Cardinal Hospice

“Based on interview and record review, the Hospice agency failed to ensure the patient’s Comprehensive Assessment was reviewed and updated by the IDG no less frequently than every 15 days for 1 (#8) of 10 live patients reviewed in the sample. This deficient practice had the potential to affect any of the agency’s current 44 patients and any future admissions to the agency. Findings: Review of the agency’s IDG Policy, approved on 05/28/2008, as of 03/19/2026, revealed, in part, the following: Policy:The IDG meetings address each of the patient’s needs and problems at least every 15 days, or as necessary. Patient #8Review of Patient #8’s Clinical Record revealed she was admitted to the agency on 09/17/2025 and was in a current Certification Period of 02/13/2026 through 04/12/2026. Review of Patient #8’s IDG Meeting with updates to her Comprehensive Assessment, dated 09/17/2025 through 03/18/2026, revealed, in part, an IDG Meeting was held with her Comprehensive Assessment reviewed and updated on 01/23/2026 then not again until 29 days later, on 02/20/2026. Further review revealed no documented evidence present in her Clinical Record to indicate an IDG Meeting was held to review and update her comprehensive assessment on 02/06/2026. Review attempted on 03/18/2026 and 03/19/2026 of any documented evidence available to indicate an IDG Meeting was held to update Patient #8’s Comprehensive Assessment on 02/06/2026 and no documented evidence was made available for review.An interview was conducted on 03/19/2026 at 3:30 p.m. with S2DON. S2DON confirmed every patient was required to receive an IDG Meeting with review and updates made to their Comprehensive Assessment every 14 days. S2DON confirmed the IDG Meeting and updated Comprehensive Assessment should be filed in the patient’s Clinical Record available for review by the end of business hours on the day following the IDG Meeting, typically within 24 hours. S2DON confirmed it should not take weeks, or even a month, for a patient’s IDG Meeting and updated Comprehensive Assessment to be available in their Clinical Record for review.”

“Based on interviews and record review, the Hospice agency failed to develop a written individualized, patient specific Plan of Care which accurately reflected all goals, interventions and services necessary to meet the needs of the patient for 1 (#13) of 10 live patients reviewed in the sample. This deficient practice had the potential to affect any of the agency’s current 44 patients and any future admissions to the agency. Findings: Review conducted on 003/19/2026 of the agency’s Plan of Care Policy, approved on 05/28/2008, revealed, in part, the following: Purpose: To provide guidance for development of an individualized POC for each patient. Policy: 1. A written POC is developed and maintained for each individual admitted to the agency prior to providing care. The care provided will be in accordance with the POC. 3. The agency has the overall responsibility for development and maintenance of the POC and quality of services delivered. 4. The POC is based on the following data: A. Patient/family goals; B. Primary and secondary diagnoses and co-morbidities;C. Current medical findings; and D. IDG assessments of patient symptoms, patient/family/caregiver functional status, coping status, and family resource status. 5. The POC includes: A. Goals/Outcomes;B. Patient/family needs or problems; and C. Scope, frequency, and type of services, including interventions, pharmaceuticals, and medical supplies and equipment to be provided. 6. A RN is designated to coordinate the overall POC for each patient. Review of Patient #13’s Clinical Record revealed she was admitted to the agency on 01/21/2026 with a current Certification Period of 01/21/2026 through 04/20/2026 and co-morbidities which included Left Sided Hemiparesis and Epilepsy. Patient #13 was incontinent of bowel/bladder and required a PEG Tube and feeding pump for feedings/medications. Further review revealed she lived in a private home and received a SNV once a week. Review of Patient #13’s Initial Plan of Care and POC Updates, dated 01/21/2026 through 03/19/2026, revealed, in part, the following: Neurological Status:Goals: Seizures will be controlled. Interventions: Blank. Musculoskeletal Status: Interventions: Provide assistive devices (specify): Selected with no required devices documented. Integumentary Status: Interventions: Assess and Instruct on Skin Breakdown Prevention: Selected with no required care documented.Stoma Care as follows: Not selected with no care documented. Genitourinary Status: Assess Bladder Status: Selected with continence status not documented. Gastrointestinal Status: Interventions: Enteral Nutrition: Not selected.Gastrostomy Tube (specify): Blank. No indication of who performed site care and/or when. Assess Bowel Status: Selected with continence status not documented. Medications: Special Procedures/Interventions: No indication feedings administered via feeding pump through PEG Tube and no indication of medications being administered via PEG Tube. An interview was conducted on 03/19/2026 at 3:00 p.m. with S4RN. S4RN confirmed Patient #13 was on seizure precautions, required a PEG Tube with a feeding pump for feedings/medications, was incontinent of bowel and bladder, had a history of skin issues at her PEG site, and had left sided hemiparesis. S4RN reviewed the aforementioned sections of Patient #13’s POC and confirmed it did not accurately reflect all goals, interventions and services necessary to meet her needs.An interview was conducted on 03/19/2026 at 3:30 p.m. with S2DON. S2DON confirmed each patient’s POC should be individualized to reflect their status and needs and should provide a detailed outline of all assigned care to be provided by the agency’s staff.”

“Based on observations, interviews and record review, the Hospice agency failed to have a system in place to ensure the patient’s individualized Plan of Care (POC) reflected accurate orders for drugs necessary to manage the terminal illness and related conditions for 1 (#7) of 3 sampled patients with home visits conducted. This deficient practice had the potential to affect any of the 69 admissions during the past 12 months, a current census of 44, and any future admissions to the agency. Review of Patient #7’s Clinical Record revealed she was admitted to the agency on 02/06/2025 with a terminal diagnosis of Alzheimer’s Disease and was in a Certification Period of 02/01/2026 through 04/01/2026. Observation of Patient #7’s Clinical Record during a Home Visit conducted on 03/17/2026 at 9:00 a.m. revealed Physician Orders for the following medications: Melatonin 10 mg by mouth at bed time;Miralax 17 gm by mouth daily as needed for constipation;Periactin 4mg by mouth once daily;No evidence on Hospice Medication list of Metoprolol Tartrate 50 mg by mouth twice daily. An interview was conducted on 03/17/2026 at 9:00 a.m. with S3LPN. S3LPN confirmed the medications Patient #7 was currently taking should match the Hospice medications listed in her Clinical Record/ Plan of Care, and did not. An interview was conducted on 03/17/2026 at 9:30 a.m. with Patient #7’s spouse. He confirmed he manages and administers Patient #7’s medication daily. He confirmed Patient #7 was taking the following: Melatonin 10 my by mouth was only taken as needed for restlessness;Miralax 17 gm ½ capful by mouth once daily scheduled for constipation;Periactin 4 mg had been discontinued for several months; and,Metoprolol Tartrate 50 mg by mouth twice daily. An interview was conducted on 03/19/2026 at 3:30 p.m. with S2DON. S2DON confirmed the list of hospice medications listed in a patient’s Plan of Care should match the medications the patient is currently taking and Patient #7’s did not.”

“Based on interviews and record review, the Hospice agency failed to ensure the RN prepared a written, individualized, patient specific Plan of Care which included all supplies and appliances necessary to meet the needs of the patient for 1 (#13) of 10 live patients reviewed in the sample. This deficient practice had the potential to affect any of the agency’s current 44 patients and any future admissions to the agency. Findings: Review of the agency’s Plan of Care Policy, approved on 05/23/2008, as of 03/19/2026, revealed, in part, the following: Purpose: To provide guidance for development of an individualized POC for each patient. Policy: 1. A written POC is developed and maintained for each individual admitted to the agency prior to providing care. The care provided will be in accordance with the POC. 3. The agency has the overall responsibility for development and maintenance of the POC and quality of services delivered. 5. The POC includes: C. Medical supplies and equipment to be provided. 6. A RN is designated to coordinate the overall POC for each patient. Review of Patient #13’s Clinical Record revealed she was admitted to the agency on 01/21/2026 with a current Certification Period of 01/21/2026 through 04/20/2026 and co-morbidities which included Left Sided Hemiparesis and Epilepsy. Patient #13 was incontinent of bowel/bladder and required a PEG Tube and feeding pump for feeding/medications. Further review revealed she lived in a private home and received an SNV once a week. Review of Patient #13’s Initial Plan of Care and POC Updates, dated 01/21/2026 through 03/19/2026, revealed, in part, there was no documented evidence of the medical supplies and appliances necessary to care for Patient #13’s PEG Tube, feeding pump, and/or other supplies necessary to provide her care. Further review revealed, in part, the following: Neurological Status:Goals: Seizures will be controlled. Interventions: Blank. No supplies documented. Musculoskeletal Status: Interventions: Provide assistive devices (specify): Selected with no devices documented. No supplies documented. Integumentary Status: Interventions: Assess and Instruct on Skin Breakdown Prevention: Selected with no care documented.Stoma Care as follows: Not selected with no care documented. No supplies documented. Genitourinary Status: Assess Bladder Status: Selected with continence status not documented. No supplies documented. Gastrointestinal Status: Interventions: Enteral Nutrition. The care/use of equipment include: Not selected and care/use of equipment: Blank;Gastrostomy Tube (specify): Blank. Assess Bowel Status: Selected with continence status not documented. No supplies or equipment documented. Medications: Special Procedures/Interventions: No indication medications are administered via PEG Tube or necessary supplies and equipment documented.An interview was conducted on 03/19/2026 at 3:00 p.m. with S4RN. S4RN confirmed Patient #13 was on seizure precautions, required a PEG Tube with a feeding pump for feedings/medications, was incontinent of bowel and bladder, had a history of skin issues at her PEG site, and had left sided hemiparesis. S4RN reviewed the aforementioned sections of Patient #13’s POC and confirmed it did not reflect the necessary supplies and/or equipment required to meet her needs. S4RN stated the agency’s process was to document supply needs in an administrative binder kept at the office and did not document it in the patient’s POC or Clinical Record. An interview was conducted on 03/19/2026 at 3:30 p.m. with S2DON. S2DON confirmed a patient’s POC should include documentation of all supplies and/or appliances necessary to meet their needs.”

“Based on interview and record review, the Hospice agency failed to ensure the patient’s POC was reviewed and updated by the IDG no less frequently than every 15 days for 1 (#8) of 10 live patients reviewed in the sample. This deficient practice had the potential to affect any of the agency’s current 44 patients and any future admissions to the agency. Findings: Review of the agency’s Plan of Care Policy, approved on 05/28/2008, as of 03/19/2026, revealed, in part, the following: Purpose: To provide guidance for development of an individualized POC for each patient. Policy: 1. A written POC is developed and maintained for each individual admitted to the agency prior to providing care. The care provided will be in accordance with the POC. 3. The agency has the overall responsibility for development and maintenance of the POC and quality of services delivered. Comprehensive Plan of Care: C. The IDG reviews and revises the POC at designated intervals, or as needed, to reflect the changing needs of the patient, family and caregiver. Review of the agency’s IDG Policy, approved on 05/28/2008, as of 03/19/2026, revealed, in part, the following: Policy:The IDG meetings address each of the patient’s needs and problems at least every 15 days, or as necessary. Procedure:A. IDG Notes are POC updates. Patient #8Review of Patient #8’s Clinical Record revealed she was admitted to the agency on 09/17/2025 and was in a current Certification Period of 02/13/2026 through 04/12/2026. Review of Patient #8’s IDG POC Updates present in her Clinical Record, dated 09/17/2025 through 03/18/2026, revealed, in part, her POC was updated on 01/23/2026 then not again until 02/20/2026. Further review revealed no documented evidence of her POC being updated by the IDG on 02/06/2026.Review attempted on 03/18/2026 and 03/19/2026 of any documented evidence available to indicate Patient #8’s POC was updated by the IDG on 02/06/2026 and no documented evidence was made available for review.An interview was conducted on 03/19/2026 at 3:30 p.m. with S2DON. S2DON confirmed every patient was required to receive a POC Update every 14 days. S2DON confirmed the POC Updates should be filed in the patient’s Clinical Record available for review by the end of business on the day following the IDG Meeting, typically within 24 hours. S2DON confirmed it should not take weeks, or even a month, for a patient’s updated POC to be available in their Clinical Record for review and implementation.”

“Based on interviews and record review, the Hospice agency failed to have a system in place to ensure nursing care 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 description every 7 days for 1 (#9) of 1 patient reviewed for wounds. This deficient practice affected 100% of the agency’s patients currently receiving treatment for wounds and had the potential to affect any future patients admitted with 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 agency’s undated policy titled, “Pressure Ulcer Dressing Change” revealed, in part, the following: Documentation Guidelines: 1. Document in the Clinical Record a. Date and time of procedure; b. Specific treatment; c. Location, size of ulcer; d. Color and appearance of wound bed; e. Amount color and consistency of drainage; f. Condition of surrounding tissue; g. Changes in general condition- complaints of pain, elevated temperature; h. Physician notification; i. Preventive measures taken; j. Teaching done; k. Client response Review of Patient #9’s Clinical Record revealed she was admitted to the Hospice agency on 06/12/2025 and was in a current Certification Period of 02/07/2026 through 04/07/2026. Further review revealed Patient #9 was currently receiving treatment from the agency for a Stage 3 Pressure Ulcer to the Sacrum was ordered to receive a SNV one time per week Review of Patient #9’s SNV Notes and Pressure Ulcer Assessment Form, dated 08/14/2025 through 02/26/2026, revealed in part, no documented evidence of an RN performing an assessment with documented measurements and description of her wound during the following visits: 08/14/2025 – RN SNV; 8/21/2025 – LPN SNV; 08/28/2025 – RN SNV; 09/04/2025 – RN SNV; 09/11/2025 – LPN SNV;09/18/2025 – RN SNV; 09/25/2025 – RN SNV; 10/02/2025 – RN SNV; 10/08/202 5- RN SNV; 10/16/2025 - RN SNV; 10/23/2025 – RN SNV; 10/30/2025 – LPN SNV; 11/06/2025 – RN SNV - Sacral Wound resolved; 11/26/2025 – RN SNV – Sacral Wound reopened. 12/11/2025 - RN SNV; 12/24/2025 - RN SNV; 01/08/2026 - RN SNV; 01/22/2026 - RN SNV; 01/28/2026 - RN SNV; 02/05/2026 - RN SNV; 02/12/2026 - RN SNV; and02/26/2026 - RN SNV. Review attempted on 03/18/2026 and 03/19/2026 of any documented evidence available to indicate an RN assessed and measured Patient #9’s wound every 7 days from 08/14/2025 through 02/26/2026 and no documented evidence was made available for review. An interview was conducted on 03/18/2026 at 12:46 p.m. with S6RN. S6RN stated Pressure Ulcer wounds should be measured once monthly by an RN. She stated if Patient #9’s family or caregiver changed her sacral dressing before she arrived, she would not remove the dressing to assess and measure because dressings were expensive and she did not want to waste them. S6RN stated once a dressing was removed, it would not stick to the skin anymore and would require a totally new dressing be applied. She stated due to Patient #9’s terminal diagnosis and current condition, she experienced increased amounts of pain at times. S6RN confirmed if Patient #9 were having increased pain during her visit, she would not perform wound care or assess and measure her wound. S6RN confirmed she did not indicate in her SNV note if Patient #9 was having too much pain to complete the required wound assessment or measurements. S6RN reviewed Patient #9’s Clinical Record and confirmed her wounds were not assessed and measured weekly and was not aware they should have been. An interview was conducted on 03/19/2026 at 3:57 p.m. with S2DON. S2DON confirmed she expected the RN to measure and assess wounds weekly. S2DON stated an LPN could measure the wound, but not stage it. She confirmed the agency’s current system did not ensure an RN measured a patient’s wounds every 7 days. S2DON reviewed Patient #9’s Clinical Record and confirmed her wounds were not measured by an RN weekly, and should have been.”

“Based on interviews and record review, the Hospice agency failed to ensure the RN prepared written individualized, patient specific care instructions for the HA to utilize when providing care for 1 (#13) of 10 live patients reviewed in the sample. This deficient practice had the potential to affect any of the agency’s current 44 patients who received HA services and any future admissions to the agency who received HA services. Findings: Review of the agency’s undated HA Supervision Policy, as of 03/19/2026, revealed, in part, the agency ensured all services provided by the HAs are monitored to maintain the quality of care outlined in the patient’s HA POC. Review conducted on 03/19/2026 of the agency’s Plan of Care Policy, approved on 05/23/2008, revealed, in part, the following: Policy: 1. A written POC is developed and maintained for each individual admitted to the agency prior to providing care. The care provided will be in accordance with the POC. 6. A RN is designated to coordinate the overall POC for each patient. Review of Patient #13’s Clinical Record revealed she was admitted to the agency on 01/21/2026 and in a current Certification Period of 01/21/2026 through 04/20/2026 with co-morbidities which included Left Sided Hemiparesis and Epilepsy. Further review revealed she lived in a private home and received a HA visit three times a week. Review of Patient #13’s HA POC, dated 01/21/2026 through 03/19/2026, revealed, in part, no indication of the following: Left Sided Hemiparesis and/or how/if she should be transferred; Continence or incontinence of bowel and bladder; Presence of PEG Tube and/or if the HA was responsible for site cleaning; andSupplies needed for the HA to provide assigned care.Further review revealed documentation of the following were blank:Code status - “Do CPR” or “Do not do CPR;Special Equipment; andSpecial Instructions.An interview was conducted on 03/19/2026 at 3:00 p.m. with S4RN. S4RN confirmed she admitted Patient #13, created her HA POC and was familiar with the patient. S4R confirmed Patient #13 was bed bound and should not be transferred by the HA. S4RN confirmed Patient #13 was incontinent of bowel and bladder, and she would require incontinence supplies. S4RN confirmed Patient #13 had a PEG Tube and the family performed all site care with agency provided supplies. S4RN confirmed Patient #13 was a DNR. S4RN confirmed the HA’s POC did not specify any supplies the HA would need to bring with them to perform assigned care duties. S4RN stated all of the aforementioned information was communicated between the nurse and the HA verbally should have been included in Patient #13’s POC and was not. An interview was conducted on 03/19/2026 at 3:30 p.m. with S2DON. S2DON confirmed each patient’s HA POC should be individualized to their current status and include provision of required care by HA and was not.”

“Based on interviews and record reviews, the Hospice agency failed to ensure the RN performed an on-site HA Supervisory visit at the patient’s home no less frequently than every 14 days to assess the HA’s quality of care and to ensure the patient’s needs were being met for 5 (#8, #11, #12, #13 and #14) of 10 live patients reviewed in the sample. This deficient practice had the potential to affect any of the agency’s current 44 patients receiving HA services and any future admissions to the agency who received HA services. Findings: Review of the agency’s undated HA Supervision Policy, as of 03/19/2026, revealed, in part, the following: The agency ensures all services provided by the HAs are monitored to maintain the quality of care outlined in the patient’s HA POC. Routine Oversight: RN shall conduct on-site visits to the patient’s residence at regular intervals, generally no less than every 14 days. Patient #8Review of Patient #8’s Clinical Record revealed she was admitted to the agency on 09/17/2025 and was in a current Certification Period of 02/13/2026 through 04/12/2026. Further review revealed she was ordered to receive an HA visit three times a week. Review of Patient #8’s HA Visits, dated 09/17/2025 through 03/19/2026, revealed, in part, an HA Visit was conducted on the following dates:September 2025: 09/18/2025; 09/20/2025; 09/23/2025; 09/25/2025; 09/27/2025; and 09/30/2025. October 2025: 10/02/2025; 10/04/2025; 10/07/2025; 10/09/2025; 10/11/2025; 10/14/2025; 10/16/2025; 10/18/2025; 10/21/2025; 10/23/2025; 10/28/2025; 10/25/2025; and 10/30/2025.November 2025: 11/01/2025; 11/03/2025; 11/04/2025; 11/06/2025; 11/11/2025; 11/13/2025; 11/15/2025; 11/18/2025; 11/20/2025; 11/22/2025; 11/25/2025; 11/27/2025; and 11/29/2025.December 2025: 12/02/2025; 12/04/2025; 12/06/2025; 12/09/2025; 12/11/2025; 12/13/2025; 12/16/2025; 12/18/2025; 12/20/2025; 12/23/2025; 12/27/2025; and 12/30/2025.January 2026: 01/01/2026; 01/03/2026; 01/06/2026; 01/08/2026; 01/10/2026; 01/13/2026; 01/15/2026; 01/17/2026; 01/20/2026; 01/22/2026; 01/24/2026; 01/27/2026; 01/29/2026; and 01/31/2026.February 2026:02/03/2026; 02/05/2026; 02/07/2026; 02/10/2026; 02/12/2026; 02/14/2026; 02/17/2026; 02/19/2026; 02/21/2026; 02/24/2026; 02/26/2026; and 02/28/2026.March 2026: 03/03/2026; and 03/07/2026.Review of Patient #8’s SNV Notes, dated 09/17/2025 through 03/19/2026, revealed, in part, no documented evidence an RN Supervisory Visit was conducted during the following timeframes:09/25/2025 through 10/14/2025;11/18/2025 through 12/21/2025; 12/23/2025 through 01/11/2026;01/13/2026 through 01/26/2026; and 01/28/2026 through 03/09/2026. Review of the agency’s HA Supervisory Visit Binder for Patient #8, dated 09/17/2025 through 03/19/2026, revealed, in part, one signature of S4RN with no valid date to indicate when the visit was conducted. Further review revealed no documented evidence a RN Supervisory Visit was conducted from 09/25/2025 through 10/14/2025; 11/18/2025 through 12/21/2025; 12/23/2025 through 01/11/2026; 01/13/2026 through 01/26/2026; and 01/28/2026 through 03/09/2026. Review attempted on 03/18/2026 and 03/19/2026 of any documented evidence available to indicate RN Supervisory Visits were performed for Patient #8’s HA during the aforementioned timeframes and no documented evidence was made available for review. Patient #11Review of Patient #11’s Clinical Record revealed she was admitted to the agency on 12/03/2025 and was in a current Certification Period of 03/02/2026 through 05/31/2026. Further review revealed she was ordered to receive an HA visit three times a week. Review of Patient #11’s HA Visits, dated 01/01/2026 through 03/19/2026, revealed, in part, an HA Visit was conducted on the following dates:January 2026:01/14/2026; 01/16/2026; 01/19/2026; 01/21/2026; 01/23/2026; 01/28/2026; and 01/30/2026.February 2026:02/02/2026; 02/04/2026; 02/13/2026; 02/16/2026; 02/18/2026; 02/20/2026; 02/23/2026; and 02/25/2026.Review of Patient #11’s SNV Notes, dated 01/01/2026 through 03/19/2026, revealed, in part, no documented evidence a RN Supervisory Visit was conducted during the following timeframes:01/22/2026 through 02/10/2026; and02/12/2026 through 03/03/2026. Review of the agency’s HA Supervisory Visit Binder for Patient #11, dated 01/01/2026 through 03/19/2026, revealed, in part, no documented evidence a RN Supervisory Visit was conducted from 01/22/2026 through 02/10/2026; and 02/12/2026 through 03/03/2026. Review attempted on 03/18/2026 and 03/19/2026 of any documented evidence available to indicate RN Supervisory Visits were performed for Patient #11’s HA from 01/22/2026 through 03/03/2026 and no documented evidence was made available for review. Patient #12Review of Patient #12’s Clinical Record revealed she was admitted to the agency on 05/15/2025 and was in a current Certification Period of 02/10/2026 through 04/10/2026. Further review revealed she was ordered to receive an HA visit five times a week. Review of Patient #12’s HA Visits, dated 07/23/2025 through 03/19/2026, revealed, in part, an HA Visit was conducted on the following dates: July 2025:07/23/2025; 07/24/2025; 07/25/2025; 07/28/2025; 07/29/2025; 07/30/2025; and 07/31/2025.August 2025:08/01/2025; 08/04/2025; 08/05/2025; 08/06/2025; 08/07/2025; 08/08/2025; 08/11/2025; 08/12/2025; 08/13/2025; 08/14/2025; 08/15/2025; 08/18/2025; 08/20/2025; 08/22/2025; 08/25/2025; 08/26/2025; 08/27/2025; 08/28/2025; and 08/29/2025.September 2025:09/02/2025.October 2025: 10/07/2025; 10/08/2025; 10/09/2025; 10/10/2025; 10/13/2025; 10/14/2025; 10/15/2025; 10/16/2025; 10/17/2025; 10/20/2025; 10/21/2025; 10/22/2025; 10/23/2025; 10/24/2025; 10/27/2025; 10/28/2025; 10/29/2025; 10/30/2025; and 10/31/2025.November 2025:11/03/2025; 11/04/2025; 1/05/2025; 11/06/2025; 11/07/2025; 11/10/2025; 11/24/2025; 11/25/2025; 11/26/2025; 11/27/2025; and 11/28/2025.December 2025:12/01/2025; 12/02/2025; 12/03/2025; 12/04/2025; 12/05/2025; 12/08/2025; 12/09/2025; 12/10/2025; 12/11/2025; 12/12/2025; 12/15/2025; 12/16/2025; 12/17/2025; 12/18/2025; 12/19/2025; 12//22/2025; 12/23/2025; 12/24/2025; 12/25/2025; and 12/26/2025.February 2026: 02/16/2025; 02/17/2025; 02/18/2025; 02/19/2025; 02/20/2025; 02/23/2025; 02/24/2025; 02/25/2025; 02/26/2025; and 02/27/2025.March 2026: 03/02/2025.Review of Patient #12’s SNV Notes, dated 07/23/2025 through 03/19/2026, revealed, in part, no documented evidence a RN Supervisory Visit was conducted during the following timeframes:07/23/2025 through 09/01/2025;10/08/2025 through 11/09/2025;11/11/2025 through 12/07/2025;12/09/2025 through 12/28/2025; and 02/03/2026 through 03/16/2026.Review of the agency’s HA Supervisory Visit Binder for Patient #12, dated 07/23/2025 through 03/19/2026, revealed, in part, the following:12/02/2025 – Signature of S4RN with no RN SNV performed on or around that date; and 02/23/2026 – Signature of S4RN with no documentation to indicate Supervision was performed on the corresponding RN SNV. Further review revealed no documented evidence an RN Supervisory Visit was conducted during the aforementioned timeframes. Review attempted on 03/18/2026 and 03/19/2026 of any documented evidence available to indicate RN Supervisory Visits were performed for Patient #12’s HA during the aforementioned timeframes and no documented evidence was made available for review. Patient #13Review of Patient #13’s Clinical Record revealed she was admitted to the agency on 01/21/2026 with a current Certification Period of 01/21/2026 through 04/20/2026. Further review revealed she was ordered to receive a HA visit three times a week. Review of Patient #13’s HA Visits, dated 01/21/2026 through 03/05/2026, revealed, in part, an HA visit was conducted on the following dates:January 2026: 01/23/2026; 01/26/2026; 01/28/2026; and 01/30/2026.February 2026: 02/02/2026; 02/04/2026; 02/06/2026; 02/09/2026; 02/11/2026; 02/13/2026; 02/16/2026; 02/18/2026; 02/20/2026; 02/23/2026; 02/25/2026; and 02/27/2026.March 2026:03/02/2026; and 03/04/2026.Review of Patient #13’s SNV Notes, dated 01/21/2026 through 03/05/2026, revealed, in part, no documented evidence an RN Supervisory Visit was conducted from 01/24/2026 through 03/05/2026.Review of the agency’s HA Supervisory Visit Binder for Patient #13, dated 01/21/2026 through 03/05/2026, revealed, in part, no documented evidence an RN Supervisory Visit was conducted from 01/24/2026 through 03/05/2026.Review attempted on 03/19/2026 of any documented evidence available to indicate RN Supervisory Visits were performed for Patient #13’s HA from 01/24/2026 through 03/05/2026 and no documented evidence was made available for review. Patient#14Review of Patient #14’s Clinical Record revealed she was admitted to the agency on 10/08/2025 and was in a current Certification Period of 01/06/2025 through 04/04/2026. Further review revealed she was ordered to receive an HA visit three times a week. Review of Patient #14’s HA Visits, dated 10/30/2025 through 02/24/2026, revealed, in part, an HA Visit was conducted on the following dates:October 2025:10/30/2025November 2025: 11/01/2025; 11/04/2025; 11/06/2025; 11/08/2025; 11/11/2025; 11/13/2025; 11/15/2025; 11/18/2025; 11/20/2025; 11/22/2025; 11/25/2025; 11/27/2025, and 11/29/2025.February202602/17/2026; 02/19/2026; 02/21/2026; and 02/24/2026.Review of Patient #14’s SNV Notes, dated 10/29/2025 through 12/03/2025 and 02/03/2026 through 02/24/2026, revealed, in part, no documented evidence a RN Supervisory Visit was conducted every 14 days.Review of the agency’s HA Supervisory Visit Binder for Patient #14, dated 10/08/2025 through 03/19/2026, revealed, in part, no documented evidence a RN Supervisory Visit was conducted from 10/29/2025 through 12/03/2025 and 02/03/2026 through 02/24/2026.Review attempted on 03/19/2026 of any documented evidence available to indicate a RN Supervisory Visit was performed for Patient #14’s HA from 10/29/2025 through 12/03/2025 and 02/03/2026 through 02/24/2026. One in-person HA supervisory visit was conducted on 01/02/2026. An interview was conducted on 03/18/2026 at 1:00 p.m. with S6RN. S6RN confirmed a RN was required to perform an HA Supervisory Visit every14 days and it was documented on the nurse’s SNV note. S6RN confirmed after the nurse turned their SNV note in to the agency, one of the administrative staff transcribed the date the HA Supervisory Visit was conducted onto the patient’s list of Supervisory Visits located in the agency’s RN Supervisory Visit Binder so the most recent date was able to be referenced easily. S6RN confirmed the HA Supervisory Visit Binder was not where the nurse should document the results of their visit and it should be documented within the SNV note. An interview was conducted on 03/19/2026 at 3:30 p.m. with S2DON. S2DON confirmed she expected an RN to perform an HA Supervisory visit every month.”

“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 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 Healthcare POA, and code status directive signed by the patient/representative and physician in the Clinical Record for 1 (Patient #7) of 14 total sampled patients. This deficient practice had the potential to affect any of the 61 patient deaths during the past 12 months, a current census of 44 patients, and any future patient’s admitted to the agency and any future patient deaths. Review of the agency’s undated policy and procedure, titled “Withholding Resuscitation or Withdrawing Life-Sustaining Care” revealed, in part, the following: Policy: 5. If a DNR order is given, it must be adequately documented. Documentation of the patient’s request for DNR status shall be made. The order shall be included in the patient’s chart. Procedure: On admission to agency service, the admitting staff members determines whether the patient has any signed directive regarding withholding of resuscitation or the withdrawing of life-sustaining care. The staff member documents this discussion and the patient’s understanding of it in the clinical record. Review of Patient #7’s Clinical Record revealed she was admitted to the agency on 02/06/2025 with a terminal diagnosis of Alzheimer’s Disease and was in a Certification Period of 02/01/2026 through 04/01/2026. Further review revealed Patient #7 was not cognitively intact during her time with this agency. Review of Patient #7’s Clinical Record revealed a “Full Code” sticker on the outside of the binder, and a signed Physician’s Order dated 02/06/2025 which stated “patient is a full code.” Review of Patient #7’s Clinical Record as of 03/16/2026 at 4:00 p.m. revealed no evidence of documentation of a POA, signed “Louisiana Declaration” or Living Will.An interview was conducted on 03/17/2026 at 9:29 a.m. with S3LPN. S3LPN stated Patient #7 was a DNR. S3LPN stated she obtained this information by asking Patient #7’s spouse during a home visit. S3LPN reviewed Patient #7’s Clinical Record and confirmed the Clinical Record did not contain Patient # 7’s POA, Living Will or a signed Louisiana Declaration. S3LPN further confirmed Patient #7’s current Clinical Record only contained documentation to indicate she was a “full code” An interview was conducted during Home Visit on 03/17/2026 at 9:30 a.m. with Patient #7’s spouse. He confirmed Patient #7 no longer had decision making capacity and he was her healthcare POA. He further confirmed she was DNR for several years as per her Living Will and since admission to the agency in February 2025 he has desired DNR status for his spouse. He confirmed the hospice staff never asked for their POA, or Living Will on admission or thereafter. Resident #7’s spouse provided Patient #7’s Healthcare POA signed September 20th, 2023, indicating Patient #7’s spouse had the power to make decisions in regards to her healthcare due to her impaired cognition. Patient #7’s spouse also provided evidence of a Living Will Declaration, signed July 22, 2008 by Patient #7 indicating DNR status. An interview was conducted on 03/17/2026 at 2:40 p.m. with S4RN. S4RN stated when she took over Patient #7’s care, around 11/13/2025, Patient #7’s “Face sheet” did not indicate DNR status. S4RN stated she spoke with Patient #7’s spouse during her SNV on 11/13/2025 and determined she should be a DNR. S4RN confirmed she did not rectify the reassessed DNR code status with Patient #7’s Clinical Record. S4RN confirmed she did not obtain copies of Patient #7’s Advance Directives nor did she obtain a Physician’s Order to change Patient #7 from Full Code to DNR status. S4RN reviewed Patient #7’s Clinical Record and confirmed it did not contain any of the legal paperwork naming her spouse as Healthcare POA or making her DNR status and it should. An interview was conducted on 03/19/2026 at 3:30 p.m. with S2DON. She reviewed Patient #7’s Clinical Record and confirmed it indicated she was “Full code” and had been since admission to the agency. S2DON was informed Patient #7’s spouse reported during home visit on 3/17/2026, he was Patient #7’s Healthcare POA and she should be a DNR. S2DON confirmed the agency should have obtained Patient #7’s Advance Directives during admission and they should be present in her Clinical Record but they were not. S2DON confirmed a patient’s code status should accurately reflect all current Advance Directives for the patient and Patient #7’s did not. S2DON confirmed if an agency staff member became aware a patient’s code status was incorrect, they should immediately obtain copies of the Advance Directive(s) and ensure their Clinical Record was update to reflect the new information, including Physician’s Orders and prior to 03/17/20026, Patient #7’s did not.”

“Based on record review and interview, the Hospice agency failed to implement an effective system to ensure the safe use and management of controlled drugs in the patient’s home in accordance with accepted standards of practice. The Hospice agency failed to ensure current and accurate records were maintained of the disposition of all controlled substances provided by the Hospice agency to the patient for 5 (#7, #8, #9, #12, #13) of 10 live patients reviewed in the sample. This deficient practice had the potential to affect any of the 69 patients admitted to the agency during the past 12 months, a current census of 44 patients, and any future admissions to the agency. Findings: Review of the United States GAO’s Report titled Preventing Drug Diversion, published 04/2020, revealed, in part, the following: Misuse of controlled substances continues to be a serious public health problem in the United States.1 National survey data from the Substance Abuse and Mental Health Services Administration show that in 2017, 53 percent of people 12 years of age and older in the United States who misused prescription pain relievers in the past year, obtained the drugs from friends and family. The most commonly misused controlled substances include opioids (such as oxycodone), which are used to treat pain, and central nervous system depressants (such as diazepam), which are used to treat anxiety and sleep disorders. These types of drugs are prescribed for a large portion of patients in hospice care. Patients select hospice care when they no longer want treatment for their terminal illness, but rather choose a hospice team to provide symptom management and control. In 2017, approximately 1.5 million Medicare beneficiaries received hospice services, and 56 percent of those patients received care in the patient’s home. Medicare is the largest payer for hospice services.The Controlled Substances Act regulates the manufacture, distribution, use, and disposal of controlled substances.13 In general, the Controlled Substances Act was enacted to facilitate the use of controlled substances for legitimate medical, scientific, research, and industrial purposes while preventing them from being diverted for illegal uses.What GAO Found: Best Practices for Reducing the Risk of DiversionHospice officials identified best practices for preventing diversion of controlled substances. Best practices include routine prescription drug counts performed by hospice employees to determine if controlled substances are being used properly.Narcotic counts can also help ensure that unused or expired medications are properly disposed of, preventing potential misuse or accidental ingestion. Review of the agency’s undated “Controlled Substances Policy” revealed, in part, the following: Purpose: To ensure the safe management, administration, and disposal of controlled substances in the home or inpatient setting, preventing diversion and ensuring compliance with Louisiana Revised Statues. 4. Monitoring and Pill Counts: Hospice nurses should perform a count of controlled substances during patient visit to monitor for proper use.Patient #7Review of Patient #7’s Clinical Record revealed she was admitted to the agency on 02/06/2025 and was in a current Certification Period of 02/01/2026 through 04/01/2026. Further review revealed she lived in a private home and received a SNV once a week. Review of Patient #7’s Physician Orders revealed orders for the following controlled substances: Lorazapam 0.5mg; andRoxanol 20mg/mL.Review of Patient #7’s Nursing Clinical Notes dated 09/04/2025 to 02/26/2026 revealed, in part no documented evidence of the remaining count of controlled substances present in the home during the following SNVs. 09/04/2025; 09/11/2025;09/18/2025; 09/26/2025;10/02/2025;10/10/2025;10/16/2025; 10/23/2025;10/30/2025;11/06/2025; 11/13/2025; 11/21/2025;11/26/2025; 12/03/2025; 12/11/2025;12/18/2025; 12/24/2025;12/31/2025; 01/08/2026;01/15/2026;01/22/2026; 01/29/2026; 02/05/2026; 02/12/2026; 02/19/2026; and 02/26/2026.Review of Patient #7’s Controlled Drug Receipt/Record/Disposition Forms, dated 09/04/2025 through 03/18/2026, revealed no documented evidence of the remaining count of controlled substances present in the home during the timeframe reviewed.Review attempted on 03/18/2026 and 03/19/2026 of any documented evidence available to indicate a count of Patient #7’s remaining controlled substances was performed with the remaining count documented and none was made available for review.On 03/17/2026 at 9:00 a.m. a home visit was conducted with S3LPN. Observation revealed S3LPN did not conduct a count of Patient #7’s controlled substances during the SNV. On 03/17/2026 at 10:15 a.m. an interview was conducted with S3LPN. S3LPN confirmed controlled substance counts should be performed during each SNV. She further confirmed she did not perform a count of controlled substances during Patient #7’s home visit the morning of 03/17/2026 and should have. Patient #8Review of Patient #8’s Clinical Record revealed she was admitted to the agency on 09/17/2025 and was in a current Certification Period of 02/13/2026 through 04/12/2026. Further review revealed she lived in a local nursing home and received a SNV once a week. Review of Patient #8’s Physician Orders revealed orders for the following controlled substances: Lorazepam 2mg;Roxanol 20mg/mL;Tramadol 50mg; andXanax 0.25mg.Review of Patient #8’s Nursing Clinical Notes, dated 09/17/2025 through 03/18/2026, revealed, in part, no documented evidence of the remaining count of controlled substances present in the home during the following SNVs:09/22/2025;09/25/2025; 09/29/2025;10/06/2025; 10/13/2025;10/15/2025;10/20/2025;10/27/2025;11/03/2025;11/05/2025;11/10/2025;11/17/2025;11/24/2025 (No documented evidence a count was performed for Xanax);12/01/2025;12/08/2025 (No documented evidence a count was performed for Tramadol);12/15/2025;12/22/2025;01/05/2026 (No documented evidence a count was performed for Xanax); 01/12/2026;01/19/2026;01/27/2026;02/02/2026;02/09/2026;02/16/2026;02/23/2026;03/02/2026; and 03/09/2026.Review of Patient #8’s Controlled Drug Receipt/Record/Disposition Forms, dated 09/17/2025 through 03/18/2026, revealed no documented evidence of the remaining count of controlled substances present in the home during the timeframe reviewed.Review attempted on 03/18/2026 and 03/19/2026 of any documented evidence available to indicate a count of Patient #8’s remaining controlled substances was performed with the remaining count documented and none was made available for review. Patient #9Review of Patient #9’s Clinical Record revealed she was admitted to the agency on 06/12/2025 and was in a current Certification Period of 02/07/2026 through 04/07/2026. Further review revealed she lived in a private home and received a SNV once a week. Review of Patient #9’s Physician Orders revealed orders for the following controlled substances: Lorazepam 0.5mg; Hydrocodone 5/325mg; Hydrocodone 7.5mg; andFentanyl Patch 25 mcg. Review of Patient #9’s Nursing Clinical Notes, dated 08/21/2025 through 02/26/2026, revealed, in part, no documented evidence of the remaining count of controlled substances present in the home during the following SNVs:08/21/2025; 08/28/2025;09/04/2025;09/11/2025;09/18/2025; 09/25/2025;10/02/2025;10/08/2025;10/16/2025;10/30/2025;11/06/2025;11/13/2025;11/20/2025;11/26/2025;12/04/2025; 12/11/2025;12/18/2025;12/24/2025 (No documented evidence a count was performed for Lorazepam);01/02/2026 (No documented evidence a count was performed for Lorazepam);01/08/2026 (No documented evidence a count was performed for Lorazepam); 01/15/2026; 01/22/2026 (No documented evidence a count was performed for Lorazepam);02/05/2026 (No documented evidence a count was performed for Lorazepam);02/12/2026; 02/19/2026 (No documented evidence a count was performed for Lorazepam); and02/26/2026 (No documented evidence a count was performed for Lorazepam).Review of Patient #9’s Controlled Drug Receipt/Record/Disposition Forms, dated 08/21/2025 through 02/26/2026, revealed no documented evidence of the remaining count of controlled substances present in the home during the timeframe reviewed.Review attempted on 03/18/2026 and 03/19/2026 of any documented evidence available to indicate a count of Patient #9’s remaining controlled substances was performed with the remaining count documented and none was made available for reviewPatient #12Review of Patient #12’s Clinical Record revealed she was admitted to the agency on 05/15/2025 and was in a current Certification Period of 02/10/2026 through 04/10/2026. Further review revealed she lived in a private home and received a SNV once a week. Review of Patient #12’s Physician Orders revealed orders for the following controlled substances: Lorazepam 0.5mg;Roxanol 20mg/mL; and Tramadol 50mg.Review of Patient #12’s Nursing Clinical Notes, dated 12/03/2025 through 03/18/2026, revealed, in part, no documented evidence of the remaining count of controlled substances present in the home during the following SNVs:12/08/2025;12/15/2025;12/22/2025; 12/29/2025; 01/05/2026; 01/12/2026;01/19/2026;01/27/2026;02/02/2026;02/09/2026;02/16/2026; 02/23/2026; 03/02/2026; 03/09/2026; and 03/16/2026. Review of Patient #12’s Controlled Drug Receipt/Record/Disposition Forms, dated 12/03/2025 through 03/18/2026, revealed no documented evidence of the remaining count of controlled substances present in the home during the timeframe reviewed.Review attempted on 03/18/2026 and 03/19/2026 of any documented evidence available to indicate a count of Patient #12’s remaining controlled substances was performed with the remaining count documented and none was made available for review. Patient #13Review of Patient #13’s Clinical Record revealed she was admitted to the agency on 01/21/2026 and in a current Certification Period of 01/21/2026 through 04/20/2026. Further review revealed she lived in a private home and received a SNV once a week. Review of Patient #13’s Physician Orders revealed orders for the following controlled substances: Lorazepam 1mg; and Roxanol 20mg/mL.Review of Patient #13’s Nursing Clinical Notes, dated 01/21/2026 through 03/19/2026, revealed, in part, no documented evidence of the remaining count of controlled substances present in the home during the following SNVs:01/23/2026;01/29/2026;02/05/2026;02/12/2026;02/19/2026;02/26/2026; and03/05/2026.Review of Patient #13’s Controlled Drug Receipt/Record/Disposition Forms, dated 01/21/2026 through 03/19/2026, revealed no documented evidence of the remaining count of controlled substances present in the home during the timeframe reviewed.Review attempted on 03/19/2026 of any documented evidence available to indicate a count of Patient #13’s remaining controlled substances was performed with the remaining count documented and none was made available for review. An interview was conducted on 03/19/2026 at 3:00 p.m. with S4RN. S4RN reviewed Patient #13’s Clinical Record and confirmed no counts were performed for either of Patient #13’s controlled substances since she was admitted to the agency on 01/21/2026. S4RN confirmed nurses were expected to count and document the remaining amount of all controlled substances in a patient’s home during every nurse visit. S4RN confirmed the remaining counts would be documented in their SNV Note and not on a separate form within the Clinical Record or a separate form kept in the office. An interview was conducted on 03/17/2026 at 1:30 p.m. with S5RN. S5RN confirmed nurses were expected to count and document the remaining amount of all controlled substances in a patient’s home during every nurse visit. S5RN confirmed the remaining counts would be documented in their SNV Note and not on a separate form within the Clinical Record or a separate form kept in the office. An interview was conducted on 03/17/2026 at 1:55 p.m. with S6RN. S6RN confirmed that controlled substance counts should be performed every visit and documented in nursing notes. An interview was conducted on 03/19/2026 at 3:30 p.m. with S2DON. S2DON confirmed no matter where a patient lived, private home, nursing home or assisted living facility, she expected their nurses to count 100% of the patient’s controlled substances during every SNV. S2DON confirmed the agency was responsible for maintaining the disposition of all controlled substances provided to the patient by the agency. S2DON confirmed if the remaining count was not documented, the results could not referenced in the future and she could not provide documented evidence to indicate the count was performed as it should have been. S2DON confirmed if the remaining counts were documented, the information would be in the SNV Note, not on a separate form within the Clinical Record or a separate form kept in the office.”

“Based on interviews and record review, the hospice agency failed to ensure nursing services met the needs for 2 (#8 and #10) of 3 (#8, #10 and #11) patients reviewed for pressure wounds. The agency failed to follow acceptable standards of practice for wound care by failing to complete wound assessments and weekly wound measurements, including the size and stage of the wounds, for Patients #8 and #10. Review of the agencys policy titled, “;Assessment/Staging of Pressure Ulcers” revealed the following, in part: Applies to: Registered Nurse. Pressure Ulcer Assessment Guide: In assessing the pressure ulcer, the following parameters should be addressed consistently. 1. Site. 2. Stage of ulcer, and size of ulcer (including length, width, and depth). 3. Presence of tunneling or undermining. 4. Presence of necrotic tissue (slough or eschar). 5. Drainage amount, color, and odor. 6. Granulation. 7. Pain. 8. Condition of surrounding tissue. Review of the Louisiana State Board of Nursing Declaratory Statement Scope of Practice for Registered Nurses - Wound Care Management adapted 02/1999 revealed the following in part: Registered nurses render care that is directed towards the prevention and treatment of wounds. Wounds are a common health care challenge that often occur with or result from chronic disorders such as impaired circulation and malnutrition. Nursing care of skin/wound conditions involves the identification, assessment, management, and ongoing evaluation of patients with alterations in skin/tissue integrity that includes but is not limited to draining wounds, pressure ulcers, and vascular ulcers, and conditions resulting from incontinence, surgical procedures, and/or trauma. Scope of Practice - The Louisiana State Board of Nursing recognizes that assessment, planning, intervention, teaching, evaluation, and supervision are the major responsibilities of the Registered Nurse in the practice setting. The registered nurse is responsible for performing a nursing assessment and physical examination for preventative and restorative nursing and for providing patient/family teaching. Recognizing that the physician must always prescribe wound care, the following roles are defined to delineate the scope of practice for each member of the nursing team members. The Registered Nurse initiates appropriate wound preventative measures, stages wounds and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by an authorized prescriber. Review of the National Pressure Ulcer Advisory Panel Prevention and Treatment of Pressure Ulcers: Quick Reference Guide revealed, in part, the following: Pressure Ulcer Assessment 1. Assess the Pressure Ulcer initially and re-assess it at least weekly. 1.1. Document the results of all wound assessments. Assess and document physical characteristics including: location, Category/Stage, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. Patient #8 Review of the Clinical Record for Patient #8 revealed a start of care date of 01/20/2023. Review of the Plan of Care for certification period 09/17/2023 - 11/15/2023 and 11/16/2023 - 01/14/2024 revealed a diagnosis of Sacral Pressure Ulcer. Further review of the Plan of Care revealed orders for the following frequency of Skilled Nurse visits; 1 time every 14 days and every day as needed for changes in status. Review of the Physician Order for Patient #8 revealed the following: Wet to dry dressing changes. Review of the Nurses Notes for Patient #8 for the weeks of 11/12/2023 and 11/19/2023 revealed there was no documentation a weekly wound assessment was completed to include measurements of Patient #8’s Sacral Pressure Ulcer. Further review revealed no documentation a Registered Nurse assessed the wound at least once a week. An interview was conducted on 11/28/2023 at 11:00 a.m. with S3RN. She said, on 11/06/2023, she visited Patient #8 and identified a Sacral Pressure Ulcer. She said she documented an assessment and measurements on 11/06/2023. She said she could not provide documented wound measurements since 11/06/2023. She said Patient #8s Sacral Pressure Ulcer should have been assessed and measured by a RN weekly and had not been. An interview was conducted on 11/28/2023 at 12:15 p.m. with S2NP. She said she visited Patient #8 on 11/14/2023 to assess her urinary catheter. She said she did not perform wound care nor did she obtain sacral wound measurements during this visit. She said she was told by Patient #8s daughter that the wound had decreased in size. She said she had not seen additional documentation of measurements to indicate if the wound had improved or deteriorated. Patient #10 Review of the Clinical Record for Patient #10 revealed a start of care date of 11/03/2023. Review of the Plan of Care for certification period 11/03/2023- 01/31/2023 revealed a diagnosis of Stage 3 Sacral Pressure Ulcer. Further review of the Plan of Care revealed orders for the following frequency of Skilled Nurse visits; 1 time every 14 days and every day as needed for changes in status. Review of the Physician Order for Patient #10 revealed the following: Clean wound with Normal Saline and pat dry with gauze. Cut, fit and apply Silver Collagen to the open wound bed then cover with a Hydrocolloid three times a week. (Once by RN) Review of the Nurses Notes for Patient #10 for the weeks of 11/12/2023 and 11/19/2023 revealed there was no documentation a weekly wound assessment was completed to include measurements of Patient #10’s Sacral Pressure Ulcer. Further review revealed no documentation a Registered Nurse assessed the wound at least once a week. An interview was conducted on 11/28/2023 at 2:00 p.m. with S4RN. She verified Patient #10 had a Sacral Pressure Ulcer which was identified on 11/03/2023. She confirmed Patient #10s Sacral Pressure Ulcer was not assessed and measured the weeks of 11/12/2203 and 11/19/2023 and should have been. An interview was conducted on 11/29/2023 at 12:00 p.m. with S1DON. She verified Patient #8 and Patient #10 had a Sacral Pressure Ulcer. She said the agency did not have a policy in regards to weekly measurements by the RN. She said it depended on the cooperation of the patient if measurements were taken. She reviewed Patient #8 and #10s Clinical Record and verified on the weeks listed above there was no wound measurements documented. S1DON confirmed there was no documentation to indicate a complete weekly assessment of the wounds were obtained by the Registered Nurse. She confirmed there was no documentation indicating if Patient #8 and #10s wounds had improved or deteriorated. She said measurements and description of the wound should be documented weekly by the Registered Nurse.”

“Based on record review and interview, the agency failed to ensure the Registered Nurse conducted an on-site Hospice Aide Supervisory visit at least every 14 days to assess the quality of care and services provided by the hospice aide for 1 (#7) of 10 (#1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) patients reviewed who received Hospice Aide services. Review of the Clinical Record for Patient #7 revealed she was admitted to the agency on 03/09/2023 with diagnoses which included Hypertension and Coronary Artery Disease. Review of the Plan of Care revealed orders which included Hospice Aide Services 3 times a week. Review of Hospice Aide visit notes for Patient #7 revealed visits were conducted during the weeks of 10/01/2023 and 10/08/2023. Review of Skilled Nurse visit notes for Patient #7 revealed there was no documentation of an on-site Hospice Aide Supervisory visit conducted by a Registered Nurse for the weeks of 10/01/2023 and 10/08/2023. An interview was conducted on 11/29/2023 at 2:00 p.m. with S1DON. After reviewing the Clinical Record for Patient #7, she verified on-site Hospice Aide Supervisory visit had not been conducted at least every 14 days as required.”