St Joseph Hospice and Palliative Care Northshore,

“Based on interviews and record reviews, the Hospice agency failed to meet the COP for the Organization and Administration of Services. This deficient practice was evidenced by failure to have a system in place to ensure: 1. A patient’s Clinical Record contained their most recent LaPOST Advance Directive in a location accessible by the patient’s attending physician and/or all agency staff for 3 (#4, #5, and #12) of 12 patients in the sample (See Findings L677); 2. A patient’s Clinical Record contained their HCPOA Advance Directive in a location accessible by the patient’s attending physician and/or all agency staff for 7 (#5, #6, #8, #9, #11, #12, and #13) of 12 patients in the sample (See Findings in L677);3. The SN documented the presence of a witness when completing the final count of all remaining controlled substances immediately following a patient’s death for 2 ( #3 and #4) of 2 death records reviewed (See Findings in L686 and L694); 4. The SN documented the final count of all remaining controlled substances immediately following a patient’s death for 1 of 2 (#4) death records reviewed (See Findings in L686 and L694);5. A written policy and procedure was established in accordance with accepted standards of practice to maintain current and accurate records of the disposition of all controlled substances provided by the Hospice agency to the patient for 10 of 10 (#5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) live patients in the sample (See Findings in L686 and L694); 6. Current and accurate records were maintained of the disposition of all controlled substances provided by the Hospice agency to the patient for 10 of 10 (#5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) live patients in the sample (See Findings in L686 and L694).This deficient practice had the potential to affect a current census of 36 patients, any future patients admitted to the agency and any future patient deaths. .”

“Based on observation, interviews and record review, the Hospice agency failed to meet the Condition of Participation for Drugs and Biologicals. This deficient practice was evidenced by failure to have a system in place to ensure the safe use, management and/or destruction of all controlled substances provided by the Hospice agency to the patient. The Hospice agency failed to:1. Ensure the SN documented the presence of a witness when completing the final count of all remaining controlled substances immediately following a patient’s death for 2 ( #3 and #4) of 2 death records reviewed (See Findings in L694); 2. Ensure the SN documented the final count of all remaining controlled substances immediately following a patient’s death for 1 of 2 (#4) death records reviewed (See Findings in L694); 3. Establish a written policy and procedure in accordance with accepted standards of practice to maintain current and accurate records of the disposition of all controlled substances provided by the Hospice agency to the patient for 10 of 10 (#5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) live patients in the sample (See Findings in L694); 4. Ensure current and accurate records were maintained of the disposition of all controlled substances provided by the Hospice agency to the patient for 10 of 10 (#5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) live patients in the sample (See Findings in L694); and 5. Ensure the patient/patient representative/family received a copy of the agency’s written Policies and Procedures regarding the Management and Disposal of Controlled Substances for 10 of 10 (#5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) live patients in the sample (See Findings in L695).This deficient practice had the potential to affect a current census of 36 patients, any future patients admitted to the agency and any future patient deaths. .”

“Based on interviews and record review, the Hospice agency failed to ensure the patient was free to exercise their right to be involved in decision making regarding their care, treatment and services without being compelled to revoke by the Hospice agency. This deficient practice was evidenced by the failure to have a system in place to prevent improper Revocation of Hospice Benefits when a patient/family chose to seek treatment and/or services which would not require a Revocation of Hospice Benefits for 1 (#1) of 2 patients reviewed for Revocations.This deficient practice had the potential to affect a current census of 36 patients, any future admissions to the agency, along with any of the agency’s patients who revoked Hospice benefits during the past 12 months. Findings: Review of a nationally recognized expert Hospice organization’s published Guidelines to Revocation of Hospice Benefits, revealed, in part, the following: Revocation of the Hospice Benefit is defined as a patient-initiated, voluntary decision to stop Hospice care and resume/seek curative treatments of the terminal diagnosis. Note: The decision to revoke is that of the patient/patient representative. A Hospice agency cannot pressure a patient to revoke. Review of a nationally recognized medical resource’s publication titled “The Impact of Biliary Drainage on Quality of Life in Unresectable Biliary and Pancreatic Cancer”, dated 02/14/2025, revealed, in part, the following:A biliary drain/stent in pancreatic cancer is primarily used for palliation/comfort to relieve jaundice, itching and pain caused by blocked bile ducts, rather than as a curative treatment. While it does not cure the cancer, it improves Quality of Life. Palliative/Comfort Role: It reduces jaundice (yellowing of skin/eyes), relieves intense itching, prevents infection, and improves appetite.Conclusion: Biliary drainage is a critical intervention for symptom management in patients with pancreatic cancer, particularly in alleviating pruritus and enhancing physical well-being. Effectiveness in providing immediate symptom relief is well-documented. Review of Patient #1’s Clinical Record for his Initial Admission revealed he was admitted to the Hospice agency on 09/20/2025 with a terminal diagnosis of Malignant Neoplasm of Pancreas and an Initial Certification Period of 09/20/2025 through 11/02/2025. Further review revealed he was discharged from the Hospice agency on 11/02/2025 due to revocation. Review of Patient #1’s Revocation of Hospice Benefits Statement, dated 11/02/2025, revealed, in part, the form was signed by his spouse with the following reason selected: I choose aggressive treatment for my terminal illness revoking palliative care by the Hospice.Review of Patient #1’s Coordination Note for an After Hours Call on 11/02/2025, revealed, in part, the following: Patient #1’s spouse called to report he was bleeding from and had severe pain at his biliary drain site. She requested a SNV. S6LPN assigned at 5:54 a.m.Review of Patient #1’s SNV Note, dated 11/02/2025 by S6LPN, revealed, in part, the following: Patient #1’s spouse reported his biliary drain bag was not draining and the gauze dressing around it was bloody. He was not able to rest and his pain medications were not managing his pain. Patient #1 requested to go to the hospital for the uncontrolled pain. Informed spouse of revocation. Spouse stated she would call EMS for transport to local ED. Review of Patient #1’s Hospital Notes, dated 11/02/2025 through 11/07/2025, revealed, in part, the following: Prior Medical History and Reason for Visit: History of Pancreatic Cancer s/p whipple, recurrent pancreatic cancer with biliary drain placement on 09/02/2025, gastrointestinal stromal tumor who presented to ED on 11/02/2025 due to decreased output of his biliary drain placement for the past 3 days. Noted purulent drainage around the incision. Stated he first noticed incisional pain around 3 days ago and that was when output decreased. Patient confirmed nausea without vomiting. Reported he decided to pursue hospice care. Stated he would not like to pursue aggressive treatment but is on board with possible drain replacement and antibiotics. Make past tenseReview of Patient #1’s Clinical Record for his Second Admission revealed he was readmitted to the Hospice agency on 11/08/2025 and in a Certification Period of 11/08/2025 through 11/19/2025. Further review revealed he was discharged from the Hospice agency on 11/19/2025 due to revocation. Review of Patient #1’s Revocation of Hospice Benefits Statement, dated 11/19/2025, revealed, in part, the form was signed by his spouse with the following reason selected: I choose aggressive treatment for my terminal illness revoking palliative care by the Hospice.Review of Patient #1’s SNV Note, dated 11/19/2025 by S2RN, revealed, in part, the following: Upon arrival, patient’s Biliary Drain in place with no output in bag. Drain flushed and bag changed with no output. Patient reported pain at insertion site and bleeding with bandage saturation. Patient and caregiver wished to seek treatment of his dislodged internal drain. Review of Patient #1’s Hospital Notes, dated 11/19/2025 through 11/25/2025, revealed, in part, the following: Prior Medical History and Reason for Visit: Patient #1 presented due to concern of his biliary tube not draining. At home his drain was giving less output and it had mostly blood with clots. He was advised by his Hospice nurse to come to the ED. Upon arrival, epigastric pain was worsening and had blood leaking around insertion site of Biliary Drain. Received an upsize of his drain. Review of Patient #1’s Clinical Record for his Third Admission revealed he was readmitted to the Hospice agency on 11/26/2025 and in a Certification Period of 11/26/2025 through 11/29/2025. Further review revealed he was discharged from the Hospice agency on 11/29/2025 due to revocation. Review of Patient #1’s SNV Note, dated 11/29/2025 by S6LPN, revealed, in part, the following: Patient’s spouse called the after-hours call service to request a SNV due to the patient’s Biliary Drain no longer draining. Upon arrival, Biliary Drain inspected with bleeding noted around insertion site. Sutures were intact. Drainage bag contained multiple blood clots and minimal output. Attempted to gently flush with no resistance noted. Blood clot visualized in drain tubing. Attempted to milk tubing to dislodge the blood clot. Attempted to educate spouse on care of the Biliary Drain without success. Spouse unable to provide the care for the patient. Informed patient and spouse if symptoms continue, he may need to be evaluated in the local ED. Both declined emergency treatment at this time. Revocation policy reviewed. Patient continuously declined to receive emergency treatment. Review of Patient #1’s Revocation of Hospice Benefits Statement, dated 11/29/2025, revealed, in part, the form was signed by his spouse with the following reason selected: I choose aggressive treatment for my terminal illness revoking palliative care by the Hospice.Review of Patient #1’s Hospital Notes, dated 11/29/2025 through 12/15/2025, revealed, in part, the following: Prior Medical History and Reason for Visit: Patient #1 was status post biliary drain placement. The drain has been closed and blocked a few times necessitating readmission to the hospital for drain clearance. The drain bled into the bag earlier today. The patient’s wife called the Hospice nurse who came and flushed the catheter which apparently causes the patient significant pain. The Hospice nurse directed them to come to the ED but told them they would have to revoke Hospice. He may not be readmitted back to the Hospice agency due to the number of admissions and revocations prior to this one. Patient and spouse requested assistance with nursing home placement. An interview was conducted on 02/11/2026 at 4:28 p.m. with S6LPN. S6LPN stated the Hospice agency required a patient/family to sign a Revocation of Hospice Benefits if the patient/family chose to seek treatment of outside of the Hospice agency. S6LPN confirmed if a patient and/or their family wanted transport to the ED for treatment, she educated them on the revocation of Hospice benefits to ensure they wished to proceed. S6LPN confirmed if after being educated, the patient/family still wished to proceed, she contacted S1ED or whomever was on-call to inform them of the pending revocation and why they wished to. S6LPN confirmed after that and prior to the patient being transported to the ED, she had the patient/family sign a form revoking their Hospice benefits. An interview was conducted on 02/12/2026 at 3:15 p.m. with S1ED. S1ED confirmed the Hospice agency required a patient/family to sign a Revocation of Hospice Benefits prior to the patient receiving any type of treatment in the ED. S1ED confirmed Patient #1 had a terminal diagnosis of pancreatic cancer and a Biliary Drain was not a curative approach to his cancer but was instead used for comfort and palliation of symptoms caused by his cancer. S1ED reviewed Patient #1’s chart and confirmed his Revocation of Hospice Benefits on 11/02/2025, 11/19/2025, and 11/29/2025 were because his Biliary Drain was clogged. S1ED confirmed all three times, the Hospice agency’s SNs attempted to unclog it in his home but were unsuccessful, which meant, if Patient #1 wanted it fixed, he required transport to the ED which required a revocation of Hospice benefits. S1ED confirmed having a Biliary Drain unclogged did not constitute an aggressive, curative treatment for Pancreatic Cancer and it did not mean he no longer wished to receive Hospice services.”

“Based on observation, interviews, and record reviews, the Hospice agency failed to ensure care and services were provided in accordance with the patient’s POC. This deficient practice was evidenced by S5RN’s failure to perform wound care per Physician’s Orders for 1 (#6) of 1 patients observed for wound care. This deficient practice had the potential to affect any of the 5 wounds currently being treated by the agency, and any future wounds which would require treatment by the agency. Findings: An interview was conducted on 02/09/2026 at 9:30 a.m. with S1ED. S1ED confirmed the agency utilized an EHR for all Clinical Records and did not maintain paper Clinical Records in their office. Review of Patient #6’s Clinical Record revealed she was admitted to the agency on 01/07/2026, and was in a current Certification Period of 01/07/2026 through 04/06/2026. Further review revealed she was currently receiving treatment for a Stage 4 Pressure Ulcer to her Sacrum and a Stage 2 Pressure Ulcer to the Left Shin. Review of Patient #6’s POC and Physician’s Orders from her admission 01/07/2026 through 02/10/2026 was conducted on 02/10/2026 at 12:40 p.m., with the following active orders for wound care:01/28/2026 - Perform wound care to Stage 4 Pressure Ulcer on Sacrum utilizing clean technique. Cleanse with wound cleanser, apply ointment, and cover with bandage. Change every 3 days and PRN. Instruct caregiver in wound care; and02/06/2026 - Perform wound care to Left Lower Extremity. Cleanse with wound cleanser, paint with betadine and cover.An observation was conducted on 02/09/2026 at 3:02 p.m. of Patient #6 receiving wound care from S5RN. During wound care to Patient #6’s Sacrum, S5RN cleaned the wound with wound cleanser and gauze, applied iodine soaked gauze to pack the wound bed, then covered the wound with a border gauze dressing. During wound care to Patient #6’s Left Shin, S5RN applied zinc ointment to a reddened area of skin then left the area open to air. An interview was conducted on 02/09/2026 at 3:20 p.m. with S5RN. S5RN confirmed she cleaned Patient #6’s Sacrum with wound cleanser and gauze, applied iodine soaked gauze to pack the wound bed, and covered the wound with a border gauze dressing. S5RN confirmed she applied zinc ointment to the reddened area of skin on Patient #6’s Left Shin and left the area open to air. Review of Patient #6’s SNV Note for 02/09/2026 written by S5RN was performed on 02/11/2026 at 10:30 a.m. and revealed, in part, the following: Wound #2 – Stage 4 Pressure Ulcer to Sacrum:Wound care provided: Cleaned with wound cleanser, patted dry, packed wound, covered with bandage. Wound #6 – Stage 2 Pressure Ulcer to Left Shin: Wound care provided: Cleaned right lower extremity with wound cleanser, painted with betadine, and covered. An interview was conducted on 02/11/2026 at 3:36 p.m. with S1ED. S1ED reviewed Patient #6’s current orders for wound care. S1ED confirmed Patient #6’s Sacrum wound care included the following: cleanse with wound cleanser, apply ointment, and cover with bandage. S1ED confirmed a betadine soaked gauze applied to pack the sacral wound was not per physician’s orders, and should have been. S1ED confirmed Patient #6’s Left Shin, wound care included the following: wound cleansed with wound cleanser, painted with betadine and covered. S1ED confirmed applying zinc ointment to the left shin and leaving it open to air was not per physician’s orders and should have been. S1ED confirmed she expected all of her staff to review and follow all Physician’s Orders as they were written.”

“Findings:Review of the state’s RS 9:111, effective 07/01/2010, revealed, in part, the following: A. A person will be considered dead if in the announced opinion of a physician, duly licensed in the state of Louisiana based on ordinary standards of approved medical practice, the person has experienced an irreversible cessation of spontaneous respiratory and circulatory functions….B. The medical pronouncement of death by a coroner may also be based on personal observation, information, or statements obtained from coroner investigators, Registered Nurses, physician assistants, or emergency medical technicians at the scene who are reporting from firsthand observation of the physical condition of the deceased. …Review of the agency’s Death at Home and Within a Contracted Facility, revised 01/26/2026, was conducted on 02/18/2026 and revealed, in part, the following: Policy: Nurses may visit the residence/facility when it is reported a patient has died. Individual state and community regulations and practices will be followed. Note: Hospice should check specific state law regarding death at home and adapt this policy to meet state law/statute. Procedure: 1. Following a patient’s death, the nurse will make a visit. 2. The nurse will assist the family/caregiver/contracted facility staff either via phone or intervention or at the home/facility with notification of the attending physician and coroner.3. The nurse will notify the attending physician of the patient’s death. It will ne the attending physician’s responsibility to pronounce death. The physician will routinely accept Hospice’s description or report of the absence of vital signs when assuming this responsibility. Patient #4 Review of Patient #4’s Clinical Record revealed he was admitted to the agency on 01/17/2025 and was in a current Certification Period of 01/17/2025 through 03/04/2025 at the time of his death on 03/04/2025. Review of Patient #4’s Death Visit performed by S8LPN on 03/04/2025 revealed no documented evidence to indicate a RN was present during this visit. Review of Patient #4’s Clinical Record, as of 02/18/2026, revealed no documented evidence to indicate a RN was present during Patient #4’s Death Visit.An interview was conducted on 02/18/2026 at 3:10 p.m. with S1ED. S1ED confirmed the agency’s policy and procedure for a Death Visit did not specify if a Death Visit and assessment to confirm death must be performed by a RN. S1ED confirmed according to LA RS 9:111, the performance of this assessment was not within an LPN’s Scope of Practice within the State of Louisiana. S1ED reviewed Patient #4’s Clinical Record and confirmed an LPN performed his death assessment and should not have.”

“Based on interview and record review, the Hospice agency failed to have a system in place to ensure nursing care and services were provided under the supervision of a RN in order to meet all of the patient’s needs. This deficient practice was evidenced by failure to ensure the RN assessed and documented wound measurements and wound descriptions every 7 days for 1 (#8) of 3 patients reviewed for wounds. This deficient practice had the potential to affect any of the 5 wounds currently being treated by the agency and any future wounds which would require treatment by the agency. Review of the state’s Board of Nursing Declaratory Statement Scope of Practice for a RN - Wound Care Management, adapted 02/1999, revealed, in part, the following: RNs render care that is directed towards the prevention and treatment of wounds. Wounds are a common health care challenge that often occur with or result from chronic disorders such as impaired circulation and malnutrition. RN care of skin/wound conditions involves the identification, assessment, management, and ongoing evaluation of patients with alterations in skin/tissue integrity that includes but is not limited to draining wounds, pressure ulcers, and vascular ulcers, and conditions resulting from incontinence, surgical procedures, and/or trauma.Scope of Practice - The state’s Board of Nursing recognizes that assessment, planning, intervention, teaching, evaluation, and supervision are the major responsibilities of the RN in the practice setting. The RN is responsible for performing a nursing assessment and physical examination for preventative and restorative nursing and for providing patient/family teaching. Recognizing that the physician must always prescribe wound care, the following roles are defined to delineate the scope of practice for each member of the nursing team members. The RN initiates appropriate wound preventative measures, stages wounds and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by an authorized prescriber. Review of the National Pressure Ulcer Advisory Panel Prevention and Treatment of Pressure Ulcers: Quick Reference Guide revealed, in part, the following:Pressure Ulcer Assessment 1. Assess the pressure ulcer initially and re-assess it at least weekly.1.1. Document the results of all wound assessments. Assess and document physical characteristics including: location, Category/Stage, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. Review of the Hospice agency’s Wound Care Protocol, dated 10/19/2020, revealed, in part, the following: Process: Wound care treatment and interventions will be individualized and may include, but not limited to the following: 3. Weekly wound care measurements by the RN.The wound care assessment will contain the documentation below, but is not limited to: Location of wound;Type of wound;Measurement/Staging;Wound bed;Wound edges;Drainage;Odor;Surrounding Tissue;Infection;Pain; and Response to Care/Treatment Plan. Review of Patient #8’s Clinical Record revealed he was admitted to the Hospice agency on 12/12/2025 with a terminal diagnosis of Malignant Melanoma of the Skin and was in a current Certification Period of 12/12/2025 through 03/11/2026. Further review revealed he was currently receiving treatment for a Stage 2 Pressure Ulcer to his Sacrum. Review of Patient #8’s POC for his current Certification Period revealed, in part, he was ordered to receive a SNV twice a week for 1 week and then once for 13 weeks. Review of Patient #8’s Physician Orders for his current Certification Period, as of 02/22/2026 at 1:18 p.m., revealed, in part, the following: 12/22/2025 – SN to perform wound care to Stage 2 on Sacrum. Utilizing clean technique. Cleanse with wound cleanser. Apply ointment. Cover with bandage every 3 days and PRN. Review of Patient #8’s Visit Calendar revealed in part, the following SNVs visits were conducted during his current Certification Period:12/12/2025 - RN Visit; 12/13/2025 - LPN visit;12/15/2025 - RN Visit;12/18/2025 - RN Visit; 12/22/2025 - RN Visit; 12/27/2025 through 01/03/2026 – Patient unavailable for home SNVs due to IPU admission;01/08/2026 - RN Visit;01/12/2026 - RN Visit;01/15/2026 - RN Visit; and 01/19/2026 - RN Visit. Review of Patient #8’s SNV Notes for his current Certification Period, as of 02/12/2026 at 1:18 p.m. revealed, in part, the following: 12/13/2025 - No documented evidence of wound measurements or description by an RN;12/15/2025 – No documented evidence of wound measurements or description by an RN;12/18/2025 - No documented evidence of wound measurements or description by an RN;12/22/2025 - No documented evidence of wound measurements or description by an RN;01/08/2026 - No documented evidence of wound measurements or description by an RN; and01/19/2026 - No documented evidence of wound measurements or description by an RN; An interview was conducted on 02/11/2026 at 3:15 p.m. with S1ED. S1ED confirmed wounds should be measured with the measurements and description documented every 7 days by the RN. S1ED reviewed Patient #8’s Clinical Record and confirmed it did not contain documented evidence to indicate the RN performed wound measurements including a description every 7 days and should. An interview was conducted on 02/09/2026 at 9:30 a.m. with S1ED. S1ED confirmed the agency utilized an EHR for all Clinical Records and did not maintain paper Clinical Records in their office.”

“Based on interviews and record reviews, the Hospice agency failed to have a system in place to ensure newly hired HA’s met at least one of the required qualifications for their position prior to being allowed to provide HA services to the agency’s patients. This deficient practice was evidenced by S1ED’s failure to perform and document a Competency Evaluation of all required skills upon hire for 1 (S4HA) of 1 HA personnel files reviewed. This deficient practice had the potential to affect any of the agency’s current patients who received HA services and any future admissions who received HA services. Findings: Review of S4HA’s Personnel File revealed she was hired as a HA on 02/09/2021 and had provided HA services to the agency’s patients since that time. Review of S4HA’s documented evidence of completion of an approved HA Training and Competency Program and/or completion of a State Licensure Program was attempted on 02/18/2026 at 2:20 p.m. and again at 3:00 p.m. with no documented evidence available for review. Review of S4HA’s undated Initial Competency Assessment Skills Checklist – HA was performed on 02/18/2026 at 2:22 p.m. with no documented evidence to indicate S1ED performed the competency assessment of the 107 required skills listed on the 5 page document. Further review revealed, in part, the following: Evaluation Method of Competency utilized by the Hospice agency for each skill: Blank for 100% of the skills listed; and Competency Validation indicated by Preceptors Initials/Date Performed next to each of the skills listed: Blank for 100% of the skills listed.An interview was conducted on 02/18/2026 at 3:10 p.m. with S1ED. S1ED confirmed the agency utilized a Competency Evaluation of all required skills upon hire to ensure their HA’s met the qualifications for their position. S1ED confirmed S4HA had not completed an approved HA Training and Competency Program and/or a State Licensure Program. S1ED reviewed S4HA’s aforementioned Initial Competency Assessment Skills Checklist – HA and confirmed it did not contain documented evidence to indicate she completed the required Competency Evaluation for S4HA prior to allowing her to provide HA services on behalf of the agency and it should. An interview was conducted on 02/18/2026 at 3:15 p.m. with S3RD. S3RD reviewed S4HA’s aforementioned Initial Competency Assessment Skills Checklist – HA and confirmed it did not contain sufficient documented evidence to indicate S1ED ensured the required Competency Evaluation was completed for S4HA prior to allowing her to provide HA services on behalf of the agency. S3RD confirmed the method of evaluation utilized and the preceptor’s initials and date performed were required next to each of the required skills in order for the Competency Assessment to be valid. S3RD confirmed he would expect S1ED to ensure the competency of all required skills prior to allowing any employee to provide services on behalf of the agency.”

“Based on interview and record reviews, the Hospice agency failed to ensure the RN conducted an on-site HA Supervisory Visit at least every 14 days to assess the quality of care and services provided by the HA for 1 (#13) of 10 living patients reviewed. This deficient practice had the potential to affect any of the agency’s current patient who received HA services and any future admissions who received HA services. Findings: An interview was conducted on 02/09/2026 at 9:30 a.m. with S1ED. S1ED confirmed the agency utilized an EHR for all Clinical Records and did not maintain paper Clinical Records in their office. Review of Patient #13’s Clinical Record revealed he was admitted to the agency on 09/18/2025 with a terminal diagnosis of Interstitial Pulmonary Disease and was in a current Certification Period of 12/17/2025 through 02/14/2026. Review of Patient #13’s Plan of Care and Physician’s Orders for the current Certification Period revealed, in part, the following: SNV Frequency: Once weekly for one week then twice weekly for eight weeks; and HA Visit Frequency: Twice weekly for one week, then three times weekly for eight weeks. Review of Patient #13’s Visit Calendar, dated 01/13/2026 through 02/08/2026, was conducted on 02/12/2026 at 12:29 p.m. and revealed the following HA visits were conducted:01/12/2026;01/14/2026; 01/16/2026;01/19/2026;01/21/2026;01/23/2026;01//26/2026;01/28/2026;01/30/2026;02/02/2026; and02/06/2026. Review of Patient #13’s RN Supervisory Visits, dated 01/13/2026 through 02/08/2026, was conducted on 02/12/2026 at 12:32 p.m. with no documented evidence of a RN Supervisory Visit occurring for the HA from 01/14/2026 through 02/05/2026. An interview was conducted on 02/12/2026 at 2:45 p.m. with S1ED. S1ED reviewed the aforementioned documentation and confirmed Patient #13 did not receive a RN Supervisory Visit for their HA every 14 days, and they should have.”

“Based on observations, interviews, and record reviews, the Hospice agency’s Governing Body and Administrator failed to assume full responsibility for the management of the Hospice agency, the provision of all Hospice services, its fiscal operations, and continuous QAPI. This deficient practice is evidenced by failure to have a system in place to ensure the Hospice agency met: 1. The COP for Clinical Records in regards to ensuring a patient’s Clinical Record contained their most recent LaPOST Advance Directive in a location accessible by the patient’s attending physician and/or all agency staff for 3 (#4, #5, and #12) of 12 patients in the sample; 2. The COP for Clinical Records in regards to ensuring a patient’s Clinical Record contained their HCPOA Advance Directive in a location accessible by the patient’s attending physician and/or all agency staff for 7 (#5, #6, #8, #9, #11, #12, and #13) of 12 patients in the sample;3. The COP for Drugs and Biologicals in regards to ensuring the SN documented the presence of a witness when completing the final count of all remaining controlled substances immediately following a patient’s death for 2 ( #3 and #4) of 2 death records reviewed; 4. The COP for Drugs and Biologicals in regards to ensuring the SN documented the final count of all remaining controlled substances immediately following a patient’s death for 1 of 2 (#4) death records reviewed;5. The COP for Drugs and Biologicals in regards to establishing a written policy and procedure in accordance with accepted standards of practice to maintain current and accurate records of the disposition of all controlled substances provided by the Hospice agency to the patient for 10 of 10 (#5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) live patients in the sample; and6. The COP for Drugs and Biologicals in regards to ensuring current and accurate records were maintained of the disposition of all controlled substances provided by the Hospice agency to the patient for 10 of 10 (#5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) live patients in the sample.This deficient practice had the potential to affect a current census of 36 patients, any future patients admitted to the agency and any future patient deaths. Cross Reference: L677, L686, and L694. Findings:1. An interview was conducted on 02/09/2026 at 9:30 a.m. with S1ED. S1ED confirmed the agency utilized an EHR for all Clinical Records and did not maintain paper Clinical Records in their office. Patient #4Review of Patient #4’s Clinical Record revealed he was admitted to the agency on 01/17/2025 with a Certification Period of 01/17/2025 through 03/04/2025 and a terminal diagnosis of Alzheimer’s Disease. Patient #4 was not cognitive during his time with the agency and his Patient Information indicated DNR status upon admission. Patient #4’s Advanced Directive in his EHR revealed Full Code status. An interview was conducted on 02/18/2026 at 12:18 p.m. with S1ED. S1ED confirmed the only Advance Directive present in Patient #4’s EHR indicated Full Code Status, which did not match the patient/family’s current wishes. S1ED provided a printed copy of an LaPOST completed on 01/17/2026 which indicated DNR and confirmed she located his most recent LaPOST in a paper “to be scanned” file located in the Hospice agency’s office. S1ED confirmed only she and the agency’s Office Manager had access to the file and their office hours were Monday through Friday from 8:00 a.m. to 4:30 p.m. S1ED confirmed if a patient’s Advance Directive was located in a paper file at the agency’s office and not present in their EHR, it was not accessible to their attending physician and/or all Hospice staff and should be. S1ED confirmed Patient #4’s most recent LaPOST was not in his EHR and should have been. Patient #5Review of Patient #5’s Clinical Record revealed she was admitted to the agency on 03/12/2025 with a current Certification Period of 01/06/2026 through 03/06/2026 and a terminal diagnosis of Senile Degeneration of the Brain. Patient #5 was not cognitive and her Patient Information indicated DNR status upon admission. Patient #5’s LaPOST was not located in her EHR. An interview was conducted on 02/12/2026 at 2:50 p.m. with S1ED. S1ED provided a printed copy of Patient #5’s LaPOST at this time and confirmed it was not located in her EHR or the agency’s paper files, and should have been. S1ED confirmed the document was sent to her by Patient #5’s SN via electronic message when she was admitted to the agency, but was never added into the patient’s EHR. Patient #12Review of Patient #12’s Clinical Record revealed she was admitted to the agency on 04/09/2024 with a current Certification Period of 01/29/2026 through 03/29/2026 and a terminal diagnosis of Malignant Neoplasm of Pancreas. Patient #12’s Initial MSW and Initial RN Visits indicated DNR status upon admission. Patient #12’s LaPOST was not located in her EHR. An interview was conducted on 02/12/2026 at 11:09 a.m. with S1ED. S1ED provided a printed copy of Patient #12’s LaPOST and confirmed she located it in a paper “to be scanned” file located in the agency’s office. S1ED confirmed Patient #12’s LaPOST was not in her EHR and should have been. 2. Patient #5Review of Patient #5’s Clinical Record revealed she was admitted to the agency on 03/12/2025 with a current Certification Period of 01/06/2026 through 03/06/2026 and a terminal diagnosis of Senile Degeneration of the Brain. Patient #5 was not cognitive and her Patient Information indicated a legal representative was identified upon admission. Patient #5’s HCPOA was not located in her EHR. An interview was conducted on 02/12/2026 at 9:10 a.m. with S1ED. S1ED confirmed she could not provide a copy of Patient #5’s HCPOA because the agency did not obtain a copy of it upon admission or thereafter and should have. Patient #6Review of Patient #6’s Clinical Record revealed she was admitted to the agency on 01/07/2026 with a current Certification Period of 01/07/2026 through 04/06/2026 and a terminal diagnosis of Senile Degeneration of the Brain. Patient #6 was not cognitive and her Patient Information indicated a legal representative was identified upon admission. Patient #6’s HCPOA was not located in her EHR. An interview was conducted on 02/11/2026 at 8:45 a.m. with S1ED. S1ED confirmed Patient #6’s son was her HCPOA and made all decisions for her medical care, not her spouse. S1ED confirmed she could not provide a copy of Patient #6’s HCPOA because the agency did not obtain a copy of it upon admission or thereafter and should have. S1ED confirmed the Hospice agency had “taken the son’s word for it” when he informed them he was her legal HCPOA and should not have.Patient #8Review of Patient #8’s Clinical Record revealed he was admitted to the agency on 12/12/2025 with a current Certification Period of 12/12/2025 through 03/11/2026 and a terminal diagnosis of Malignant Melanoma of Skin. Patient #6 was not cognitive, his Patient Information indicated a legal representative was identified upon admission, and his Initial MSW Visit indicated a HCPOA was in place upon admission. Patient #8’s HCPOA was not located in his EHR. An interview was conducted on 02/11/2026 at 2:05 p.m. with Patient # 8’s daughter. She confirmed she was her father’s HCPOA at the time he was admitted to the Hospice agency and since he was no longer cognitive, she made all decisions regarding his care. She confirmed she participated in all of her father’s Hospice admission and neither the SN nor the MSW asked for a copy of his HCPOA. She confirmed no one from the Hospice agency had asked for a copy of his HCPOA since he was admitted in December. An interview was conducted on 02/12/2026 at 10:45 a.m. with S1ED. S1ED confirmed she could not provide a copy of Patient #8’s HCPOA because the agency did not obtain a copy of it upon admission or thereafter and should have. Patient #9Review of Patient #9’s Clinical Record revealed she was admitted to the agency on 10/08/2025 with a current Certification Period of 01/06/2026 through 04/05/2026 and a terminal diagnosis of Senile Degeneration of the Brain. Patient #9 was not cognitive and her Patient Information indicated no legal representative was identified upon admission. Patient #9’s Initial MSW Visit indicated a HCPOA was in place upon admission. Patient #9’s HCPOA was not located in her EHR. An interview was conducted on 02/11/2026 at 2:50 p.m. with S1ED. S1ED provided a copy of Patient #9’s HCPOA at this time after she located and printed it from her email. S1ED confirmed Patient #9’s HCPOA was emailed to her by the patient’s SN upon admission, but it was never added into her EHR and should have been. Patient #11Review of Patient #11’s Clinical Record revealed he was admitted to the agency on 01/22/2026 with a current Certification Period of 01/22/2026 through 04/21/2026 and a terminal diagnosis of Malignant Neoplasm of Nasopharynx. Patient #11 was not cognitive, his Patient Information indicated a legal representative was identified upon admission, and his Initial MSW Visit indicated a HCPOA was in place upon admission. Patient #11’s HCPOA was not located in his EHR. An interview was conducted on 02/12/2026 at 10:45 a.m. with S1ED. S1ED confirmed she could not provide a copy of Patient #11’s HCPOA for review because it had not been obtained since his admission to the agency and should have been. S1ED confirmed the agency had “taken the family’s word for it” when they informed the agency his daughter was the legal HCPOA. Patient #12Review of Patient #12’s Clinical Record revealed she was admitted to the agency on 04/09/2024 with a current Certification Period of 01/29/2026 through 03/29/2026 and a terminal diagnosis of Malignant Neoplasm of Pancreas. Patient #12’s Patient Information indicated a legal representative was identified upon admission and her Initial MSW indicated a HCPOA was in place upon admission. Patient #12’s HCPOA was not located in her EHR. An interview was conducted on 02/12/2026 at 11:09 a.m. with S1ED. S1ED confirmed she could not provide a copy of Patient #12’s HCPOA because the agency did not obtain a copy of it upon admission or thereafter and should have. Patient #13Review of Patient #13’s Clinical Record revealed he was admitted to the agency on 09/18/2025 with a current Certification Period of 12/17/2025 through 02/14/2026 and a terminal diagnosis of Interstitial Pulmonary Disease. Patient #13’s Patient Information indicated no legal representative was identified upon admission. Patient #13’s Initial MSW Visit indicated a HCPOA was in place upon admission. Patient #13’s HCPOA was not located in his EHR. An interview was conducted on 02/12/2026 at 12:59 p.m. with S1ED. S1ED confirmed she could not provide a copy of Patient #13’s HCPOA because the agency did not obtain a copy of it upon admission or thereafter and should have. S1ED confirmed when the Hospice agency did not obtain a copy of the patient’s Advance Directive, they took the patient/family’s word for it and honored what the patient/family told them the Advance Directive indicated. S1ED confirmed if the Hospice agency took the patient/family’s word for it, the Hospice agency could not confirm if they were following the patient’s wishes. S1ED confirmed an Advance Directive was a required legal document within the patient’s Clinical Record. S1ED confirmed when a patient was admitted to the Hospice agency, the SN and MSW were expected to ask if any Advance Directives existed and if they did, they should obtain a copy for the patient’s EHR. S1ED confirmed if staff emailed her a patient’s Advance Directive, it was her responsibility to print the document so it could be added to the patient’s EHR. S1ED confirmed once she printed the patient’s Advance Directive, it went into a paper “to be scanned” file in the agency’s office until it could be added to the patient’s EHR by the Office Manager. S1ED confirmed if staff brought a printed Advance Directive into the office, it was placed in the paper “to be scanned” file also. S1ED confirmed the paper “to be scanned” file was only accessible to her and the Office Manager when they were in the office. S1ED confirmed the Hospice agency’s office hours were Monday through Friday from 8:00 a.m. to 4:30 p.m. and she and the Office Manager would not typically be in the office outside of that timeframe. S1ED confirmed paperwork in the “to be scanned” file was not readily available for review by a physician and/or Hospice staff when they were working in the field and/or if she or the Office Manager were not present in the office. S1ED confirmed the Hospice agency did not have a system to ensure the SN and MSW were obtaining copies of Advance Directives to be added to the Patient’s EHR. S1ED confirmed the Hospice agency did not have a system to ensure patient documents emailed to her were printed and added to the patient’s EHR. S1ED confirmed the Hospice agency did not have a system to ensure required documents in the “to be scanned” file had been added to a patient’s EHR. S1ED confirmed she was not aware Patient #4, #5, #6, #8, #9, #11, #12, and #13’s were not present in their EHRs and should have been. 3. Review of the state’s RS 40:2191 revealed upon a patient’s death, the Hospice agency was responsible for performing and documenting the remaining count of a patient’s unused controlled substances followed by their disposal in the presence of a witness. Review of the Hospice agency’s Death at Home and Within a Contracted Facility’s Policy, revised 01/26/2026, as of 02/18/2026 at 10:45 a.m., revealed, in part, the SN should dispose of all medications, including controlled substances, per federal, state, local regulations and organizational policy. (See Home Use and Disposal of Controlled Substances Policy.)Review of the Hospice agency’s Home Use and Disposal of Controlled Substances Policy, revised 03/28/2023, as of 02/18/2026 at 10:45 a.m., revealed, in part, upon death of a patient receiving Hospice services, in the presence of a witness, the SN shall record in the medical record the name and quantity of each unused controlled substance. Patient #3Review of Patient #3’s Clinical Record revealed she was admitted to the agency on 04/08/2025 and expired on 04/17/2025 with active Physician Orders for Lorazepam and Morphine Concentrate at the time of her death. Further review revealed no documented evidence a witness was present during the SN’s final count of Patient #3’s controlled substances following her death.Patient #4Review of Patient #4’s Clinical Record revealed he was admitted to the agency on 01/17/2025 and expired on 03/40/2025 with active Physician Orders for Ativan and Morphine Concentrate at the time of his death. Further review revealed no documented evidence a witness was present during the SN’s final count of Patient #4’s controlled substances following his death. An interview was conducted on 02/18/2026 at 3:10 p.m. S1ED. S1ED reviewed Patient #3 and #4’s Death Visit Note and confirmed neither contained documented evidence a witness was present during the SN’s final count of the controlled substances following each patient’s death and should. S1ED confirmed she was not aware of this issue because the agency had not identified it.4. Review of Patient #4’s Clinical Record revealed he was admitted to the agency on 01/17/2025 and expired on 03/40/2025 with active Physician Orders for Ativan and Morphine Concentrate at the time of his death. Further review revealed no documented evidence the SN completed a final count of Patient #4’s remaining controlled substances following his death. An interview was conducted on 02/18/2026 at 3:10 p.m. S1ED. S1ED reviewed Patient #4’s Death Visit Note and confirmed it did not contain documented evidence of the SN’s final count of the controlled substances following death and should. S1ED confirmed she was not aware of this issue because the agency had not identified it.An interview was conducted on 02/18/2026 at 3:12 p.m. S3RD. S3RD confirmed the agency’s SN were responsible for meeting the requirements for the count and disposal of a patient’s remaining controlled substances following their death, which included the proper documentation. S3RD confirmed the Hospice agency should have routinely monitored to identify and correct these issues at the time they occurred so staff education could be performed to prevent recurrence moving forward. 5. Review of the Hospice agency’s Home Use and Disposal of Controlled Substances Policy, revised 03/28/2023, as of 02/18/2026 at 10:45 a.m., revealed the policy and procedure did not include a process for the agency’s SNs to maintain current and accurate records of the disposition of all controlled substances provided by the agency to the patient. An interview was conducted on 02/12/2026 at 2:30 p.m. with S1ED. S1ED confirmed the Hospice agency was ultimately responsible for all controlled substances the Hospice agency provided to a patient, which included maintaining current and accurate records of the medications disposition. S1ED confirmed she expected SNs to perform a count of the medications present in the patient’s home during SNVs but did not expect it to be documented in the patient’s EHR. S1ED confirmed this was her personal expectation and to her knowledge not a requirement of their corporate office because their policies and procedures did not indicate they should. An interview was conducted on 02/18/2026 at 3:12 p.m. S3RD. S3RD confirmed the Hospice agency was ultimately responsible for all controlled substances the Hospice agency provided to a patient. S3RD confirmed the SN performing and documenting the count of remaining controlled substances during their SNVs was a best practice and he expected best practices to be implemented. S3RD confirmed the Hospice agency’s current policies and procedures did not include this as a requirement. 6. Patient #5Review of Patient #5’s Clinical Record revealed she was admitted to the agency on 03/12/2025 and was in a current Certification Period of 01/06/2026 through 03/06/2026 with active Physician Orders for Ativan, Morphine Concentrate and Tramadol. Further review revealed no documented evidence the SN performed a count of these controlled substances from 01/06/2026 through 02/11/2026. Patient #6Review of Patient #6’s Clinical Record revealed she was admitted to the agency on 01/07/2026 and was in a current Certification Period of 01/07/2026 through 04/06/2026 with active Physician Orders for Hydrocodone-Acetaminophen, Lorazepam, and Morphine Concentrate. Further review revealed no documented evidence the SN performed a count of these controlled substances from 01/07/2026 through 02/11/2026.An observation and interview was conducted on 02/09/2026 at 3:09 p.m. during Patient #6’s Home Visit with S5RN. S5RN asked the family if they required any medication refills and did not visualize or perform a count of Patient #6’s controlled substances present in the home. Patient #7Review of Patient #7’s Clinical Record revealed she was admitted to the agency on 08/27/2025 and was in a current Certification Period of 12/23/2025 through 02/20/2026 with active Physician Orders for Lorazepam and Morphine Concentrate. Further review revealed no documented evidence the SN performed a count of these controlled substances from 01/06/2026 through 02/10/2026.Patient #8Review of Patient #8’s Clinical Record revealed he was admitted to the agency on 12/12/2025 and was in a current Certification Period of 12/12/2025 through 03/11/2026 with active Physician Orders for Lorazepam, Morphine Concentrate, MS Contin, and Oxycodone-Acetaminophen. Further review revealed no documented evidence the SN performed a count of these controlled substances from 12/12/2025 through 02/11/2026.Patient #9Review of Patient #9’s Clinical Record revealed she was admitted to the agency on 10/08/2025 and was in a current Certification Period of 01/06/2026 through 04/05/2026 with active Physician’s Orders for Ativan, Lorazepam, and Morphine Concentrate. Further review revealed no documented evidence the SN performed a count of these controlled substances from 01/06/2026 through 02/11/2026Patient #10 Review of Patient #10’s Clinical Record revealed she was admitted to the agency on 12/03/2025 and was in a current Certification Period of 12/18/2025 through 03/17/2026 with active Physician’s Orders for Clonazepam, Lorazepam, MS Contin, and Temazepam. Further review revealed no documented evidence the SN performed a count of these controlled substances from 12/04/2025 through 02/10/2026Patient #11Review of Patient #11’s Clinical Record revealed he was admitted to the agency on 01/22/2026 and was in a current Certification Period of 01/22/2026 through 04/21/2026 with active Physician’s Orders for Hydromorphone, Lorazepam 0.5mg, Lorazepam 1mg, Morphine Concentrate, and MS Contin. Further review revealed no documented evidence the SN performed a count of these controlled substances from 01/22/2026 through 02/13/2026.Patient #12Review of Patient #12’s Clinical Record revealed she was admitted to the agency on 04/09/2024 and was in a current Certification Period of 01/29/2026 through 03/29/2026 with active Physician’s Orders for Lorazepam, Morphine Concentrate, and Oxycodone. Further review revealed no documented evidence the SN performed a count of these controlled substances from 01/29/2026 through 02/12/2026.Patient #13Review of Patient #13’s Clinical Record revealed he was admitted to the agency on 09/18/2025 and was in a current Certification Period of 12/17/2025 through 02/14/2026 with active Physician’s Orders for Lorazepam, Morphine Concentrate, and Temazepam. Further review revealed no documented evidence the SN performed a count of these controlled substances from 01/01/2026 through 02/12/2026.Patient #14Review of Patient #14’s Clinical Record revealed she was admitted to the agency on 01/13/2026 was in a current Certification Period of 01/13/2026 through 04/12/2026 with active Physician’s Orders for Lorazepam and Morphine Concentrate. Further review revealed no documented evidence the SN performed a count of these controlled substances from 01/13/2026 through 02/12/2026. An interview was conducted on 02/09/2026 at 3:09 p.m. with S5RN. S5RN confirmed she did not perform or document a count of the patient’s controlled substances during her SNVs and was not aware she should. An interview was conducted on 02/10/2026 at 2:22 p.m. with S2RN. S2RN confirmed she did not perform a count nor document a patient’s controlled substances during her SNVs and was not aware she should. An interview was conducted on 02/12/2026 at 2:30 p.m. with S1ED. S1ED reviewed the aforementioned visits for Patients #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14 and confirmed the Hospice agency could not account for the disposition of the controlled substances they provided them and should be able to.”

“Based on interviews and record reviews, the Hospice agency failed to have a system in place to ensure the competency of all individuals providing care on behalf of the agency at the required times. This deficient practice was evidenced by failure to perform and document a Competency Evaluation of all required Skills upon hire and annually thereafter for 5 (S2RN, S4HA, S5RN, S6LPN, and S7SW) of 8 personnel files reviewed. This deficient practice had the potential to affect a current census of 36 patients and any future admissions to the agency. Findings: S2RNReview of S2RN’s Personnel File revealed she was hired as an RN on 05/16/2025 and had provided SN services to the agency’s patients since that time. Review of S2RN’s Initial Competency Assessment Skills Checklist – RN, dated 02/03/2026, as of 02/18/2026 at 2:22 p.m., revealed, in part, no documented evidence to indicate S1ED performed a Competency Assessment of the required skills listed on the 12 page document prior to S2RN being allowed to provide SN services to patients. Further review revealed, in part, the following:Competency Evaluation Method: Blank for 100% of the skills listed. Competency Validation indicated by Initials/Date Performed: Blank for 100% of the skills listed. Supervisor Signature (12th page of document): S1ED’s signature, dated 02/03/2026. Review of any additional Competency Assessment Skills Checklist performed upon hire for S2RN prior to allowing her to provide SN services was attempted on 02/18/2026 at 2:20 p.m. and 3:00 p.m., with no documented evidence produced for review. S4HAReview of S4HA’s Personnel File revealed she was hired as a HA on 02/09/2021 and provided HA services to the agency’s patients since that time. Review of 4HA’s Competency Assessment Skills Checklist – HA for 2022, 2023, 2024, and 2025 were attempted on 02/18/2026 at 2:20 p.m. and again at 3:00 p.m. with no documented evidence produced for review. S5RNReview of S5RN’s Personnel File revealed she was hired as an RN on 07/31/2025 and had provided SN services to the agency’s patients since that time. Review of S5RN’s Initial Competency Assessment Skills Checklist – RN, dated 09/12/2025, as of 02/18/2026 at 2:22 p.m., revealed, in part, no documented evidence to indicate S1ED performed a Competency Assessment of the required skills listed on the 12 page document prior to S5RN being allowed to provide SN services to patients. Further review revealed, in part, the following: Competency Evaluation Method: Blank for 100% of the skills listed.Competency Validation indicated by Initials/Date Performed: Blank for 100% of the skills listed. Supervisor Signature (12th page of document): S1ED’s signature, dated 09/12/2025. Review of any additional Competency Assessment Skills Checklist performed upon hire for S5RN prior to allowing her to provide SN services was attempted on 02/18/2026 at 2:20 p.m. and 3:00 p.m., with no documented evidence produced for review. S6LPNReview of S6LPN’s Personnel File revealed she was hired as an LPN on 06/10/2024 and had provided SN services to the agency’s patients since that time. Review of S6LPN’s Initial Competency Assessment Skills Checklist – LPN, dated 06/20/2024 as of 02/18/2026 at 2:22 p.m., revealed, in part, no documented evidence to indicate S1ED performed a Competency Assessment of the required skills listed on the 8 page document prior to S6LPN being allowed to provide SN services to patients. Further review revealed, in part, the following:Competency Evaluation Method: Blank for 100% of the skills listed.Supervisor Signature (8th page of document): S1ED’s signature, dated 08/24/2024. Review of S6LPN’s Annual Competency Assessment Skills Checklist – LPN for 2025 was attempted on 02/18/2026 at 2:20 p.m. and again at 3:00 p.m., with no documented evidence produced for review. S7SWReview of S7SW’s Personnel File revealed she was hired as an LMSW on 05/25/2021 and had provided MSW services to the agency’s patients since that time. Review of S7SW’s Annual Competency Assessment Skills Checklist – MSW, dated 10/23/2025 as of 02/18/2026 at 2:22 p.m., revealed, in part, no documented evidence to indicate S1ED performed a Competency Assessment of the required skills listed on the 6 page checklist prior to S7SW being allowed to provide MSW services to patients. Further review revealed, in part, the following:Competency Evaluation Method: Blank for 100% of the skills listed.Supervisor Signature (6th page of document): S1ED’s signature, dated 10/23/2025. An interview was conducted on 02/18/2026 at 3:10 p.m. with S1ED. S1ED confirmed the agency was required to perform a Competency Evaluation for all individuals who provided care on behalf of the agency for all required skills prior to allowing them to provide services upon hire and annually thereafter; including the HA, LPN, MSW and RN. S1ED reviewed the aforementioned Personnel Files for S2RN, S4HA, S5RN, S6LPN and S7SW, and confirmed there was no documented evidence she performed their required Competency Evaluations immediately upon hire prior to allowing them to provide patient services and/or annually thereafter. An interview was conducted on 02/18/2026 at 3:15 p.m. with S3RD. S3RD confirmed the aforementioned personnel files did not contain sufficient documented evidence to indicate S1ED ensured their required Competency Evaluations were completed at the required intervals and should. S3RD confirmed the method of evaluation utilized and the preceptor’s initials and date performed were required next to each of the required skills in order for the Competency Assessment to be valid. S3RD confirmed he would expect S1ED to ensure the competency of all required skills prior to allowing any individual to provide services on behalf of the agency.”

“Based on interviews and record review, the Hospice agency failed to have a system in place to ensure a patient’s Clinical Record contained their most recent Advance Directive(s) in a location accessible by the patient’s attending physician and/or all agency staff. This deficient practice was evidenced by failure to ensure the agency obtained and/or maintained: 1. The patient’s most recent Advanced Medical Directive (LaPOST) within the patient’s EHR for 3 (#4, #5, and #12) of 12 patients in the sample; and 2. The patient’s Healthcare Power of Attorney (HCPOA) within the patient’s EHR for 7 (#5, #6, #8, #9, #11, #12, and #13) of 12 patients in the sample. This deficient practice had the potential to affect a current census of 36 patients, any future patients admitted to the agency, and any future patient deaths. Findings: Review of the undated publication by the state’s Governor’s Office of Elderly Affairs titled Planning for Incapacity - Advance Directive Forms for Louisiana, revealed, in part, the following: A competent adult can communicate preferences about future medical treatment through a legal document called an Advance Directive. What are three types of Advance Directives? In Louisiana, there are three types of advance care planning documents available. These include the HCPOA, the living will, and the LaPOST document.Review of the agency’s Advance Directives Policy and Procedure, revised 10/2016, as of 02/12/2026, revealed, in part, the following: Policy: The agency recognizes that all adults have the fundamental right to make decisions related to their own medical treatment, including the right to accept or refuse medical care. Valid Advance Directives, such as Living Wills, HCPOA, and LaPOST orders will be followed to the extent permitted and required by law. Definitions: 2. Advance Directive: A document in which a person states choices for medical treatment. Procedure: 4. During the admission/evaluation visit, the admitting clinician will ask the patient whether or not he/she has completed an Advance Directive, HCPOA, or LaPOST order. If an Advance Directive has been completed, the admitting clinician will ask for a copy so it may be placed in the Clinical Record. If a copy is not immediately available, the patient will be informed that it is his/her responsibility to provide a copy of the Advance Directive to the agency as soon as possible. 9. All clinicians providing care for the patient will: A. Review the Advance Directive and report any discrepancies between the Directive and current treatment plan. An interview was conducted on 02/09/2026 at 9:30 a.m. with S1ED. S1ED confirmed the agency utilized an EHR for all Clinical Records and did not maintain paper Clinical Records in their office. 1. The patient’s most recent Advanced Medical Directive (LaPOST) within the patient’s EHR. Patient #4Review of Patient #4’s Clinical Record revealed he was admitted to the agency on 01/17/2025 with a terminal diagnosis of Alzheimer’s disease and was in a Certification Period of 01/17/2025 through 03/04/2025 at the time of his death on 03/04/2025. Further review revealed Patient #4 was not cognitive during his time with the agency. Review of Patient #4’s Patient Information - Clinical Details revealed Code Status: DNR as of 02/18/2026 at 12:00 p.m.Review of Patient #4’s EHR revealed an Advanced Medical Directive from the VA indicating Code Status: Full Code, which was scanned into his chart upon his admission on 01/17/2025. An interview was conducted on 02/18/2026 at 12:18 p.m. with S1ED. S1ED confirmed the only Advance Directive present in Patient #4’s EHR indicated Full Code Status, which did not match the patient/family’s current wishes. S1ED provided a printed copy of an LaPOST completed on 01/17/2026 which indicated DNR and confirmed she located his most recent Advance Directive in a paper “to be scanned” file located in the agency’s office. S1ED confirmed only she and the agency’s Office Manager had access to the file and their office hours were Monday through Friday from 8:00 a.m. to 4:30 p.m. S1ED confirmed if a patient’s Advance Directive was located in an paper file at the agency’s office and not present in their EHR, it was not accessible to their attending physician and/or all Hospice staff and should be. S1ED confirmed Patient #4’s most recent LaPOST was not in his EHR and should have been. Patient #5Review of Patient #5’s Clinical Record revealed she was admitted to the agency on 03/12/2025 with a terminal diagnosis of Senile Degeneration of the Brain. and was in a current Certification Period of 01/06/2026 through 03/06/2026. Further review revealed Patient #5 was not cognitive. Review of Patient #5’s Initial MSW Visit, dated 03/14/2025, revealed she had a DNR in place. Review of Patient #5’s EHR revealed no documented evidence of a LaPOST available for review on 02/11/2026 at 11:55 a.m., 1:45 p.m., and 2:15 p.m., then again on 02/12/2026 at 9:00 a.m.A request was made to S1ED for Patient #5’s LaPOST on 02/11/2026 at 11:55 a.m., 1:45 p.m., and 2:15 p.m., then again on 02/12/2026 at 9:00 a.m.An interview was conducted on 02/12/2026 at 2:50 p.m. with S1ED. S1ED provided a printed copy of Patient #5’s LaPOST at this time and confirmed it was not located in her EHR or the agency’s paper files, and should have been. S1ED confirmed the document was sent to her by Patient #5’s SN via electronic message when she was admitted to the agency, but was never added into the patient’s EHR. S1ED confirmed Patient #9’s LaPOST was not in her EHR and should have been. Patient #12Review of Patient #12’s Clinical Record revealed she was admitted to the agency on 04/09/2024 with a terminal diagnosis of Malignant Neoplasm of Pancreas. and was in a current Certification Period of 01/29/2026 through 03/29/2026. Review of Patient #12’s Initial MSW Visit, dated 04/12/2024, revealed, she had a DNR in place. Review of Patient #12’s Initial RN Assessment, dated 04/10/2024, revealed, patient opted for DNR status. Review of Patient #12’s EHR revealed no documented evidence of a LaPOST available for review on 02/12/2026 at 9:48 a.m.A request was made to S1ED for Patient #12’s LaPOST on 02/12/2026 at 9:20 a.m. and again at 10:30 a.m.An interview was conducted on 02/12/2026 at 11:09 a.m. with S1ED. S1ED provided a printed copy of Patient #12’s LaPOST and confirmed she located it in the paper “to be scanned” file located in the agency’s office. S1ED confirmed Patient #12’s LaPOST was not in her EHR and should have been. 2. The patient’s Healthcare Power of Attorney (HCPOA) within the patient’s EHR. Patient #5Review of Patient #5’s Clinical Record revealed she was admitted to the agency on 03/12/2025 with a terminal diagnosis of Senile Degeneration of the Brain. and was in a current Certification Period of 01/06/2026 through 03/06/2026. Further review revealed Patient #5 was not cognitive. Review of Patient #5’s Initial MSW Visit, dated 03/14/2025, revealed she had a HCPOA in place. Review of Patient #5’s Patient Information – Contact Information revealed Patient #5’s daughter was not indicated as being her legal representative as of 02/11/2026 at 1:30 p.m.Review of Patient #5’s EHR revealed no documented evidence of an HCPOA available for review on 02/11/2026 at 11:55 a.m., 1:45 p.m., and 2:15 p.m. then again on 02/12/2026 at 9:00 a.m.A request was made to S1ED for Patient #5’s HCPOA on 02/11/2026 at 11:55 a.m., 1:45 p.m., and 2:15 p.m. then again on 02/12/2026 at 9:00 a.m., with the document not provided for review prior to exit of the survey on 02/18/2026 at 5:00 p.m. An interview was conducted on 02/12/2026 at 9:10 a.m. with S1ED. S1ED confirmed the agency did not obtain a copy of Patient #5’s HCPOA upon admission or thereafter and should have. Patient #6Review of Patient #6’s Clinical Record revealed she was admitted to the agency on 01/07/2026 with a terminal diagnosis of Senile Degeneration of the Brain and was in a current Certification Period of 01/07/2026 through 04/06/2026. Further review revealed Patient #6 was not cognitive.Review of Patient #6’s Patient Information – Contact Information revealed Patient #6’s son was her legal representative as of 02/10/2026 at 12:00 p.m.Review of Patient #6’s EHR revealed no documented evidence of a HCPOA available for review on 02/11/2026 at 11:55 a.m., 1:45 p.m., and 2:15 p.m. then again on 02/12/2026 at 9:00 a.m.A request was made to S1ED for Patient #6’s HCPOA on 02/10/2026 at 11:55 a.m., 12:00p.m., 12:30 p.m., 1:20 p.m., 2:30 p.m., 4:30 p.m., and again on 02/11/2026 at 8:35 a.m. and 11:00 a.m. An interview was conducted on 02/10/2026 at 1:41 p.m. with S7MSW. S7MS confirmed the agency did not have a copy of Patient #6’s HCPOA.An interview was conducted on 02/11/2026 at 8:45 a.m. with S1ED. S1ED confirmed Patient #6’s son was her HCPOA and made all decisions for her medical care. S1ED confirmed she could not provide a copy of Patient #6’s HCPOA because the agency did not obtain a copy of her it upon admission or thereafter and should have. S1ED confirmed the Hospice agency had “taken the son’s word for it” when he informed the agency he was her legal HCPOA and should not have. Patient #8Review of Patient #8’s Clinical Record revealed he was admitted to the agency on 12/12/2025 with a terminal diagnosis of Malignant Melanoma of Skin and was in a current Certification Period of 12/12/2025 through 03/11/2026. Review of Patient #8’s Patient Information – Contact Information revealed Patient #8’s daughter was not indicated as being his legal representative as of 02/11/2026 at 2:55 p.m.Review of Patient #8’s Initial MSW Visit, dated 12/12/2025, revealed he had a HCPOA in place. Review of Patient #8’s EHR revealed no documented evidence of a HCPOA available for review on 02/10/2026 at 3:00 p.m.A request was made to S1ED for Patient #8’s HCPOA on 02/11/2026 at 3:30p.m.with the document not provided for review prior to exit of the survey on 02/18/2026 at 5:00 p.m.An interview was conducted on 02/11/2026 at 2:05 p.m. with Patient # 8’s daughter. She confirmed she was her father’s HCPOA and had been since prior to his admission to the Hospice agency. She confirmed he was no longer cognitive and she was responsible for making all of his care decisions. She confirmed she participated in all of her father’s Hospice admission and neither the SN or MSW asked for a copy of his HCPOA. She confirmed no one from the Hospice agency had asked for a copy of his HCPOA since he was admitted in December. An interview was conducted on 02/12/2026 at 10:45 a.m. with S1ED. S1ED confirmed the agency had not obtained a copy of Patient #8’s HCPOA upon admission and should have. S1ED confirmed Patient #8’s HCPOA was not in his EHR and should have been. Patient #9Review of Patient #9’s Clinical Record revealed she was admitted to the agency on 10/08/2025 with a terminal diagnosis of Senile Degeneration of the Brain and was in a current Certification Period of 01/06/2026 through 04/05/2026. Further review revealed Patient #9 was not cognitive.Review of Patient #9’s Patient Information – Contact Information revealed Patient #9’s daughter was not indicated as being her legal representative as of 02/11/2026 at 1:30 p.m.Review of Patient #9’s LaPOST, dated 10/08/2025, revealed it was completed and signed by her Daughter and indicated she was the patient’s HCPOA. Review of Patient #9’s Initial MSW Visit, dated 10/10/2025, revealed she had a HCPOA in place. Review of Patient #9’s EHR revealed no documented evidence of a HCPOA available for review on 02/11/2026 at 1:45 p.m.A request was made to S1ED for Patient #9’s HCPOA on 02/11/2026 at 1:45 p.m. and again at 2:15 p.m.An interview was conducted on 02/11/2026 at 2:50 p.m. with S1ED. S1ED provided a printed copy of Patient #9’s HCPOA at this time and confirmed she printed it from her email. S1ED confirmed the document was sent to her by Patient #9’s SN via email when she was admitted to the agency, but it was never added into the patient’s EHR. S1ED confirmed Patient #9’s HCPOA was not in his EHR and should have been. Patient #11Review of Patient #11’s Clinical Record revealed he was admitted to the agency on 01/22/2026 with a terminal diagnosis of Malignant Neoplasm of Nasopharynx and was in a current Certification Period of 01/22/2026 through 04/21/2026. Further review revealed Patient #11 was not cognitive.Review of Patient #11’s Patient Information – Contact Information revealed Patient #11’s daughter was indicated as being his legal representative.Review of Patient #11’s Initial MSW Visit, dated 01/26/2026, revealed he had a HCPOA in place. Review of Patient #11’s EHR revealed no documented evidence of a HCPOA available for review on 02/12/2026 at 9:15 a.m. A request was made to S1ED for Patient #11’s aforementioned HCPOA on 02/12/2026 at 9:20 a.m. and again at 10:30 a.m., with the document not provided for review prior to exit of the survey on 02/18/2026 at 5:00 p.m.An interview was conducted on 02/12/2026 at 10:45 a.m. with S1ED. S1ED confirmed she could not provide a copy of Patient #11’s HCPOA for review because it had not been obtained since his admission to the agency and should have been. S1ED confirmed the agency had “taken the family’s word for it” when they informed the agency his daughter was the legal HCPOA. Patient #12Review of Patient #12’s Clinical Record revealed she was admitted to the agency on 04/09/2024 with a terminal diagnosis of Malignant Neoplasm of Pancreas and was in a current Certification Period of 01/29/2026 through 03/29/2026. Review of Patient #12’s Patient Information – Contact Information revealed no contacts were identified as her legal representative as of 02/12/2026 at 10:38 a.m.Review of Patient #12’s Initial MSW Visit, dated 04/12/2024, revealed she had a HCPOA in place. Review of Patient #12’s EHR revealed no documented evidence of a HCPOA available for review on 02/12/2026 at 9:48 a.m.A request was made to S1ED for Patient #12’s aforementioned HCPOA on 02/12/2026 at 9:20 a.m. and again at 10:30 a.m., with the document not provided prior to exit of the survey on 02/18/2026 at 5:00 p.m.An interview was conducted on 02/12/2026 at 11:09 a.m. with S1ED. S1ED confirmed she could not provide a copy of Patient #12’s HCPOA for review because it was not obtained upon admission or thereafter and should have been. Patient #13Review of Patient #13’s Clinical Record revealed he was admitted to the agency on 09/18/2025 with a terminal diagnosis of Interstitial Pulmonary Disease and was in a current Certification Period of 12/17/2025 through 02/14/2026. Review of Patient #13’s Patient Information – Contact Information revealed no contacts were identified as his legal representative as of 02/12/2026 at 11:47 a.m.Review of Patient #13’s Initial MSW Visit, dated 09/19/2025, revealed he had a HCPOA in place.Review of Patient #13’s EHR revealed no documented evidence of a HCPOA available for review on 02/12/2026 at 11:56 a.m.A request was made to S1ED for Patient #13’s aforementioned HCPOA on 02/12/2026 at 12:00 p.m. and again at 12:55 p.m., with the document not provided for review prior to exit of the survey on 02/18/2026 at 5:00 p.m.An interview was conducted on 02/12/2026 at 12:59 p.m. with S1ED. S1ED confirmed she could not provide a copy of Patient #13’s HCPOA for review because it was not obtained upon admission or thereafter and should have been. S1ED confirmed an Advance Directive was a legal document and upon a patient’s admission, she expected the SN and MSW to inquire whether any Advance Directives may exist and document its presence accordingly in the EHR. S1ED confirmed if the agency was not provided with a copy of an Advance Directive, the agency would take the patient/family’s “word for it”. S1ED confirmed the agency had not consistently obtained a copy of all Advance Directives to be added to the patient’s EHR and should have. S1ED confirmed the agency had not ensured all Advance Directives provided to them by a patient/family were added to the patient’s EHR and should have.”

“Based on interview and record reviews, the Hospice agency failed to have a system in place to ensure each patient’s Clinical Record contained Physician’s Orders for Wound Care for 2 (#6 and #8) of 2 patients reviewed for wound care orders. This deficient practice had the potential to affect any of the 5 wounds currently being treated by the agency and any future wounds which would require treatment by the agency. Findings: An interview was conducted on 02/09/2026 at 9:30 a.m. with S1ED. S1ED confirmed the agency utilized an EHR for all Clinical Records and did not maintain paper Clinical Records in their office. Patient #6Review of Patient #6’s Clinical Record revealed she was admitted to the agency on 01/07/2026 and was in a current Certification Period of 01/07/2026 through 04/06/2026. Further review revealed she was currently receiving treatment for a Stage 4 Pressure Ulcer to her Sacrum and a Stage 2 Pressure Ulcer to the Left Shin. Review of Patient #6’s POC and Physician’s Orders from her admission through 02/10/2026 was conducted on 02/10/2026 at 12:40 p.m. with no active physician orders for wound care which specified the type of ointment or bandage to be used for wound care.Patient #8Review of Patient #8’s Clinical Record revealed he was admitted to the agency on 12/12/2025 and was in a current Certification Period of 12/12/2025 through 03/11/2026. Further review revealed he was receiving treatment for a Stage 3 Pressure Ulcer to the Right Lower Buttock/Sacrum.Review of Patient #8’s POC and Physician Orders from his admission through 02/11/2026 was conducted on 02/11/2026 at 12:27 p.m. with no active physician orders for wound care which specified the type of ointment or bandage to be used for wound care.An interview was conducted on 02/11/2026 at 3:15 p.m. with S1ED. S1ED reviewed Patient #6 and #8’s Physician Orders for wound care and confirmed there were no active orders which contained the specific type of ointment to be used and/or what type of dressing should be applied to cover the wound and they should have.”

“Based on observation, interviews and record review, the Hospice agency failed to have a system in place to ensure the safe use, management and disposal of controlled substances in the patient’s home in accordance with all applicable laws, regulations and accepted standards of practice. This deficient practice was evidenced by the agency’s failure to: 1. Ensure the SN documented the presence of a witness when completing the final count of all remaining controlled substances immediately following a patient’s death for 2 ( #3 and #4) of 2 death records reviewed; 2. Ensure the SN documented the final count of all remaining controlled substances immediately following a patient’s death for 1 of 2 (#4) death records reviewed; 3. Establish a written policy and procedure in accordance with accepted standards of practice to maintain current and accurate records of the disposition of all controlled substances provided by the Hospice agency to the patient for 10 of 10 (#5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) live patients in the sample; and 4. Ensure current and accurate records were maintained of the disposition of all controlled substances provided by the Hospice agency to the patient for 10 of 10 (#5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) live patients in the sample. This deficient practice had the potential to affect a current census of 36 patients, any future patients admitted to the agency and any future patient deaths. Findings: An interview was conducted on 02/09/2026 at 9:30 a.m. with S1ED. S1ED confirmed the agency utilized an EHR for all Clinical Records and did not maintain paper Clinical Records in their office. 1. SN documented the presence of a witness during the final count of controlled substances following a patient’s death. Review of the state’s RS 40:2191 revealed the following, in part: Disposal of deceased patient’s unused controlled substances:(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.Review of the Hospice agency’s Death at Home and Within a Contracted Facility’s Policy, revised 01/26/2026, as of 02/18/2026 at 10:45 a.m., revealed, in part, the following: Policy: Individual state and community regulations and practices will be followed. NOTE: Hospice should check specific state law regarding death at home and adapt this policy to meet state law/statue.Procedure: 9. The nurse will dispose of all medications, including controlled substances, per federal, state, local regulations and organizational policy. (See Home Use and Disposal of Controlled Substances Policy.)Review of the Hospice agency’s Home Use and Disposal of Controlled Substances Policy, revised 03/28/2023, as of 02/18/2026 at 10:45 a.m., revealed, in part, the following: Procedure: 2. Medication management and disposal policies include: Disposal of controlled substances: Upon death of a patient receiving Hospice services, in the presence of a witness, the SN shall record in the medical record the name and quantity of each unused controlled substance. Patient #3Review of Patient #3’s Clinical Record revealed she was admitted to the agency on 04/08/2025 and was in a current Certification Period of 04/08/2025 through 04/17/2025 at the time of her death on 04/17/2025. Review of Patient #3’s active Physician Orders at the time of her death revealed the patient was prescribed the following controlled substances:Lorazepam 2mg/mL Oral Concentrate; andMorphine Concentrate 20mg/mL. Review of Patient #3’s Death Visit Note, revealed, in part, the following: Date/Time of Death: 04/17/2025 at 2:54 p.m.Lorazepam 0.5mg tablets – 60 tablets; and Morphine Concentrate 20gm/mL - 23.5mL. Further review revealed no documented evidence a witness was present during the SN’s final count of the aforementioned controlled substances following Patient #3’s death.Review of Patient #3’s Clinical Record revealed no documented evidence of a witness being present during the SN’s final count of the controlled substances Lorazepam and Morphine, following her death.Patient #4Review of Patient #4’s Clinical Record revealed he was admitted to the agency on 01/17/2025 and was in a current Certification Period of 01/17/2025 through 03/04/2025 at the time of his death on 03/04/2025. Review of Patient #4’s active Physician Orders at the time of her death revealed the patient was prescribed the following controlled substances:Ativan 0.5mg tablet; and Morphine Concentrate 20mg/mL. Review of Patient #4’s Death Visit Note revealed, in part, the following: Date/Time of Death: 03/04/2025 at 9:49 p.m.Further review revealed no documented evidence of the presence of a witness when completing the final count of all remaining controlled substances immediately following a patient’s deathReview of Patient #4’s Clinical Record revealed no documented evidence of the presence of a witness when completing the final count of the controlled substances, Ativan and Morphine, following his death.An interview was conducted on 02/18/2026 at 3:10 p.m. S1ED. S1ED reviewed Patient #3 and Patient #4’s Death Visit Note and confirmed neither contained documented evidence a witness was present for the SN’s final count of the controlled substances following each patient’s death and should. 2. SN documented the final count of controlled substances following a patient’s death. Patient #4Review of Patient #4’s Clinical Record revealed he was admitted to the agency on 01/17/2025 and was in a current Certification Period of 01/17/2025 through 03/04/2025 at the time of his death on 03/04/2025. Review of Patient #4’s active Physician Orders at the time of her death revealed the patient was prescribed the following controlled substances:Ativan 0.5mg tablet; and Morphine Concentrate 20mg/mL. Review of Patient #4’s Death Visit Note revealed, in part, the following: Date/Time of Death: 03/04/2025 at 9:49 p.m.Further review revealed no documented evidence the SN completed a final count of all remaining controlled substances immediately following a patient’s deathReview of Patient #4’s Clinical Record revealed no documented evidence of the SN performing a final count of the controlled substances, Ativan and Morphine, following his death.An interview was conducted on 02/18/2026 at 3:10 p.m. S1ED. S1ED reviewed Patient #4’s Death Visit Note and confirmed it did not contain documented evidence of the SN’s final count of the controlled substances following death and should. An interview was conducted on 02/18/2026 at 3:12 p.m. S3RD. S3RD confirmed the agency’s SN were responsible for meeting the requirements regarding a count of remaining controlled substances following a patient’s death. 3. Written policy and procedure to maintain current and accurate records of the disposition of controlled substances provided to the patient.Review of the Hospice agency’s Home Use and Disposal of Controlled Substances Policy, revised 03/28/2023, as of 02/18/2026 at 10:45 a.m., revealed the policy and procedure did not include a process for the agency’s SNs to maintain current and accurate records of the disposition of all controlled substances provided by the agency to the patient. An interview was conducted on 02/12/2026 at 2:30 p.m. with S1ED. S1ED confirmed the agency’s policies and procedures did not require SNs to perform and/or document a current count of all controlled substances present in the patient’s home during SNVs. S1ED confirmed without requiring the remaining count of controlled substances to be documented in the patient’s clinical record, the agency was not maintaining current and accurate records of the disposition of all controlled substances the agency provided to the patient.4. Current and accurate records of the disposition of controlled substances provided to the patient.Patient #5Review of Patient #5’s Clinical Record revealed she was admitted to the agency on 03/12/2025 and was in a current Certification Period of 01/06/2026 through 03/06/2026. Review of Patient #5’s POC and Physician Orders for the current Certification Period revealed the following orders for controlled substances: 03/13/2025 – Ativan 0.5mg tablet. Give 1 tablet every 6 hours PRN for agitation; 03/13/2025 – Morphine Concentrate 20mg/mL. Give 0.5mL by mouth every 3 hours PRN for pain, shortness of breath or anxiety; and03/13/2025 – Tramadol 50mg tablet. Give 1 tablet every 6 hours PRN for pain. Review of Patient #5’s SNVs conducted from 01/06/2026 through 02/11/2026 revealed no documented evidence of a count of the aforementioned controlled substances being performed and/or documented by the SN during any of the following SNVs:01/08/2026; 01/16/2026;01/20/2026; 01/23/2026;01/30/2026;02/02/2026;02/06/2026; and 02/09/2026.Review of Patient #5’s Clinical Record, as of 02/11/2026, revealed no documented evidence to indicate a count of the aforementioned controlled substances was performed and/or documented by the SN from 01/06/2026 through 02/11/2026.Patient #6Review of Patient #6’s Clinical Record revealed she was admitted to the agency on 01/07/2026 and was in a current Certification Period of 01/07/2026 through 04/06/2026. Review of Patient #6’s POC and Physician Orders for the current Certification Period revealed the following orders for controlled substances: 01/21/2026 – Hydrocodone-Acetaminophen 5-325mg. Give 1 tablet three times daily PRN for pain;01/07/2026 – Lorazepam 1mg tablet. Give 1 tablet every 4 hours as needed for anxiety or agitation; and 01/07/2026 - Morphine Concentrate 20mg/mL. Give 0.5mL by mouth every 2 hours PRN for pain or shortness of breath.Review of Patient #6’s SNVs conducted from 01/07/2026 through 02/11/2026 revealed no documented evidence of a count of the aforementioned controlled substances being performed and/or documented by the SN during any of the following SNVs:01/07/2026;01/08/2026;01/13/2026;01/15/2026;01/19/2026; 01/20/2026;01/21/2026;01/22/2026;01/23/2026;01/24/2026;01/26/2026;01/28/2026; 01/30/2026;02/02/2026;02/04/2026;02/06/2026; and 02/09/2026.Review of Patient #6’s Clinical Record, as of 02/11/2026 revealed no documented evidence to indicate a count of the aforementioned controlled substances was performed and/or documented by the SN from 01/07/2026 through 02/11/2026.An observation and interview was conducted on 02/09/2026 at 3:09 p.m. during Patient #6’s Home Visit with S5RN. S5RN was observed to ask the family if they required any medication refills and did not visualize or perform a count of Patient #6’s controlled substances present in the home. S5RN confirmed she did not perform or document a count of the patient’s controlled substances during her SNVs and was not aware she should. Patient #7Review of Patient #7’s Clinical Record revealed she was admitted to the agency on 08/27/2025 and was in a current Certification Period of 12/23/2025 through 02/20/2026. Review of Patient #7’s POC and Physician Orders for the current Certification Period revealed the following orders for controlled substances: 08/28/2025 - Lorazepam 0.5mg tablet. Give 1 tablet every 6 hours PRN for anxiety; and06/25/2025 - Morphine Concentrate 100mg/5mL. Give 0.25mL every 3 hours PRN for shortness of breath.Review of Patient #7’s SNVs conducted from 01/06/2026 through 02/10/2026 revealed no documented evidence of a count of the aforementioned controlled substances being performed and/or documented by the SN during any of the following SNVs: 01/06/2026; 01/09/2026;01/14/2026; 01/16/2026; 01/21/2026;01/23/2026; 01/30/2026;02/02/2026;02/06/2026; and 02/10/2026.Review of Patient #7’s Clinical Record, as of 02/11/2026, revealed no documented evidence to indicate a count of the aforementioned controlled substances was performed and/or documented by the SN from 01/06/2026 through 02/10/2026.Patient #8Review of Patient #8’s Clinical Record revealed he was admitted to the agency on 12/12/2025 and was in a current Certification Period of 12/12/2025 through 03/11/2026. Review of Patient #8’s POC and Physician Orders for the current Certification Period revealed the following orders for controlled substances: 12/12/2025 - Lorazepam 1 mg tablet by mouth every 4 hours as needed for anxiety; 12/12/2025 - Morphine Concentrate 20 mg/mL. Give 0.5mL every 2 hours PRN for pain; 12/12/2025 - MS Contin 15 mg tablet. Give 1 tablet every 6 hours for pain; and12/12/2025 - Oxycodone-Acetaminophen 10-325mg. Give 1 tablet every 4 hours PRN for pain.Review of Patient #8’s SNVs conducted from 12/12/2025 through 02/11/2026 revealed no documented evidence of a count of the aforementioned controlled substances being performed and/or documented by the SN during any of the following SNVs: 12/15/2025;12/18/2025;01/08/2026;01/12/2026; 01/15/2026;01/19/2026;01/22/2026;01/27/2026;02/05/2026; and 02/09/2026. Review of Patient #8’s Clinical Record, as of 02/11/2026, revealed no documented evidence to indicate a count of the aforementioned controlled substances was performed and/or documented by the SN from 12/12/2025 through 02/11/2026.Patient #9Review of Patient #9’s Clinical Record revealed she was admitted to the agency on 10/08/2025 and was in a current Certification Period of 01/06/2026 through 04/05/2026. Review of Patient #9’s POC and Physician Orders for the current Certification Period revealed the following orders for controlled substances: 01/26/2026 – Ativan 1mg tablet. Give 1 tablet twice daily for anxiety and restlessness;10/08/2025 – Lorazepam 0.5mg tablet. Give 1 tablet every 4 hours as needed for anxiety and agitation; and 10/08/2025 - Morphine Concentrate 20mg/mL. Give 0.5mL by mouth every 2 hours PRN for pain or shortness of breath,Review of Patient #9’s SNVs conducted from 01/06/2026 through 02/11/2026 revealed no documented evidence of a count of the aforementioned controlled substances being performed and/or documented by the SN during any of the following SNVs: 01/08/2026;01/09/2026;01/16/2026; 01/19/2026;01/23/2026; 01/27/2026;01/29/2026; 02/02/2026;02/05/2026; and02/09/2026.Review of Patient #9’s Clinical Record, paper and electronic, as of 02/11/2026, revealed no documented evidence to indicate a count of the aforementioned controlled substances was performed and/or documented by the SN from 01/06/2026 through 02/11/2026.Patient #10 Review of Patient #10’s Clinical Record revealed she was admitted to the agency on 12/03/2025 and was in a current Certification Period of 12/18/2025 through 03/17/2026. Review of Patient #10’s POC and Physician Orders for the current Certification Period revealed the following orders for controlled substances: 12/03/2025 - Clonazepam 0.5mg. Give 1 tablet every evening; 12/03/2025 - Lorazepam 0.5mg. Give 1 tablet every 4 hours PRN for anxiety; 12/03/2025 - MS Contin 15mg. Give 1 tablet twice daily; and12/03/2025 - Temazepam 15mg. Give 1 tablet every evening. Review of Patient #10’s SNVs conducted from 12/04/2025 through 02/10/2026, revealed no documented evidence of a count of the aforementioned controlled substances being performed and/or documented by the SN during any of the following SNVs: 12/04/2025;12/09/2025;12/11/2025;12/15/2025; 12/16/2025;12/18/202512/26/202512/29/2025;01/02/2026;01/05/2026;01/08/2026; 01/13/2026; 01/15/2026; 01/20/2026; 01/22/2026; 01/26/2026; 02/05/2026; and02/10/2026. Review of Patient #10’s Clinical Record, as of 02/12/2026, revealed no documented evidence to indicate a count of the aforementioned controlled substances was performed and/or documented by the SN from 12/04/2025 through 02/10/2026.Patient #11Review of Patient #11’s Clinical Record revealed he was admitted to the agency on 01/22/2026 and was in a current Certification Period of 01/22/2026 through 04/21/2026. Review of Patient #11’s POC and Physician Orders for the current Certification Period revealed the following orders for controlled substances: 02/03/2026 – Hydromorphone 4mg tablet. Give 1 tablet every 4 hours PRN for pain; 02/03/2026 – Hydromorphone 4mg tablet. Give 1 tablet every 4 hours PRN for pain; 01/22/2026 – Lorazepam 0.5mg tablet. Give 1 tablet every 4 hours PRN for anxiety or agitation; 02/13/2026 – Lorazepam 1mg tablet. Give 1 tablet every 4 hours for anxiety or agitation;02/13/2026 - Morphine Concentrate 20mg/mL. Give 1mL by mouth every 2 hours PRN for pain or shortness of breath; and 01/22/2026 – MS Contin 30mg tablet. Give 1 tablet twice daily for pain. Review of Patient #11’s SNVs conducted from 01/22/2026 through 02/13/2026, revealed no documented evidence of a count of the aforementioned controlled substances being performed and/or documented by the SN during any of the following SNVs: 01/22/2026;01/23/2026;01/27/2026;01/29/2026;02/03/2026;02/06/2026;02/10/2026; and 02/11/2026.Review of Patient #11’s Clinical Record, as of 02/18/2026, revealed no documented evidence to indicate a count of the aforementioned controlled substances was performed and/or documented by the SN from 01/22/2026 through 02/13/2026.Patient #12Review of Patient #12’s Clinical Record revealed she was admitted to the agency on 04/09/2024 and was in a current Certification Period of 01/29/2026 through 03/29/2026. Review of Patient #12’s POC and Physician Orders for the current Certification Period revealed, in part, the following orders for controlled substances: 04/10/2024 – Lorazepam 0.5mg tablet. 1 tablet every 4 hours PRN for agitation or anxiety;01/15/2026 – Morphine Concentrate 20mg/1mL. Give 1mL 3 hours PRN for breakthrough pain; and 01/15/2026 – Oxycodone 30mg tablet. Give 2 tablets every 4 hours PRN for pain.Review of Patient #12’s SNVs conducted from 01/29/2026 through 02/12/2026, revealed no documented evidence of a count of the aforementioned controlled substances being performed and/or documented by the SN during any of the following SNVs:01/29/2026;02/06/2026; and 02/12/2026.Review of Patient #12’s Clinical Record, as of 02/12/2026, revealed no documented evidence to indicate a count of the aforementioned controlled substances was performed and/or documented by the SN from 01/29/2026 through 02/12/2026.Patient #13Review of Patient #13’s Clinical Record revealed he was admitted to the agency on 09/18/2025 and was in a current Certification Period of 12/17/2025 through 02/14/2026. Review of Patient #13’s POC and Physician Orders for the current Certification Period revealed the following orders for controlled substances: 09/05/2025 – Lorazepam 0.5mg tablet. Give 1 tablet every 4 hours PRN agitation/anxiety;09/05/2025 – Morphine Concentrate 20mg/1mL. Give 0.5mL every 3 hours PRN for pain/dyspnea; and10/07/2025 – Temazepam 15mg capsule. Give 1 capsule at bedtime for insomnia.Review of Patient #13’s SNVs conducted from 01/01/2026 through 02/12/2026, revealed no documented evidence of a count of the aforementioned controlled substances being performed and/or documented by the SN during any of the following SNVs: 01/02/2026;01/05/2026;01/08/2026;01/12/2026;01/14/2026;01/15/2026;01/19/2026;01/21/2026;01/23/2026;01/26/2026;01/30/2026;02/02/2026;02/05/2026; and02/09/2026.Review of Patient #13’s Clinical Record, as of 02/12/2026, revealed no documented evidence to indicate a count of the aforementioned controlled substances was performed and/or documented by the SN from 01/01/2026 through 02/12/2026.Patient #14Review of Patient #14’s Clinical Record revealed she was admitted to the agency on 01/13/2026 was in a current Certification Period of 01/13/2026 through 04/12/2026. Review of Patient #14’s POC and Physician Orders for the current Certification Period revealed the following orders for controlled substances: 01/13/2026 – Lorazepam 1mg tablet. Give 1 tablet every 4 hours PRN for agitation/anxiety; and 01/13/2026 – Morphine Concentrate 20mg/1mL. Give 0.5mL every 3 hours PRN for pain/dyspnea.Review of Patient #14s SNVs conducted from 01/13/2026 through 02/12/2026, revealed no documented evidence of a count of the aforementioned controlled substances being performed and/or documented by the SN during any of the following SNVs: 01/13/2026;01/16/2026;01/20/2026;01/22/2026;01/26/2026;01/29/2026;02/03/2026;02/05/2026; and 02/10/2026.Review of Patient #14’s Clinical Record, as of 02/12/2026, revealed no documented evidence to indicate a count of the aforementioned controlled substances was performed and/or documented by the SN from 01/13/2026 through 02/12/2026.An interview was conducted on 02/10/2026 at 2:22 p.m. with S2RN. S2RN confirmed she did not perform a count nor document a patient’s controlled substances during her SNVs and was not aware she should. An interview was conducted on 02/12/2026 at 2:30 p.m. with S1ED. S1ED confirmed she expected SNs to perform a medication reconciliation during each visit, which would include performing a count of the medications present in the patient’s home. S1ED reviewed the aforementioned visits for Patients #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14 and confirmed they did not contain documented evidence of a count of controlled substances being performed by the SN during each SNV and should. S1ED confirmed since there was no documented evidence of counts during the aforementioned SNVs, the agency was not maintaining current and accurate records of the disposition of all controlled substances they provided to the patient which was not in accordance with current standards of practice. An interview was conducted on 02/18/2026 at 3:12 p.m. with S3RD. S3RD confirmed the current standard of practice required the SN to perform and document a count of all controlled substances during each of their SNVs and they had not. S3RD confirmed he expected the agency to perform in accordance with all applicable laws, regulations and accepted standards of practice at all times and they had not.”

“Based on interview and record reviews, the Hospice agency failed to have a system in place to ensure the patient/patient representative/family received a copy of the agency’s written Policies and Procedures regarding the Management and Disposal of Controlled Substances for 10 of 10 (#5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) live patients in the sample. This deficient practice had the potential to affect a current census of 36 patients and any future patients admitted to the agency. Findings: An interview was conducted on 02/09/2026 at 9:30 a.m. with S1ED. S1ED confirmed the agency utilized an EHR for all Clinical Records and did not maintain paper Clinical Records in their office. Patient #5Review of Patient #5’s Clinical Record revealed she was admitted to the agency on 03/12/2025 and was in a current Certification Period of 01/06/2026 through 03/06/2026. Further review the patient was prescribed the controlled substances Ativan, Morphine, and Tramadol. Review of Patient #5’s Clinical Record revealed no documented evidence to indicate the patient/patient representative/family received a copy of the agency’s written Policies and Procedures regarding the Management and Disposal of Controlled Substances upon admission or at any time thereafter.Patient #6Review of Patient #6’s Clinical Record revealed she was admitted to the agency on 01/07/2026 and was in a current Certification Period of 01/07/2026 through 04/06/2026. Review of Patient #6’s Clinical Record revealed no documented evidence to indicate the patient/patient representative/family received a copy of the agency’s written Policies and Procedures regarding the Management and Disposal of Controlled Substances upon admission or at any time thereafter.Patient #7Review of Patient #7’s Clinical Record revealed she was admitted to the agency on 08/27/2025 and was in a current Certification Period of 12/23/2025 through 02/20/2026. Review of Patient #7’s Clinical Record revealed no documented evidence to indicate the patient/patient representative/family received a copy of the agency’s written Policies and Procedures regarding the Management and Disposal of Controlled Substances upon admission or at any time thereafter..Patient #8Review of Patient #8’s Clinical Record revealed he was admitted to the agency on 12/12/2025 and was in a current Certification Period of 12/12/2025 through 03/11/2026. Review of Patient #8’s Clinical Record revealed no documented evidence to indicate the patient/patient representative/family received a copy of the agency’s written Policies and Procedures regarding the Management and Disposal of Controlled Substances upon admission or at any time thereafter.Patient #9Review of Patient #9’s Clinical Record revealed she was admitted to the agency on 10/08/2025 was in a current Certification Period of 01/06/2026 through 04/05/2026. Review of Patient #9’s Clinical Record revealed no documented evidence to indicate the patient/patient representative/family received a copy of the agency’s written Policies and Procedures regarding the Management and Disposal of Controlled Substances upon admission or at any time thereafter.Patient #10Review of Patient #10’s Clinical Record revealed she was admitted to the agency on 12/03/2025 and was in a current Certification Period of 12/18/2025 through 03/17/2026. Review of Patient #10’s Clinical Record revealed no documented evidence to indicate the patient/patient representative/family received a copy of the agency’s written Policies and Procedures regarding the Management and Disposal of Controlled Substances upon admission or at any time thereafter.Patient #11Review of Patient #11’s Clinical Record revealed he was admitted to the agency on 01/22/2026 and was in a current Certification Period of 01/22/2026 through 04/21/2026. Review of Patient #11’s Clinical Record revealed no documented evidence to indicate the patient/patient representative/family received a copy of the agency’s written Policies and Procedures regarding the Management and Disposal of Controlled Substances upon admission or at any time thereafter.Patient #12Review of Patient #12’s Clinical Record revealed she was admitted to the agency on 04/09/2024 and was in a current Certification Period of 01/29/2026 through 03/29/2026. Review of Patient #12’s Clinical Record revealed no documented evidence to indicate the patient/patient representative/family received a copy of the agency’s written Policies and Procedures regarding the Management and Disposal of Controlled Substances upon admission or at any time thereafter.Patient #13Review of Patient #13’s Clinical Record revealed he was admitted to the agency on 09/18/2025 and was in a current Certification Period of 12/17/2025 through 02/14/2026. Review of Patient #13’s Clinical Record revealed no documented evidence to indicate the patient/patient representative/family received a copy of the agency’s written Policies and Procedures regarding the Management and Disposal of Controlled Substances upon admission or at any time thereafter.Patient #14Review of Patient #14’s Clinical Record revealed she was admitted to the agency on 01/13/2026 and was in a current Certification Period of 01/13/2026 through 04/12/2026. Review of Patient #14’s Clinical Record revealed no documented evidence to indicate the patient/patient representative/family received a copy of the agency’s written Policies and Procedures regarding the Management and Disposal of Controlled Substances upon admission or at any time thereafter.An interview was conducted on 02/12/2026 at 2:30 p.m. with S1ED. S1ED stated she spoke with their corporate office and confirmed this information was left out of the admission paperwork/consents and should not have been. S1ED confirmed she reviewed the Clinical Records, both paper and electronic, for Patients #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14 and they did not contain documented evidence to indicate the patient/patient representative/family was provided with written Policies and Procedures regarding the Management and Disposal of Controlled Substances upon admission or at any time thereafter and they should.”

“Based on observation, interviews and record reviews, the Hospice agency failed to ensure all care provided by the local NH where a patient resided was provided in accordance with their Hospice POC. This deficient practice was evidenced by failure to ensure Patient #7’s NH orders matched the orders present in her Hospice POC for 1 (#7) of 1 home visits performed for patients who resided 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 9 patients currently residing in a NH and any future admissions to the agency who resided in a NH. Review of Patient #7’s Clinical Record revealed she was admitted to the Hospice agency on 08/27/2025 and in a current Certification Period of 12/23/2025 through 02/20/2026. Further review revealed she resided in a local NH. An observation of Patient #7’s Clinical Record for the local NH where she resided was conducted during a Home Visit on 02/10/2026 at 2:30 p.m. The NH Physician Orders revealed, in part, the following active orders: Acetaminophen Rectal Suppository 650mg 1 rectally every 6 hours as needed for fever; Bisocodyl suppository 10mg rectally every 24 hours PRN for constipation; Morphine Sulfate 20mg/5mL give 0.5mL by mouth every 2 hours PRN for shortness of breath; Zofran 4mg 8 hours PRN for nausea/vomiting; andZinc Oxide External Paste applied to sacrum topically once daily as preventative skin measures.Further review revealed no documented evidence of a Physician’s Order for Ativan 0.5mg by mouth every 6 hours PRN for anxiety. Review of Patient #7’s Hospice POC and Hospice Physician’s Orders for current Certification Period revealed, in part, the following active orders as of 02/10/2026 at 2:30 p.m.: Morphine Sulfate 20mg/5mL give 0.25mL by mouth every 3 hours PRN for shortness of breath; Zofran 4mg by mouth every 4 hours PRN for nausea/vomiting; and Ativan 0.5mg by mouth every 6 hours PRN for anxiety. Further review revealed no documented evidence of a Physician’s Order for the aforementioned Bisocodyl Suppository 10 mg, Zinc Oxide topically to sacrum once daily, or Acetaminophen Rectal Suppository 650mg.; An interview was conducted on 02/10/2026 at 2:55 p.m. with Patient #7’s nurse at the NH. She reviewed Patient #7’s current NH orders and confirmed Patient #7 did not have a NH order for her PRN Ativan, her Morphine order was for 0.5 mL by mouth every 2 hours PRN, and her Zofran order was for 4mg every 8 hours PRN. An interview was conducted on 02/10/2026 at 3:00p.m. with S2RN. S2RN confirmed the Hospice agency was responsible for ensuring all orders in use by a patient’s NH matched the orders present in their Hospice POC. S2RN reviewed Patient #7’s NH order against her Hospice POC and confirmed they did not match and should. An interview was conducted on 02/12/2026 at 2:40 p.m. with S1ED. S1ED confirmed the Hospice agency was responsible for ensuring all orders in use by a patient’s NH matched the orders present in their Hospice POC. S1ED confirmed she expected the SN to perform a medication reconciliation during every SNV to ensure all orders were up to date and accurate. S1ED reviewed Patient #7’s NH order against her Hospice POC and confirmed they did not match and should.”