provide patients when ordered. S1ADM confirmed Patient #11’s terminal diagnosis of Primary Central Nervous System Lymphoma would be a qualifying diagnosis for PT Services. S1ADM confirmed Patient #11 received a Physician’s Order for a PT Evaluation but the agency’s contracted PT would not perform house calls where the patient lived. S1ADM stated they contacted Patient #11’s family and asked the family to transport the patient to the PT’s office in order to receive her ordered evaluation. S1ADM stated the family informed the agency they could not transport her and needed PT to come to their home to perform the evaluation. S1ADM confirmed a couple of days after the PT order was written, Patient #11 received 7 days of respite care in a local skilled nursing facility and confirmed the facility provided PT services Monday through Friday. S1ADM confirmed she did not know why the PT evaluation was not completed while she was in respite care but it should have. S1ADM confirmed when Patient #11’s hospice benefits were revoked on 06/10/2025, she had never received the ordered PT Evaluation and should have. S1ADM stated “the ball was dropped on this one”. An interview was conducted on 06/13/2025 at 2:30 p.m. with S3DON. S3DON confirmed Physical Therapy was included in the services a Hospice agency was required to provide patients when ordered if appropriate. S3DON confirmed Patient #11’s terminal diagnosis of Primary Central Nervous System Lymphoma would be a qualifying diagnosis for PT Services. S3DON confirmed Patient #11 never received the PT Evaluation ordered by the Medical Director on 05/07/2025 and should have. 2. Provision of Controlled Substances per accepted standards of practice.Review of the United States Government Accountability Office’s (GAO) Report titled “Preventing Drug Diversion”, published April 2020, revealed, in part, the following: Misuse of controlled substances continues to be a serious public health problem in the United States.1 National survey data from the Substance Abuse and Mental Health Services Administration show that in 2017, 53 percent of people 12 years of age and older in the United States who misused prescription pain relievers in the past year, obtained the drugs from friends and family. The most commonly misused controlled substances include opioids (such as oxycodone), which are used to treat pain, and central nervous system depressants (such as diazepam), which are used to treat anxiety and sleep disorders. These types of drugs are prescribed for a large proportion of patients in hospice care. Patients select hospice care when they no longer want treatment for their terminal illness, but rather choose a hospice team to provide symptom management and control. In 2017, approximately 1.5 million Medicare beneficiaries received hospice services, and 56 percent of those patients received care in the patient’s home. Medicare is the largest payer for hospice services.The Controlled Substances Act regulates the manufacture, distribution, use, and disposal of controlled substances.13 In general, the Controlled Substances Act was enacted to facilitate the use of controlled substances for legitimate medical, scientific, research, and industrial purposes while preventing them from being diverted for illegal uses.What GAO Found: Best Practices for Reducing the Risk of DiversionHospice officials we spoke to identified best practices for preventing diversion of controlled substances. Best practices include prescription drug counts performed by hospice employees to determine if controlled substances are being used properly.Narcotic counts can also help ensure that unused or expired medications are properly disposed of, preventing potential misuse or accidental ingestion. Review of the Hospice agency’s undated Policy Number PC.M70 – Medications: Use and Disposal of Controlled Substances revealed, in part, no documented evidence of a system to maintain current and accurate records of the receipt and disposition of all controlled drugs.Patient #5Review of Patient #5’s Clinical Record revealed he was admitted to the agency on 04/23/2025 and was in a current Certification Period of 04/23/2025 through 07/21/2025. Further review revealed he was ordered to receive a Nurse Visit twice weekly for twelve weeks.Review of Patient #5’s POC and Physician’s Orders for the current Certification Period revealed, in part, the following orders: Oxycodone 5mg tablet. Give 1 tablet every 4 hours as needed for pain;Lorazepam 0.5mg tablet. Give 1 tablet every 4 hours as needed for restlessness; andMorphine Sulfate Concentrate 20mg/mL. Give 0.5mL every 2 hours as needed for pain or shortness of breath. Review of Patient #5’s Nurse Visits for the current Certification Period revealed, in part, no documented evidence of controlled substance counts being performed or documented during any of his 16 ordered visits conducted from 04/23/2025 through 06/13/2025.An observation was conducted on 06/10/2025 at 8:50 a.m. during Patient #5’s Home Visit with S3DON. Just prior to conclusion of the nurse visit, S3DON was observed asking Patient #5’s spouse if they needed any medication refills as she shook pill bottles located in a basket on the counter in the kitchen then placed the bottles back into the basket without opening the lids to count the number of pills inside. Upon conclusion of the Home Visit, S3DON had not performed or documented the count for Patient #5’s controlled substances at any time during the visit. An interview was conducted on 06/10/2025 at 8:55 a.m. with Patient #5’s spouse. She confirmed S3DON did not count medications during her visits, she only asked if refills were needed. Patient #6Review of Patient #6’s Clinical Record revealed she was admitted to the agency on 01/09/2024 and was in a current Certification Period of 05/03/2025 through 07/01/2025. Further review revealed she was ordered to receive a Nurse Visit once a week as of 05/04/2025 and twice weekly as of 06/01/2025. Review of Patient #6’s POC and Physician’s Orders for the current Certification Period revealed, in part, the following order: Lorazepam 0.5mg tablet. Give 1 tablet every 4 hours as needed for restlessness.Review of Patient #6’s Nurse Visits for her current Certification Period revealed, in part, no documented evidence of controlled substance counts being performed or documented during any of her 8 ordered visits conducted from 05/03/2025 through 06/13/2025.Patient #7Review of Patient #7’s Clinical Record revealed she was admitted to the agency on 02/07/2024 and was in a current Certification Period of 06/01/2025 through 07/30/2025. Further review revealed she was ordered to receive a Nurse Visit twice a week as of 06/01/2025. Review of Patient #7’s POC and Physician’s Orders for the current Certification Period revealed, in part, the following order: Xanax Oral 0.5mg tablet. Give 1 tablet BID;Oxycodone HCL Oral 5 mg tablet. Give 1 tablet every 4 hours prn;Review of Patient #7’s Nurse Visits for her current Certification Period revealed, in part, no documented evidence of controlled substance counts being performed or documented during any of her 4 ordered visits conducted from 06/01/2025 through 06/13/2025.Patient #8Review of Patient #8’s Clinical Record revealed she was admitted to the agency on 05/09/2025 and was in a current Certification Period of 05/29/2025 through 08/26/2025. Further review revealed she was ordered to receive a Nurse Visit twice weekly for twelve weeks. Review of Patient #8’s POC and Physician’s Orders for the current Certification Period revealed, in part, the following medication orders: Morphine Sulfate Concentrate 20mg/mL. Give 0.5mL every 2 hours as needed for pain or shortness of breath; Morphine Sulfate Concentrate 20mg/mL. Give 1mL every 2 hours as needed for pain or shortness of breath; Lorazepam 1mg tablet. Give 1 tablet every 4 hours as needed for agitation or anxiety; andOxycodone 10mg tablet. Give 1 tablet every 4 hours as needed for pain;Review of Patient #8’s Nurse Visits for her current Certification Period revealed, in part, no documented evidence of controlled substance counts being performed or documented during any of her 5 ordered visits conducted from 05/29/2025 through 06/13/2025.Patient #9Review of Patient #9’s Clinical Record revealed he was admitted to the agency on 05/02/2025 and was in a current Certification Period of 05/02/2025 through 07/30/2025. Further review revealed he was ordered to receive a Nurse Visit once weekly for thirteen weeks. Review of Patient #9’s POC and Physician’s Orders for the current Certification Period revealed, in part, the following medication order: Morphine Sulfate Concentrate 20mg/mL. Give 0.5mL every 2 hours as needed for pain or shortness of breath.Review of Patient #9’s Nurse Visits for his current Certification Period revealed, in part, no documented evidence of controlled substance counts being performed or documented during any of his 7 ordered visits conducted from 05/02/2025 through 06/13/2025.Patient #11Review of Patient #11’s Clinical Record revealed she was admitted to the agency on 04/28/2025 and was in a current Certification Period of 06/06/2025 through 06/10/2025. Further review revealed she was ordered to receive a Nurse Visit twice weekly for twelve weeks. Review of Patient #11’s POC and Physician’s Orders for the current Certification Period revealed, in part, the following medication orders: Morphine Sulfate Concentrate 20mg/mL. Give 0.5mL every 2 hours as needed for pain or shortness of breath; andLorazepam 1mg tablet. Give 1 tablet every 4 hours as needed for agitation or anxiety. Review of Patient #11’s Nurse Visits for her current Certification Period revealed, in part, no documented evidence of controlled substance counts being performed or documented during any of her 4 ordered visits conducted from 06/06/2025 through 06/13/2025. Patient #12Review of Patient #12’s Clinical Record revealed he was admitted to the agency on 06/06/2025 and was in a current Certification Period of 06/06/2025 through 09/03/2025. Further review revealed he was ordered to receive a Nurse Visit once a week for 13 weeks as of 06/08/2025. Review of Patient #12’s POC and Physician’s Orders for the current Certification Period revealed, in part, the following order: Lorazepam 0.5mg tablet. Give 1 tablet every 4 hours as needed for restlessness; andHydrocodone-Acetaminophen 5-325 mg tablet. Give 1 tablet every 6 hours as needed for pain.Review of Patient #12’s Nurse Visits for his current Certification Period revealed, in part, no documented evidence of controlled substance counts being performed or documented during any of his 2 ordered visits conducted from 06/06/2025 through 06/13/2025. An interview was conducted on 06/12/2025 at 4:00 p.m. with S2DON. S2DON confirmed he was corporate’s Area Director of Nursing and he oversaw 3 Hospice agencies. S2DON confirmed the Hospice agency’s Narcotics Policy and Procedure did not currently include a system to maintain current and accurate records for the receipt and disposition of all controlled substances provided by the Hospice agency to the patient. S2DON confirmed he expected S3DON to perform a count and document all controlled substances during each of her nurse visits. An interview was conducted on 06/12/2025 at 4:02 p.m. with S1ADM. S1ADM confirmed she was corporate’s Area Administrator and she oversaw 3 Hospice agencies. S1ADM confirmed the Hospice agency’s Narcotics Policy and Procedure did not currently include a system to maintain current and accurate records for the receipt and disposition of all controlled substances provided by the Hospice agency to the patient. S1ADM confirmed she expected S3DON to perform a count and document all controlled substances during each of her nurse visits. An interview was conducted on 06/13/2025 at 2:30 p.m. with S3DON. S3DON confirmed she was the Hospice agency’s Administrator, Director of Nursing and the only nurse who saw patients in the field. S3DON confirmed there was no expectation for the performance and documentation of a patient’s controlled substances during nurse visits. S3DON confirmed she did not perform and/or document counts for controlled substances during the aforementioned 46 nurse visits she conducted in the patient’s home for Patient #5, #6, #7, #8, #9, #11, and #12 and was not aware she should have.”

“Based on interview and record review, the hospice agency failed to obtain a signed copy of the patient’s Revocation Election Statement for 1 (#1) of 2 (#1 and #2) patients reviewed for revocation of benefits. This deficient practice had the potential to affect any of the 39 admissions during the past 12 months, a current census of 18 patients and any future admissions to the agency. Findings:Review of Patient #1’s clinical record revealed she was admitted to the hospice agency on 04/03/2024 with the diagnoses that included Chronic combined systolic (congestive) and diastolic (congestive) heart failure. The certification period reviewed was from 04/03/2024 to 07/01/2024. Further review revealed her POA revoked hospice benefits on 04/06/2024.Review of the agency’s incident reports, revealed the following:Review of the Hospice agency’s Incident Report, dated 04/06/2024, revealed, in part, the following: Reported by: S1ADMEvent Type: LTCF facility called agency to report Patient #1 was declining and Patient #1’s “sister” reported she did know the Patient #1 was receiving hospice services. It was determined this family member had Power of Attorney and had not consented for hospice. She requested Patient #1 be removed from hospice services (revocation).Corrective Action: Patient #1 was transferred to local hospital.Follow Up: QAPI opened. Investigation revealed staff did not follow agency protocol to obtain POA consent. Review of Patient #1’s signed Revocation Election Statement was attempted on 06/11/2025 with no documented evidence available for review. On 06/11/2025 at 11:00 a.m., an interview was conducted with S1ADM. S1ADM confirmed the agency failed to follow protocol. S1ADM confirmed Patient #1’s termination of services was a revocation of services. She further confirmed the agency had not obtained a signed revocation of services form and should have.”

“Based on interviews and record reviews, the Hospice agency failed to ensure a Patient’s Clinical Record contained Physician’s Orders for treatments necessary to meet the needs of the patient for 2 (#6 and #8) of 10 (#5 through #14) live patients in the sample. This deficient practice had the potential to affect any of the 39 admissions during the past 12 months, a current census of 18 patients and any future admissions to the agency. Patient #6Review of Patient #6’s Clinical Record revealed she was admitted to the Hospice agency on 01/09/2024 and in a current Certification Period of 05/03/2025 through 07/01/2025. Further review revealed the local nursing home (NH) where she resided identified a Stage 2 Pressure Ulcer to the Sacral Region on 06/02/2025.An interview was conducted on 06/10/2025 at 9:40 a.m. with Patient #6’s nurse at her NH. She confirmed she was Patient #6’s regularly assigned nurse and was very familiar with her condition and care. She confirmed Patient #6 was currently receiving treatment for a Stage 2 Pressure Ulcer to the Sacral Region identified by her on 06/02/2025. She confirmed she informed S3DON as soon as she identified the wound. Review of Patient #6’s POC and Physician’s Orders, dated 06/02/2025 through 06/10/2025, revealed, in part, no documented evidence of written Physician’s Wound Care Orders for Patient #6’s Stage 2 Pressure Ulcer to the Sacral Region following identification on 06/02/2025. An interview was conducted on 06/12/2025 at 11:35 a.m. with S1ADM. S1ADM confirmed a newly identified wound would require a written Physician’s Order for Wound Care to ensure the patient’s needs were met. An interview was conducted on 06/13/2025 at 2:30 p.m. with S3DON. S3DON confirmed Patient #6’s NH nurse made her aware of Patient #6’s newly identified pressure wound at the beginning of June 2025. S3DON confirmed Patient #6’s Physician’s Orders did not include her Wound Care and should. Patient #8Review of Patient #8’s Clinical Record revealed she was admitted to the Hospice agency on 05/29/2025 with a terminal diagnosis of Parkinson’s Disease and Comorbidities including; Rectal Abscess, Fournier Gangrene, status post Colostomy. Further review revealed she was in a current Certification Period of 05/29/2025 through 08/26/2025. Review of Patient #8’s Initial RN Assessment, dated 05/29/2025, revealed, in part, the following: Patient status post colostomy placement with Colostomy intact. Review of Patient #8’s POC and Physician’s Orders for the current Certification Period, as of 06/13/2025, revealed, in part, no documented evidence of Physician’s Orders written for the care and maintenance of Patient #8’s Colostomy. An interview was conducted on 06/13/2025 at 2:30 p.m. with S3DON. S3DON confirmed Patient #8 had a colostomy in place upon admission and it remained present. S3DON confirmed Patient #6’s Physician’s Orders did not include the care and maintenance of her Colostomy and should.”

“Based on record review and interview, the Hospice agency failed to complete a discharge summary which included: a summary of the patient’s stay including treatments, symptoms and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that would assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility for 1 (#1) of 4 (#1, #2, #3, and #4) of sampled patient.This deficient practice had the potential to affect any of the 39 admissions during the past 12 months, a current census of 18 patients and any future admissions to the agency. Findings:Patient #1A review of the medical record for Patient #1 revealed she was admitted to the agency on 04/03/2024 with a diagnoses which included Chronic Combined Systolic and Diastolic Congestive Heart Failure. The certification period 04/03/2024 to 4/06/2024 was reviewed. The discharge date was 04/06/2024. There was no documented evidence a discharge summary had been completed for Patient #1.On 06/11/2025 at 11:00 a.m., an interview was conducted with S1ADM. S1ADM reviewed Patient #1’s electronic health record, she confirmed there was no documented evidence a discharge summary had been completed for Patient #1 and should have been.”

“Based on record review and interview, the Hospice agency failed to have a system in place for the safe use, management and disposal of controlled drugs in the patient’s home in accordance with all applicable laws, regulations and accepted standards pf practice. This deficient practice was evidenced by failure to: 1. Establish a written policy and procedure to ensure the safe disposal of unused controlled substances by the Hospice nurse immediately following a patient’s death;2. Ensure immediately upon a patient’s death, the Hospice nurse, in the presence of a witness, documented the name and remaining counts of all controlled substances for 1 (#4) of 2 (#3 and #4) death records reviewed; 3. Ensure immediately upon a patient’s death, the Hospice nurse, in the presence of a witness, performed the disposal of all controlled substances then documented the name and signature of the witness, along with the disposal method utilized for 1 (#4) of 2 (#3 and #4) death records reviewed; 4. Establish a written policy and procedure to maintain current and accurate records of the disposition of all controlled substances provided by the Hospice agency to the patient; and 5. Ensure current and accurate records were maintained of the disposition of all controlled substances provided by the Hospice agency to the patient for 7 of 7 (#5, #6, #7, #8, #9, #11, and #12) live patients reviewed for controlled substances. This deficient practice had the potential to affect any of the 39 admissions during the past 12 months, a current census of 18 patients and any future admissions to the agency. Cross reference: L686. Review of the memo issued by the state’s licensing authority, dated 06/25/2018, revealed the following, in part: In accordance with Act 23 of the 2018 Regular Legislative Session, regarding the 2018 Regular Legislative Session, the state’s licensing authority is issuing this notice to all licensed hospice providers. Effective 08/01/2018, Act 23 amends and reenacts LA RS 40:2191 relative to disposal of controlled substances by hospice providers; to provide for ownership; to provide for written procedures; to provide for patient records; to provide for disposal; to provide for patient notification; and to provide for related matters. Review of Louisiana Revised Statute (LA RS) 40:2191 revealed the following, in part: Disposal of deceased patient’s unused controlled substances:A. Upon death of a patient receiving hospice services, ownership of the patient’s unused Schedule II, III, IV, or V controlled substances under 21 CFR 1308 may transfer to the hospice for immediate disposal pursuant to the following provisions:(1) Each hospice shall establish a written procedure to ensure safe disposal of unused controlled substances by a hospice nurse at the time of a patient’s death.(2) Upon the death of a patient receiving hospice services, in the presence of a witness, the hospice nurse shall record in the medical record the name and quantity of each unused controlled substance.(3)(a) The hospice nurse shall conduct immediate disposal of the controlled substance at the site of care … (b) … the hospice nurse shall perform the disposal in the presence of a witness, who shall sign a document indicating their witnessing the disposal. (5) The hospice nurse shall record the method of disposal in the medical record.Review of the United States Government Accountability Office’s (GAO) Report titled “Preventing Drug Diversion”, published April 2020, revealed, in part, the following: Misuse of controlled substances continues to be a serious public health problem in the United States.1 National survey data from the Substance Abuse and Mental Health Services Administration show that in 2017, 53 percent of people 12 years of age and older in the United States who misused prescription pain relievers in the past year, obtained the drugs from friends and family. The most commonly misused controlled substances include opioids (such as oxycodone), which are used to treat pain, and central nervous system depressants (such as diazepam), which are used to treat anxiety and sleep disorders. These types of drugs are prescribed for a large proportion of patients in hospice care. Patients select hospice care when they no longer want treatment for their terminal illness, but rather choose a hospice team to provide symptom management and control. In 2017, approximately 1.5 million Medicare beneficiaries received hospice services, and 56 percent of those patients received care in the patient’s home. Medicare is the largest payer for hospice services.The Controlled Substances Act regulates the manufacture, distribution, use, and disposal of controlled substances.13 In general, the Controlled Substances Act was enacted to facilitate the use of controlled substances for legitimate medical, scientific, research, and industrial purposes while preventing them from being diverted for illegal uses.What GAO Found: Best Practices for Reducing the Risk of DiversionHospice officials we spoke to identified best practices for preventing diversion of controlled substances. Best practices include prescription drug counts performed by hospice employees to determine if controlled substances are being used properly.Narcotic counts can also help ensure that unused or expired medications are properly disposed of, preventing potential misuse or accidental ingestion. 1. Written policy and procedure for disposal of controlled substances upon death. Review of the agency’s policy titled “Controlled Medication Management and Disposal Policy” last reviewed 10/20/2023, revealed it did not meet the aforementioned requirements established in LA RS 40:2191. An interview was conducted on 06/12/2025 at 9:35 a.m. with S2DON. S2DON confirmed the agency was not aware of LA RS 40:2191 so their policy did not reflect those requirements. 2. and 3. Upon death, perform/document the witness, counts, and destruction of controlled substances.Patient #4Review of Patient #4’s Clinical Record revealed he was admitted to the Hospice agency on 06/28/2024 and expired at home on 07/12/2024. Review of Patient #4’s Death Visit, dated 07/12/2024, revealed the following, in part: 07/12/2024 at 11:30 p.m. - Patient expired at home. Medication Disposal: Morphine liquid - 27mL; Ativan tabs - 10 tablets. Further review revealed no documented evidence of the final count and/or destruction of Hydrocodone 5mg/Acetaminophen 325mg tablets. Review of Resident #4’s Physician Order, dated 07/12/2024, revealed the patient had the following current order for controlled substances prior to death: 06/28/2024 - Hydrocodone 5mg/Acetaminophen 325mg tablet. Give 1 tablet by mouth every 6 hours for pain. Further review revealed no Physician’s Orders for the aforementioned Morphine liquid and/or Ativan tablets. Review of Patient #4’s Clinical Record revealed no documented evidence of the witness signature for the final narcotic count and disposal of Morphine Liquid and Ativan tablets. Further review revealed no documented evidence of a count being conducted, witnessed or destroyed for the Hydrocodone 5mg/Acetaminophen 325mg tablets.An interview was conducted on 06/12/2025 at 9:35 a.m. with S2DON. S2DON reviewed the Clinical Record for Patient #4. He confirmed Patient #4’s death note documentation failed to contain a final narcotic count and disposal with a witness and the method used for disposal. 4. Written policy and procedure for the safe management, use and disposition of controlled substances in a patient’s home.Review of the Hospice agency’s undated Policy Number PC.M70 – Medications: Use and Disposal of Controlled Substances revealed, in part, no documented evidence of a system to maintain current and accurate records of the receipt and disposition of all controlled drugs.An interview was conducted on 06/12/2025 at 4:00 p.m. with S2DON. S2DON confirmed he was corporate’s Area Director of Nursing and he oversaw 3 Hospice agencies. S2DON confirmed the Hospice agency’s Narcotics Policy and Procedure did not currently include a system to maintain current and accurate records for the receipt and disposition of all controlled substances provided by the Hospice agency to the patient. An interview was conducted on 06/12/2025 at 4:02 p.m. with S1ADM. S1ADM confirmed she was corporate’s Area Administrator and she oversaw 3 Hospice agencies. S1ADM confirmed the Hospice agency’s Narcotics Policy and Procedure did not currently include a system to maintain current and accurate records for the receipt and disposition of all controlled substances provided by the Hospice agency to the patient. An interview was conducted on 06/13/2025 at 2:30 p.m. with S3DON. S3DON confirmed she was the Hospice agency’s Administrator, Director of Nursing and the only nurse who saw patients in the field. S3DON confirmed there was no expectation for the performance and documentation of a patient’s controlled substances during nurse visits. 5. Perform/document counts of controlled substances in the home during Nurse Visits.Patient #5Review of Patient #5’s Clinical Record revealed he was admitted to the agency on 04/23/2025 and was in a current Certification Period of 04/23/2025 through 07/21/2025. Further review revealed he was ordered to receive a Nurse Visit twice weekly for twelve weeks.Review of Patient #5’s POC and Physician’s Orders for the current Certification Period revealed, in part, the following orders: Oxycodone 5mg tablet. Give 1 tablet every 4 hours as needed for pain;Lorazepam 0.5mg tablet. Give 1 tablet every 4 hours as needed for restlessness; andMorphine Sulfate Concentrate 20mg/mL. Give 0.5mL every 2 hours as needed for pain or shortness of breath. Review of Patient #5’s Nurse Visits for the current Certification Period revealed, in part, no documented evidence of controlled substance counts being performed or documented during any of his 16 ordered visits conducted from 04/23/2025 through 06/13/2025.An observation was conducted on 06/10/2025 at 8:50 a.m. during Patient #5’s Home Visit with S3DON. Just prior to conclusion of the nurse visit, S3DON was observed asking Patient #5’s spouse if they needed any medication refills as she shook pill bottles located in a basket on the counter in the kitchen then placed the bottles back into the basket without opening the lids to count the number of pills inside. Upon conclusion of the Home Visit, S3DON had not performed or documented the count for Patient #5’s controlled substances at any time during the visit. An interview was conducted on 06/10/2025 at 8:55 a.m. with Patient #5’s spouse. She confirmed S3DON did not count medications during her visits, she only asked if refills were needed. Patient #6Review of Patient #6’s Clinical Record revealed she was admitted to the agency on 01/09/2024 and was in a current Certification Period of 05/03/2025 through 07/01/2025. Further review revealed she was ordered to receive a Nurse Visit once a week as of 05/04/2025 and twice weekly as of 06/01/2025. Review of Patient #6’s POC and Physician’s Orders for the current Certification Period revealed, in part, the following order: Lorazepam 0.5mg tablet. Give 1 tablet every 4 hours as needed for restlessness.Review of Patient #6’s Nurse Visits for her current Certification Period revealed, in part, no documented evidence of controlled substance counts being performed or documented during any of her 8 ordered visits conducted from 05/03/2025 through 06/13/2025.Patient #7Review of Patient #7’s Clinical Record revealed she was admitted to the agency on 02/07/2024 and was in a current Certification Period of 06/01/2025 through 07/30/2025. Further review revealed she was ordered to receive a Nurse Visit twice a week as of 06/01/2025. Review of Patient #7’s POC and Physician’s Orders for the current Certification Period revealed, in part, the following order: Xanax Oral 0.5mg tablet. Give 1 tablet BID;Oxycodone HCL Oral 5 mg tablet. Give 1 tablet every 4 hours prn;Review of Patient #7’s Nurse Visits for her current Certification Period revealed, in part, no documented evidence of controlled substance counts being performed or documented during any of her 4 ordered visits conducted from 06/01/2025 through 06/13/2025.Patient #8Review of Patient #8’s Clinical Record revealed she was admitted to the agency on 05/09/2025 and was in a current Certification Period of 05/29/2025 through 08/26/2025. Further review revealed she was ordered to receive a Nurse Visit twice weekly for twelve weeks. Review of Patient #8’s POC and Physician’s Orders for the current Certification Period revealed, in part, the following medication orders: Morphine Sulfate Concentrate 20mg/mL. Give 0.5mL every 2 hours as needed for pain or shortness of breath; Morphine Sulfate Concentrate 20mg/mL. Give 1mL every 2 hours as needed for pain or shortness of breath; Lorazepam 1mg tablet. Give 1 tablet every 4 hours as needed for agitation or anxiety; andOxycodone 10mg tablet. Give 1 tablet every 4 hours as needed for pain;Review of Patient #8’s Nurse Visits for her current Certification Period revealed, in part, no documented evidence of controlled substance counts being performed or documented during any of her 5 ordered visits conducted from 05/29/2025 through 06/13/2025.Patient #9Review of Patient #9’s Clinical Record revealed he was admitted to the agency on 05/02/2025 and was in a current Certification Period of 05/02/2025 through 07/30/2025. Further review revealed he was ordered to receive a Nurse Visit once weekly for thirteen weeks. Review of Patient #9’s POC and Physician’s Orders for the current Certification Period revealed, in part, the following medication order: Morphine Sulfate Concentrate 20mg/mL. Give 0.5mL every 2 hours as needed for pain or shortness of breath.Review of Patient #9’s Nurse Visits for his current Certification Period revealed, in part, no documented evidence of controlled substance counts being performed or documented during any of his 7 ordered visits conducted from 05/02/2025 through 06/13/2025.Patient #11Review of Patient #11’s Clinical Record revealed she was admitted to the agency on 04/28/2025 and was in a current Certification Period of 06/06/2025 through 06/10/2025. Further review revealed she was ordered to receive a Nurse Visit twice weekly for twelve weeks. Review of Patient #11’s POC and Physician’s Orders for the current Certification Period revealed, in part, the following medication orders: Morphine Sulfate Concentrate 20mg/mL. Give 0.5mL every 2 hours as needed for pain or shortness of breath; andLorazepam 1mg tablet. Give 1 tablet every 4 hours as needed for agitation or anxiety. Review of Patient #11’s Nurse Visits for her current Certification Period revealed, in part, no documented evidence of controlled substance counts being performed or documented during any of her 4 ordered visits conducted from 06/06/2025 through 06/13/2025. Patient #12Review of Patient #12’s Clinical Record revealed he was admitted to the agency on 06/06/2025 and was in a current Certification Period of 06/06/2025 through 09/03/2025. Further review revealed he was ordered to receive a Nurse Visit once a week for 13 weeks as of 06/08/2025. Review of Patient #12’s POC and Physician’s Orders for the current Certification Period revealed, in part, the following order: Lorazepam 0.5mg tablet. Give 1 tablet every 4 hours as needed for restlessness; andHydrocodone-Acetaminophen 5-325 mg tablet. Give 1 tablet every 6 hours as needed for pain.Review of Patient #12’s Nurse Visits for his current Certification Period revealed, in part, no documented evidence of controlled substance counts being performed or documented during any of his 2 ordered visits conducted from 06/06/2025 through 06/13/2025. An interview was conducted on 06/12/2025 at 4:00 p.m. with S2DON. S2DON confirmed he expected S3DON to perform a count and document all controlled substances during each of her nurse visits. An interview was conducted on 06/12/2025 at 4:02 p.m. with S1ADM. S1ADM confirmed she expected S3DON to perform a count and document all controlled substances during each of her nurse visits. An interview was conducted on 06/13/2025 at 2:30 p.m. with S3DON. S3DON confirmed she did not perform and/or document counts for controlled substances during the aforementioned 46 nurse visits she conducted for Patient #5, #6, #7, #8, #9, #11, and #12 and was not aware she should have.”

“Based on observations, interviews and record reviews, the Hospice agency failed to ensure all care provided by the local nursing home (NH) where a patient resided was provided in accordance with their Hospice Plan of Care (POC). This deficient practice was evidenced by failure to ensure Patient #6’s NH orders matched the orders present in her Hospice POC for 1 (#6) of 2 (#6 and #7) home visits performed in a NH. This deficient practice had the potential to affect any of the patients who resided in a NH during the past 12 months, any of the 13 patients currently residing in a NH and any future admissions to the agency who resided in a NH. Review of Patient #6’s Clinical Record revealed she was admitted to the Hospice agency on 01/09/2024 and in a current Certification Period of 05/03/2025 through 07/01/2025. Further review revealed she resided at a local nursing home (NH). An observation of Patient #6’s Clinical Record for the local NH where she resided was conducted during Home Visit on 06/10/2025 at 9:40 a.m. The most recent Hospice POC and Hospice Physician’s Orders present in Patient #6’s paper chart and electronic health record (EHR) for the NH were for the Certification Period of 03/04/2025 through 05/02/2025. Further review revealed, in part, the following active orders: Pressure Ulcer of Sacral Region, Stage 2 - Cleanse site with wound cleanser. Apply gentian violent to peri-wound. Apply Medi-honey and Silver Alginate to wound bed. Cover with bordered foam dressing. Change dressing three times a week and as needed until healed. Notify physician of signs and symptoms of infection as needed (Start Date: 06/07/2025); Preparation H External Cream 1% - Apply to rectum topically twice a day related to unspecified hemorrhoids (Start Date: 06/07/2025); and Tylenol 325mg. Give 2 tablets by mouth every 4 hours as needed for temperature of greater than 100.4 (Start Date: 05/26/2025). Review of Patient #6’s Hospice POC and Hospice Physician’s Orders for the current Certification Period, as of 06/09/2025, revealed, in part, the following: Povidone-Iodine Ophthalmic Solution 5% - Give 1 drop in both eyes three times a day for dry eye (Start Date: 04/05/2024); No documented evidence of a Physician’s Order for the aforementioned Preparation H External Cream 1%; No documented evidence of a Physician’s Order for the aforementioned Tylenol 325mg; and No documented evidence of a Physician’s Order for the aforementioned Wound Care to the Sacral Region. An interview was conducted on 06/10/2025 at 9:45 a.m. with Patient #6’s nurse at the NH. She confirmed Patient #6’s Hospice nurse, S3DON, was responsible for ensuring up to date Hospice documents were present in the patient’s NH record when she performed her visits. She reviewed Patient #6’s current NH orders and confirmed Patient #6 did not have a NH order for and did not receive Povidone-Iodine Ophthalmic Solution 5%. She confirmed Patient #6 had NH orders for and did currently receive Preparation H External Cream 1%, Tylenol 325mg and Wound Care per the aforementioned NH orders. An interview was conducted on 06/13/2025 at 2:30 p.m. with S3DON. S3DON confirmed the Hospice agency was responsible for maintaining up to date Hospice documents in a patient’s NH record at all times and for ensuring all orders in use by the NH matched the orders present in the Hospice POC. S3DON confirmed Patient #6’s NH orders did not match the orders present in her Hospice POC and should.”

“Based on observations, interviews and record reviews, the Hospice agency failed to ensure the local nursing home (NH) where Patient #6 resided was provided with her most recent Hospice Plan of Care (POC) and Hospice Physician’s Orders for 1 (#6) of 2 (#6 and #7) home visits performed in a NH. This deficient practice had the potential to affect any of the patients who resided in a NH during the past 12 months, any of the 13 patients currently residing in a NH and any future admissions to the agency who resided in a NH. Review of Patient #6’s Clinical Record revealed she was admitted to the Hospice agency on 01/09/2024 and in a current Certification Period of 05/03/2025 through 07/01/2025. Further review revealed she resided at a local nursing home (NH). An observation of Patient #6’s Clinical Record for the local NH where she resided was conducted during Home Visit on 06/10/2025 at 9:40 a.m. The most recent Hospice POC and Hospice Physician’s Orders present in Patient #6’s paper chart and electronic health record (EHR) for the NH were dated 04/29/2025 and for the Certification Period of 03/04/2025 through 05/02/2025. An interview was conducted on 06/10/2025 at 9:45 a.m. with Patient #6’s nurse at the NH. She confirmed Patient #6’s Hospice nurse, S3DON, was responsible for bringing updated Hospice documents when she performed her visits. She confirmed all Hospice documentation was immediately scanned into a patient’s chart by medical records to make them available to NH staff for review and reference if necessary. She reviewed the current Hospice documentation present in the NH for Patient #6 and confirmed the Hospice POC and Hospice Physician’s Orders were for a previous Certification Period and were not current. She confirmed Patient #6 had experienced changes in status since the documents were printed on 04/29/2025 which would have required updates to her Hospice POC and Hospice Physician’s Orders. An interview was conducted on 06/13/2025 at 2:30 p.m. with S3DON. S3DON confirmed the Hospice agency was responsible for maintaining up to date Hospice documents in a patient’s NH record at all times; including the Hospice POC and Hospice Physician’s Orders, and this was not done for Patient #6.”