My Hospice

“Based on record review and interview, the agency failed to ensure the physician signed the Do Not Resuscitate order on the advanced directive for 12 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #11, Patient #12, Patient #13, and Patient #14) of 14 (Patient #1, Patient #2, Patient #3, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, and Patient #14) sampled patients reviewed for advanced directives. Findings: Patient #1 Review of Patient #1s Louisiana Physician Orders for Scope of Treatment (LaPOST) dated 12/23/2023 revealed comfort focused treatment only, and no artificial tubes. Further review revealed the form was signed by Patient #1 but was not signed by the physician. Review of Patient #1s Hospice Do Not Resuscitate (DNR)/Do Not Intubate (DNI) Consent dated 12/24/2023 revealed Patient #1 signed requesting a DNR and DNI status; however, the physician had not signed the document. In an interview on 04/25/2024 at 10:04 a.m., S2Director of Nursing (DON) indicated neither the medical director nor Patient #1s attending physician had signed the order for DNR/DNI. Patient #2 Review of Patient #2s LaPOST dated 04/11/2024 revealed comfort focused treatment only, and no artificial tubes. Further review revealed the form was signed by Patient #2 but was not signed by the physician. Review of Patient #2s Hospice DNR/DNI Consent dated 04/11/2024 revealed Patient #2 signed requesting a DNR and DNI status; however, the physician had not signed the document. In an interview on 04/25/2024 at 10:49 a.m., S2DON indicated neither the medical director nor Patient #2s attending physician had signed the order for DNR/DNI. Patient #3 Review of Patient #3s LaPOST dated 01/04/2024 revealed DNR, comfort focused treatment only, and no artificial tubes. Further review revealed the form was signed by Patient #3 but was not signed by the physician. Review of Patient #3s Hospice DNR/DNI Consent dated 01/04/2024 revealed Patient #3 signed requesting a DNR and DNI status; however, the physician had not signed the document. In an interview on 04/25/2024 at 10:58 a.m., S2DON indicated neither the medical director nor Patient #3s attending physician had signed the order for DNR/DNI. Patient #4 Review of Patient #4s LaPOST dated 01/26/2024 revealed DNR, comfort focused treatment only, and long-term artificial nutrition by tube. Further review revealed the form was signed by Patient #4s caregiver but was not signed by the physician. Review of Patient #4s Hospice DNR/DNI Consent dated 01/26/2024 revealed Patient #4s caregiver signed requesting a DNR and DNI status; however, the physician had not signed the document. In an interview on 04/25/2024 at 11:07 a.m., S2DON indicated neither the medical director nor Patient #4s attending physician had signed the order for DNR/DNI. Patient #5 Review of Patient #5s LaPOST dated 01/12/2024 revealed DNR, comfort focused treatment only, and no artificial nutrition by tube. Further review revealed the form was signed by Patient #5s caregiver but was not signed by the physician. Review of Patient #5s Hospice DNR/DNI Consent dated 01/12/2024 revealed Patient #5s caregiver signed requesting a DNR and DNI status; however, the physician had not signed the document. In an interview on 04/25/2024 at 11:22 a.m., S2DON indicated neither the medical director nor Patient #5s attending physician had signed the order for DNR/DNI. Patient #6 Review of Patient #6s LaPOST dated 01/03/2024 revealed DNR, comfort focused treatment only, and no artificial nutrition by tube. Further review revealed the form was signed by Patient #6 but was not signed by the physician. Review of Patient #6s Hospice DNR/DNI Consent dated 01/03/2024 revealed Patient #6 signed requesting a DNR and DNI status; however, the physician had not signed the document. In an interview on 04/25/2024 at 11:33 a.m., S2DON indicated neither the medical director nor Patient #6s attending physician had signed the order for DNR/DNI. Patient #7 Review of Patient #7s LaPOST dated 09/26/2023 revealed DNR, comfort focused treatment only, and no artificial nutrition by tube. Further review revealed the form was signed by Patient #7 but was not signed by the physician. Review of Patient #7s Hospice DNR/DNI Consent dated 09/26/2023 revealed Patient #7 signed requesting a DNR and DNI status; however, the physician had not signed the document. In an interview on 04/25/2024 at 11:38 a.m., S2DON indicated neither the medical director nor Patient #7s attending physician had signed the order for DNR/DNI. Patient #8 Review of Patient #8s Record revealed no documented evidence and the agency presented no documented evidence of a LaPOST had been completed for Patient #8. Review of Patient #8s Hospice DNR/DNI Consent dated 09/06/2021 revealed Patient #8s caregiver signed requesting a DNR and DNI status; however, the physician had not signed the document. In an interview on 04/25/2024 at 11:56 a.m., S2DON indicated neither the medical director nor Patient #8s attending physician had signed the order for DNR/DNI. Patient #11 Review of Patient #11s LaPOST dated 02/23/2024 revealed comfort focused treatment only. Further review revealed the form was signed by Patient #11 but was not signed by the physician. Review of Patient #11s Hospice DNR/DNI Consent dated 02/23/2024 revealed Patient #11 signed requesting a DNR and DNI status; however, the physician had not signed the document. In an interview on 04/25/2024 at 11:22 a.m., S2DON indicated neither the medical director nor Patient #11s attending physician had signed the order for DNR/DNI. Patient #12 Review of Patient #12s LaPOST dated 01/11/2024 revealed DNR, comfort focused treatment only, and no artificial nutrition by tube. Further review revealed the form was signed by Patient #12s caregiver but was not signed by the physician. Review of Patient #12s Hospice DNR/DNI Consent dated 01/11/2024 revealed Patient #12s caregiver signed requesting a DNR and DNI status; however, the physician had not signed the document. In an interview on 04/25/2024 at 12:26 p.m., S2DON indicated neither the medical director nor Patient #12s attending physician had signed the order for DNR/DNI. Patient #13 Review of Patient #13s Record revealed no documented evidence and the agency presented no documented evidence of a LaPOST had been completed for Patient #13. Review of Patient #13s Hospice DNR/DNI Consent dated 05/11/2023 revealed Patient #13s caregiver signed requesting a DNR and DNI status; however, the physician had not signed the document. In an interview on 04/25/2024 at 12:29 p.m., S2DON indicated neither the medical director nor Patient #13s attending physician had signed the order for DNR/DNI. Patient #14 Review of Patient #14s LaPOST dated 10/10/2023 revealed DNR, comfort focused treatment only, and no artificial nutrition by tube. Further review revealed the form was signed by Patient #14s caregiver but was not signed by the physician. Review of Patient #14s Hospice DNR/DNI Consent dated 10/10/2023 revealed Patient #14s caregiver signed requesting a DNR status; however, the physician had not signed the document. In an interview on 04/25/2024 at 12:37 p.m., S2DON indicated neither the medical director nor Patient #14s attending physician had signed the order for DNR.”

“Based on record review and interview the agency failed to ensure the chaplain and/or medical social worker (MSW) assessed the patient within 5 days after the election of hospice services for 9 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #7, Patient #10, Patient #11, Patient #13) of 14 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, and Patient #14) sampled patients reviewed for completed assessments. Findings: Patient #1 Review of Patient #1s record revealed Patient #1 was admitted to the agency on 12/24/2023. Further review revealed no documented evidence and the agency presented no documented evidence the chaplain completed an initial spiritual assessment until 01/10/2024. In an interview on 04/25/2024 at 10:04 a.m., S2Director of Nursing (DON) indicated the agency had no documented evidence Patient #1 was assessed by the chaplain within 5 days of admit, nor did the agency have documented evidence as to the reason as to why the chaplain did not provide services/assessment within 5 days of admission. Patient #2 Review of Patient #2s record revealed Patient #2 was admitted to the hospice on 04/11/2024. Further review revealed no documented evidence and the agency presented no documented evidence the chaplain completed an initial spiritual assessment within 5 days of admission. In an interview on 04/25/2024 at 10:49 a.m., S2DON indicated the agency had no documented evidence Patient #2 was assessed by the chaplain within 5 days of admit, nor did the agency have documented reason why the chaplain did not provide services/assessment within 5 days of admission. Patient #3 Review of Patient #3s record revealed Patient #3 was admitted to the hospice on 01/04/2024. Further review revealed no documented evidence and the agency presented no documented evidence the chaplain completed an initial spiritual assessment within 5 days of admission. In an interview on 04/25/2024 at 10:58 a.m., S2DON indicated the agency had no documented evidence Patient #3 was assessed by the chaplain within 5 days of admit, nor did the agency have documented reason why the chaplain did not provide services/assessment within 5 days of admission. Patient #4 Review of Patient #4s record revealed Patient #4 was admitted to the hospice on 01/26/2024. Further review revealed the first documented evidence of a chaplain visit and/or spiritual assessment had been completed was dated 02/05/2024. In an interview on 04/25/2024 at 11:07 a.m., S2DON indicated the agency had no documented evidence as to the reason why the chaplain did not assess Patient #4 within 5 days of admission. Patient #5 Review of Patient #5s record revealed Patient #5 was admitted to the hospice on 01/12/2024. Further review revealed the first documented evidence of a chaplain visit and/or spiritual assessment had been completed was dated 01/29/2024. In an interview on 04/25/2024 at 11:22 a.m., S2DON indicated the agency had no documented reason why the chaplain did not assess Patient #5 within 5 days of admission. Patient #7 Review of Patient #7s record revealed Patient #7 was admitted to the hospice on 09/26/2023. Further review of Patient #7s record revealed the first documented evidence a MSW visit and/or psychosocial assessment had been completed was dated on 12/01/2023. Patient #7s record revealed the first documented evidence a chaplain and/or spiritual assessment was completed on 12/29/2023. In an interview on 04/25/2024 at 11:38 a.m., S2DON indicated the agency had no documented reason why Patient #7 was not assessed by the chaplain and MSW within 5 days of admission. Patient #10 Review of Patient #10s record revealed Patient #10 was admitted to the agency on 04/02/2024. Further review revealed no documented evidence and the agency presented no documented evidence Patient #10 had a chaplain visit and/or spiritual assessment since admit. In an interview on 04/25/2024 at 12:15 p.m., S2DON indicated the agency had no documented evidence Resident #10 had a chaplain visit and/or spiritual assessment within 5 days of admission. Patient #11 Review of Patient #11s record revealed Patient #11 was admitted to the agency on 02/23/2024. Further review revealed the first documented evidence a chaplain visit and/or spiritual assessment was completed was 03/04/2024. In an interview on 04/25/2024 at 12:22 p.m., S2DON indicated the agency had no documented reason why Patient #11 was not assessed by the chaplain within 5 days of admission. Patient #12 Review of Patient #12s record revealed Patient #12 was admitted to the agency on 01/11/2024. Further review revealed the first documented chaplain visit and/or spiritual assessment was completed on 01/26/2024. In an interview on 04/25/2024 at 12:26 p.m., S2DON indicated the agency had no documented reason why Patient #12 was not assessed by the chaplain within 5 days of admission. Patient #13 Review of Patient #13s record revealed Patient #13 was admitted to the agency on 05/11/2023 and expired on 05/19/2023. Further review revealed no documented evidence and the agency was unable to present any documented evidence that Patient #13 had either a MSW or chaplain visit prior to Patient #13 expiring on 05/19/2023. In an interview on 04/25/2024 at 12:29 p.m., S2DON indicated the agency had no documented evidence MSW and/or chaplain visits were completed with 5 days of admission, or the reason as to why the required visits and assessments were not completed.”

“Based on record review and interview, the agency failed to develop an individualized care plan for all of the patients diagnoses for 4 (Patient #1, Patient #2, Patient #3, and Patient #5) of 14 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, and Patient #14) sampled patients reviewed for comprehensive care plans. Findings: Patient #1 Review of Patient #1s Patient Intake form revealed Patient #1 had diagnoses of, in part, liver cell carcinoma (cancer), alcoholic cirrhosis of the liver (liver damage caused by excess alcohol intake), chronic obstructive pulmonary disease (disorder of the respiratory tract), gastrointestinal hemorrhage (bleeding of the gastrointestinal system), and alcohol abuse. Review of Patient #1s Plan of Care/Interdisciplinary Group (IDG) Review dated 03/22/2024 revealed, in part, Patient #1 was still drinking beer daily, and Patient #1 had pain medication stolen three times. Review of Patient #1s Nursing Progress Note dated 04/04/2023 revealed, in part, Patient #1 had a fall in the shower. Review of Patient #1s Current Plan of Care with an open date of 01/04/2024 revealed the only problems care planned for Patient #1 was for pain and altered respiratory status. Further review revealed no documented evidence and the agency presented no documented evidence of a plan of care developed for monitoring Patient #1s liver function, for gastrointestinal hemorrhage, alcohol intake, falls, or stolen pain medications. In an interview on 04/25/2024 at 10:04 a.m., S2Director of Nursing (DON) indicated Patient #1s care plan was not comprehensive and did not cover interventions for all of Patient #1s diagnoses and/or concerns. Patient #2 Review of Patient #2s Patient Intake form revealed Patient #2 had diagnoses of, in part, Alzheimers disease (disorder of the brain which affects memory and decision making); Diabetes Mellitus (disorder which affects the bodys ability to regulate glucose); Hypertensive Chronic Kidney Disease (disorder which affects the kidneys ability to filter the blood); and Congestive Heart Failure (disorder which affects the hearts ability to pump blood effectively to the body). Review of Patient #2s Current Plan of Care with an open date of 04/12/2024 revealed the only problems care planned for Patient #2 was, Patient #2 had the potential for alteration of skin; potential for altered neurological status; potential for altered nutritional status; and potential for pain. Further review revealed no documented evidence and the agency presented no documented evidence of a plan of care developed to monitor Patient #2s diabetes mellitus, chronic kidney disease, and/or congestive heart failure. In an interview on 04/25/2024 at 10:49 a.m., S2DON indicated Patient #2s care plan was not comprehensive and did not contain interventions for all of Patient #2s diagnoses. Patient #3 Review of Patient #3s Patient Intake form revealed Patient #3 had diagnoses of, in part, Cerebral Infarction (stroke); Cortical Blindness (disorder which affects the patients eye sight) Diabetes Mellitus; Hypertensive Chronic Kidney Disease; and Pulmonary Embolism (condition in which a clot blocks blood flow in the lungs). Review of Patient #3s Current Plan of Care with an open date of 01/16/2024 revealed the only problems care planned for Patient #3 was, Patient #3 had constipation, potential for alternation of skin, potential for alternate neurological status, and potential for pain. Further review revealed no documented evidence and the agency presented no documented evidence of a plan of care developed for Patient #3s cortical blindness, Diabetes Mellitus, Hypertensive Chronic Kidney Disease, and/or Pulmonary Embolism. In an interview on 04/25/2024 at 10:58 a.m., S2DON indicated Patient #3s plan of care did not cover all of Patient #3s diagnoses with appropriate interventions for each diagnoses. Patient #5 Review of Patient #5s Patient Intake form revealed Patient #5 had diagnoses of, in part, Vascular Dementia (condition which affects memory and decision making); Hypertension (high blood pressure); Congestive Heart Failure; and Diabetes Mellitus. Review of Patient #5s Current Plan of Care with an open date of 01/18/2024 revealed the only problems care planned for Patient #5 was incontinence, fall risk, agitation, potential for altered nutrition, and potential for pain. Further review revealed no documented evidence and the agency presented no documented evidence a plan of care was developed for Patient #5s hypertension, congestive heart failure, and/or diabetes mellitus. In an interview on 04/25/2024 at 11:22 a.m., S2DON indicated Patient #5s plan of care did not cover all Patient #5s diagnoses with appropriate interventions for each diagnoses.”

“Based on record review and interview the agency failed to ensure a skilled nurse visit was completed as required per the plan of care for 1 (Patient #1) of 14 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, and Patient #14) sampled patients reviewed for care and services per the plan of care. Findings: Review of Patient #1s Hospice Plan of Care and Frequency for certification period of 03/23/2024 to 06/20/2024 revealed Patient #1 was to receive skilled nursing services one to three times a week. Review of Patient #1s record revealed no documented evidence and the agency presented no documented evidence Patient #1 received skilled nursing services for the week of 04/07/2024 through 04/13/2024. In an interview on 04/25/2024 at 10:04 a.m., S2Director of Nursing indicated the agency had no documented evidence a visit was made or a reason as to why a skilled nurse visit was not completed.”

“Based on record review and interview, the agency failed to: 1. Collect data on problem prone areas for hospice of pain and shortness of breath; and 2. Use administrative data for volunteer services, durable medical equipment, pharmaceutical services, and clinical records as part of the program. Findings: 1. Review of the agencys Quality Assurance and Performance Improvement (QAPI) Binder revealed no documented evidence and the agency presented no documented evidence the agency had collected data on the agencys patients regarding signs and symptoms or verbal complaints of pain and/or shortness of breath. In an interview on 04/24/2024 at 3:23 p.m., S2Directof of Nursing (DON) indicated he had not gathered any data related to pain and/or shortness of breath. S2DON further indicated he monitored pain and shortness of breath when he completes patient visits, but did not collect the data and use it as part of the QAPI program to monitor for negative outcomes which would trigger a performance improvement project. 2. Review of the agencys QAPI Binder revealed no documented evidence of volunteer services, durable medical equipment, and pharmaceutical services had been reviewed with measurable data for the QAPI program. Further review revealed no documented evidence and the agency presented no documented evidence of data collected on the area of concern of electronic medical record documentation. In an interview on 04/24/2024 at 3:23 p.m., S2Directof of Nursing (DON) indicated he had not gathered the data on administrative items like durable medical equipment, pharmaceutical services, clinical records, and volunteer services. S2DON further indicated he did not document any record reviews into trackable data, nor had he compared each quarter and looked for trends which would require corrective action. In an interview on 04/24/2024 at 4:00 p.m., S1Administrator indicated the data was not being complied and analyzed appropriately for the agencys QAPI program.”

“Based on record review, interview, and observation the agency failed to ensure a registered nurse assessed and measured wounds weekly to monitor for wound healing. This deficient practice was identified for 3 (Patient #4, Patient #7, and Patient #9) of 3 (Patient #4, Patient #7, and Patient #9) sampled patients reviewed for wound care measurements. Findings: Review of the Wound Ostomy and Continence Nurses Society’s Guidelines revealed assessment and documentation of wound status, which includes comprehensive clinical data demonstrating evidence of progress in healing or failure to heal. Comprehensive wound assessment includes: dimensions and depth; presence, location and depth of any sinus tracts or undermining areas; status and characteristics of the wound bed; volume, color, and odor of exudates; evidence of infection in surrounding tissues. Further review revealed when recorded over time this information can be used to track the progress of wound healing. Patient #4 Review of Patient #4s Hospice Plan of Care and Frequency for certification period of 01/26/2024 to 04/24/2024 revealed Patient #4 was to receive skilled nursing services one to three times a week. Review of Patient #4s Initial Assessment dated 01/26/2024 revealed Patient #4 was assessed as having a stage III ulcer (wound which extends into the fat tissue) of the sacrum measuring 3 centimeter (cm) by 3 cm by 0.2 cm. Review of Patient #4s Skilled Nursing Notes dated 01/31/2024, 02/09/2024, 02/16/2024, and 02/19/2024 revealed no documented evidence and the agency did not present any documented evidence of wound care measurements and/or wound care assessments being completed for the above mentioned wound. Review of Patient #4s Skilled Nursing Note dated 02/27/2024 revealed no documented evidence and agency presented no documented of Patient #4s sacral wound was assessed and measured weekly as required. Review of Patient #4s Skilled Nursing Notes dated 03/08/2024, 03/12/2024, 03/19/2024, 04/03/2024, and 04/15/2024 revealed no documented evidence Patient #4s sacral wound was assessed and measured weekly as required. In an interview on 04/25/2024 at 11:07 a.m., S2Director of Nursing (DON) indicated the agency did not have weekly wound care measurements, and he was unaware wound care measurements needed to be obtained weekly. Patient #7 Review of Patient #7s Hospice Plan of Care and Frequency for certification period of 03/24/2024 to 05/22/2024 revealed Patient #7 was to receive skilled nursing services one to two times a week. Review of Patient #7s Nursing Progress Note dated 02/06/2024 revealed Patient #7 continued to have breakdowns of his skin at multiple sites. Further review revealed no documented evidence and the agency presented no documented evidence as to the location, assessment, and measurement of Patient #7s wounds. Review of Patient #7s Nursing Progress Note dated 03/28/2024 revealed no documented evidence and the agency presented no documented evidence as to the location, assessment, and measurement of Patient #7s wounds. Review of Patient #7s Nursing Progress Note dated 04/03/2024 revealed Patient #7 continued to have breakdowns to his skin elbows, heel, and sacrum. Further review revealed no documented evidence and the agency presented no documented evidence as to the location, assessment, and measurement of Patient #7s wounds. Review of Patient #7s Nursing Progress Note dated 04/04/2024 revealed no documented evidence and the agency presented no documented evidence as to the location, assessment, and measurement of Patient #7s wounds. Review of Patient #7s Nursing Progress Note dated 04/10/2024 revealed Patient #7 continued to have breakdowns on Patient #7s skin. Further review revealed no documented evidence and the agency presented no documented evidence as to the location, assessment, and measurement of Patient #7s wounds. Review of Patient #7s Nursing Progress Note dated 04/15/2024 no documented evidence and the agency presented no documented evidence as to the location, assessment, and measurement of Patient #7s wounds. In an interview on 04/22/2024 at 10:28 a.m., S2DON indicated the agency had only documented wound care measurements on the comprehensive assessments, and was not aware wound care measurements were required weekly. Resident #9 Review of Patient #9s Skilled Nursing Note dated 02/15/2024 revealed Patient #9 was assessed as having a stage III to the sacrum measuring 2.5 cm by 2.5 cm by 0.2cm. Review of Patient #9s Hospice Plan of Care and Frequency for certification period of 03/27/2024 to 05/25/2024 revealed Patient #9 was to receive skilled nursing services one to three times a week. Review of Patient #9s Skilled Nursing Note dated 03/28/2024 revealed no documented evidence and the agency did not present any documented evidence of a wound care assessment being completed or wound care measurements being taken as required. Review of Patient #9s Skilled Nursing Note dated 04/04/2024 revealed Patient #9s sacral wound was scabbed. Further review revealed no documented evidence of Patient #9s sacral wound measurements being taken as required. Observation on 04/19/2024 at 2:05 p.m. revealed Patient #9 had an open wound to the sacrum approximately 0.5 cm by 0.5 cm with pale pink moist tissue. Further observation revealed S2DON visualized Patient #9s sacral wound but did not measure Patient #9s wound. In an interview on 04/25/2024 at 12:08 p.m., S2DON indicated the nurses had not been measuring wounds weekly. S2DON further indicated the nurses were visualizing the wounds weekly but not measuring or documenting the wound assessment weekly.”

“Based on record review and interview the agency failed to ensure a registered nurse made an on-site hospice aide supervisory visit for 1 (Patient #6) of 10 (Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #8, Patient #9, Patient #10, Patient #11, and Patient #12) sampled patients who received hospice aide services. Findings: Review of Patient #6s Hospice Plan of Care and Frequency for certification period 04/02/2024 to 06/30/2024 revealed, in part, Patient #6 was to receive hospice aide services two to four times a week. Review of Patient #6s record revealed, in part, Patient #6 received hospice aide services on 04/03/2024, 04/05/2024, 04/08/2024, 04/10/2024, 04/12/2024, 04/15/2024, 04/17/2024, and 04/19/2024. Further review revealed Patient #6s last documented on-site hospice aide supervisory visit completed by a registered nurse was on 04/04/2024. The agency was not able to present any documented evidence an on-site hospice aide supervisory visit completed by a registered nurse for Patient #6 after 04/04/2024. In an interview on 04/25/2024 at 11:33 a.m., S2Director of Nursing indicated an on-site hospice aide supervisory visit by a registered nurse had not been completed since 04/04/2024 and should have been completed by 04/18/2024.”

“Based on record review and interview, the agency failed to: 1. Ensure only unpaid volunteer hours were used to calculate the level of volunteer activity; 2. Ensure only direct patient care and/or administrative services were used to calculate level of volunteer activity; and 3. Have documented evidence the level of activity had been calculated for 2023. Findings: 1. Review of the agencys Volunteer Binder, which was presented to the surveyor as the completed volunteer information for 2023, revealed volunteer hours for: -S11Volunteer on 06/20/2023 for clerical work from 8:30 a.m. through 5:00 p.m. Further review revealed the section for total financial equivalent and based on hourly rate were left blank. Review revealed a check was attached in the amount of $160.00 with subject line of 8 hours of hospice volunteer. -S12Volunteer on 06/20/2023 for clerical work from 8:30 a.m. through 5:00 p.m. Further review revealed the section for total financial equivalent and based on hourly rate were left blank. Review revealed a check was attached in the amount of $160.00 with subject line of 8 hours of hospice volunteer. In an interview on 04/24/2024 at 2:53 p.m., S1Administration indicated she was under the impression she could have paid for the volunteer services and used this information in her calculations. 2. Review of the agencys Volunteer Binder, which was presented to the surveyor as the completed volunteer information for 2023, revealed volunteer hours for: -S3Volunteer on 10/07/2023 for painting the office from 8:30 a.m. through 5:00 p.m.; 10/08/2023 for painting the office from 8:30 a.m. through 5:00 p.m. In an interview on 04/24/2024 at 2:53 p.m., S1Administrator indicated she was unaware she could not use painting services when calculating level of volunteer activity. 3. Review of Volunteer Activity Reports binder completed on 04/24/2024 at 11:10 a.m. revealed no documented evidence level and the agency did not present any documented evidence that the level of volunteer activity was calculated for volunteers for 2023. In an interview on 04/24/2024 at 2:53 p.m., S1Administrator stated she had not figured out the level of volunteer activity for 2023 and would have to run reports for the cost savings.”

“Based on record review and interview, the agency failed to ensure the nursing notes documented: 1. Monitoring the effectiveness of the patients pain medication regimen (Patient #1, Patient #2, Patient #3, and Patient #4) 2. Monitoring for alteration in skin integrity (Patient #2, Patient #3, Patient #4, and Patient #8); 3. Monitoring for changes in neurological status (Patient #2); 4. Monitoring for nutritional status changes (Patient #2); and 5. Monitoring for changes in cardiac status (Patient #4). This deficient practice was identified for 5 (Patient #1, Patient #2, Patient #3, Patient #4, and Patient #8) of 14 (Patient #1, Patient #2, Patient #3, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, and Patient #14) sampled patients records reviewed for care and services per the plan of care. Findings: Patient #1 Review of Patient #1s Patient Intake form revealed Patient #1 had diagnoses of, in part, liver cell carcinoma (cancer), alcoholic cirrhosis of the liver (liver damage caused by excess alcohol intake), chronic obstructive pulmonary disease (disorder of the respiratory tract), gastrointestinal hemorrhage (bleeding of the gastrointestinal system), and alcohol abuse. Review of Patient #1s Current Plan of Care with an open date of 01/04/2024 revealed the only problems care planned for Patient #1 was, in part: - Patient #1 was uncomfortable due to pain at admission with interventions of, in part, assess/monitor pain and severity at every visit, and monitor/assess the effectiveness of current and new medication/treatment; Review of Patient #1s Nursing Progress Notes dated 04/04/2024 revealed the only information documented on Patient #1s Nursing Progress Note was vital signs of temperature, pulse, respiratory rate, blood pressure, and oxygen saturation. Further review revealed the question of, is pain controlled to a comfortable level with current intervention was left blank and the narrative did not include any documentation and the agency presented no documented evidence Patient #1s current pain regimen was assessed. In an interview on 04/25/2024 at 10:04 a.m., S2Director of Nursing (DON) indicated the nursing progress notes mentioned above did not contain information to support Patient #1s pain regimen was being assessed per the plan of care. Patient #2 Review of Patient #2s Patient Intake form revealed Patient #2 had diagnoses of, in part, Alzheimers disease (disorder of the brain which affects memory and decision making). Review of Patient #2s Current Plan of Care with an open date of 04/12/2024 revealed problems care planned for Patient #2 was: -Patient #2 had the potential for alteration of skin with intervention of assess Patient #2 for alternation in skin integrity every visit, and assess effectiveness of current and new medication/treatment; -Patient #2 had the potential for altered neurological status with intervention of assess Patient #2 for changes in neurological/sensory status; -Patient #2 had the potential for altered nutritional status with intervention of assess nutritional status needs every visit; and -Patient #2 had the potential for pain with intervention of assess monitor pain and severity every visit, assess and report non-verbal pain, and assess effectiveness of current and new medication/treatment. Review of Patient #2s Nursing Progress Notes dated 04/18/2024 revealed the only information documented on Patient #2s Nursing Progress Note was vital signs of temperature, pulse, respiratory rate, and blood pressure; date of last bowel movement; and no edema. Further review revealed no other documentation was completed for skin assessment, neurological assessment, nutritional assessment, and/or pain assessment. In an interview on 04/25/2024 at 10:49 a.m., S2DON indicated the nurses note dated 04/18/2024 was not completed and did not contain documentation which monitoring of Patient #2s cardiac status, nutritional status, response to pain medication regimen, and changes in skin status per Patient #2s plan of care. Patient #3 Review of Patient #3s Patient Intake form revealed Patient #3 had diagnoses of, Cerebral Infarction (stroke). Review of Patient #3s Current Plan of Care with an open date of 01/16/2024 revealed problems care planned for Patient #3 was: -Patient #3 had the potential for alteration of skin with intervention of assess for alteration in skin integrity every visit; -Patient #3 had the potential for pain with intervention of assess/monitor for pain every visit and monitor for effectiveness of current and new medication/treatment; and Review of Patient #3s Nursing Progress Notes dated 04/03/2024 revealed no documented evidence of an assessment of Patient #3s skin integrity; and/or pain control assessment for current medication. Review of Patient #3s Nursing Progress Notes dated 04/03/2024 revealed no documented evidence of an assessment of Patient #3s skin integrity; and/or pain control assessment for current medication. In an interview on 04/25/2024 at 10:58 a.m., S2DON indicated the above mentioned notes did not support ongoing assessment of skin status and pain regimen effectiveness per the plan of care. Patient #4 Review of Patient #4s Patient Intake form revealed Patient #4 had diagnoses of, in part, congestive heart failure (condition where the heart does not pump blood to the body effectively); pressure ulcer (wound caused by pressure); and convulsions (seizures). Review of Patient #4s Current Plan of Care with an open date of 02/01/2024 revealed problems care planned for Patient #4 was: -Patient #4 had the potential for altered cardiac status with intervention of assess/monitor cardiac status every visit, and assess effectiveness of current medication/treatment; -Patient #4 had wounds and potential for alternation of skin with interventions of, in part, assess alteration in skin integrity every visit, assess changes in wound status; and -Patient #4 uncomfortable due to pain at admission with interventions of, in part, assess pain and severity every visit, monitor for effectiveness of current medication/treatment. Review of Patient #4s Nursing Progress Notes dated 01/31/2024 revealed no documented evidence of Patient #4s pain control with current medication had been assessed, Patient #4s skin integrity had been assessed, nor Patient #4s cardiac status had been assessed. Review of Patient #4s Nursing Progress Notes dated 02/09/2024 revealed no documented evidence of Patient #4s pain control with current medication had been assessed, nor Patient #4s cardiac status had been assessed. Review of Patient #4s Nursing Progress Notes dated 02/09/2024 revealed no documented evidence of Patient #4s pain control with current medication had been assessed, nor Patient #4s cardiac status had been assessed. Review of Patient #4s Nursing Progress Notes dated 02/19/2024 revealed no documented evidence of Patient #4s pain control with current medication had been assessed, nor Patient #4s cardiac status had been assessed. Review of Patient #4s Nursing Progress Notes dated 02/27/2024 revealed no documented evidence of Patient #4s pain control with current medication had been assessed, nor Patient #4s cardiac status had been assessed. In an interview on 04/25/2024 at 11:07 a.m., S2DON indicated the above mentioned notes did not support care had been provided per the plan of care for monitoring of Patient #4s cardiac status, alterations in skin integrity, and assessment of effectiveness of Patient #4s current pain medication regimen. Patient #8 Review of Patient #8s Patient Intake form revealed Patient #8 had diagnoses of, in part, Alzheimers Disease and Dementia. Review of Patient #8s Current Plan of Care with an open date of 03/11/2024 revealed problems care planned for Patient #8 was Patient #8 had potential for alteration of skin integrity with interventions of, in part, assess for alteration in skin integrity every visit. Review of Patient #8s Nursing Progress Notes dated 04/04/2024 and 04/11/2024 revealed no documented evidence of Patient #8s skin integrity had been assessed. In an interview on 04/25/2024 at 11:56 a.m., S2DON indicated the above mentioned notes did not support assessment of Patient #8s skin for alteration in skin integrity.”

“Based on record review and interview the agency failed to to maintain documented evidence the medical director completed the recertification of terminal illness for every certification period. This deficient practice was identified for 6 (Patient #1, Patient #3, Patient #7, Patient #8, Patient #9, and Patient #13) of 14 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, and Patient #14) sampled patients reviewed for certification of terminal illness (CTI). Findings: Patient #1 Review of Patient #1s record revealed an admit date of 12/24/2023. Review of Patient #1s record revealed Patient #1s current certification period was 03/23/2024 to 06/20/2024. Further review revealed no documented evidence and the agency presented no documented evidence the medical director had recertified Patient #1s CTI prior to or after the beginning of Patient #1s certification period 03/23/2024 to 06/20/2024. In an interview on 04/25/2024 at 10:04 a.m., S2Director of Nursing (DON) indicated the agency had not been requesting CTI for every certification period and had only requested CTI from the medical director every six months. Patient #3 Review of Patient #3s record revealed an admit date of 01/04/2024. Review of Patient #3s record revealed Patient #3s current certification period was 04/03/2024 to 07/01/2024. Further review revealed no documented evidence and the agency presented no documented evidence the medical director had recertified Patient #3s CTI prior to or after the beginning of Patient #3s certification period of 04/03/2024 to 07/01/2024. In an interview on 04/25/2024 at 10:58 a.m., S2DON indicated the agency had not been requesting CTI for every certification period and had only requested CTI from the medical director every six months. Patient #7 Review of Patient #7s record revealed an admit date of 09/26/2023. Review of Patient #7s record revealed Patient #7s current certification period was 03/24/2024 to 05/22/2024. Further review of Patient #7s record revealed no documented evidence and the agency presented no documented evidence the medical director had recertified Patient #7s CTI prior to or after the beginning of Patient #7s certification period of 03/24/2024 to 05/22/2024. In an interview on 04/25/2024 at 11:38 a.m., S2DON indicated the agency had not been requesting CTI for every certification period and had only requested CTI from the medical director every six months. Patient #8 Review of Patient #8s record revealed an admit date of 09/06/2021. Review of Patient #8s record revealed Patient #8s current certification period was 02/23/2024 to 04/22/2024. Further review revealed no documented evidence and the agency presented no documented evidence the medical director had recertified Patient #8s CTI since the certification period 03/05/2022 to 05/03/2022. In an interview on 04/25/2024 at 11:56 a.m., S2DON indicated the agency had not been requesting CTI every certification period and had only requested CTI from the medical director every six months. S2DON further indicated the agency did not have a reason why a CTI had not been completed since the certification period of 03/05/2022 to 05/03/2022. Patient #9 Review of Patient #9s record revealed an admit date of 08/12/2022. Review of Patient #9s record revealed Patient #9s current certification period was 03/27/2024 to 05/25/2024. Further review of Patient #9s record revealed no documented evidence and the agency presented no documented evidence the medical director had recertified Patient #9s CTI since the certification period 10/04/2022 to 12/02/2022. In an interview on 04/25/2024 at 12:08 p.m., S2DON indicated the agency had not been requesting CTI every certification period and had only requested CTI from the medical director every six months. S2DON further indicated the agency did not have a reason why a CTI had not been completed since the certification period 10/04/2022 to 12/02/2022. Patient #13 Review of Patient #13s record revealed an admit date of 05/11/2023. Further review revealed no documented evidence and the agency presented no documented evidence of a CTI having been completed. In an interview on 04/25/2024 at 12:29 p.m., S2DON indicated the agency had no documented evidence Patient #13s CTI had been completed.”

“Based on record review and interview, the agency failed to: 1. Conduct criminal background checks upon hire per state requirements for unlicensed personnel (S3Volunteer and S4Chaplain); and 2. Conduct a criminal background check within three months of the date of employment for licensed personnel (S2Director of Nursing (DON)); and This deficient practice was identified for 3 (S2DON, S3Volunteer, and S4Chaplain) of 10 (S1Administrator, S2DON, S3Volunteer, S4Chaplain, S5Licensed Practical Nurse (LPN), S6Hospice Aide (HA), S7Medical Social Worker (MSW), S8Medical Director, S9Office Manager, S10Alternate DON). Findings: 1. Review of Louisiana Revised Statue 40:1203.2 revealed prior to any employer making an offer to employ or to contract with a non-licensed person or any licensed ambulance personnel to provide nursing care, health-related services, medic services, or supportive assistance to any individual, the employer shall request that a criminal history and security check be conducted on the non-licensed person. S3Volunteer Review of S3Volunteers personnel file revealed, in part, S3Volunteers start date was 08/04/2023. Further review revealed no documented evidence, and the agency did not present any documented evidence a criminal background check was completed prior to hire. Review of S4Chaplains personnel file revealed, in part, S4Chaplains date of hire was 07/15/2023. Further review revealed no documented evidence, and the agency did not present any documented evident a criminal background check was completed prior to hire. 2. Review of S2DONs personnel file revealed a date of hire of 09/25/2023. Further review of S2DONs personnel file revealed no documented evidence and the agency was unable to present documented evidence the agency had completed a criminal background check since S2DONs date of hire. In an interview on 04/24/2024 at 12:10 p.m., S9Office Manager indicated she was the person responsible for completing criminal background checks on staff. S9Office Manager stated S3Volunteer and S4Chaplain required a criminal background check upon hire; however, she was on vacation and the criminal background checks were not completed in the required timeframe. S9Office Manager further indicated she was not aware S2DON was required to have a criminal background check; therefore, a criminal background check was not completed as required.”