Compassionate Care Hospice

“Upon patient record review, 1 of 19 (Patient #3) did not contain an individualized written Plan of Care. The Plan of Care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The Plan of Care must include all services, and pertinent information, necessary for the palliation and management of the terminal illness and related conditions: Patient #3: The admission consent reflected that this patient had a DPOA-Healthcare, which was filed within the clinical record. However, this pertinent information was not included on the POC.”

“Upon patient record review, 1 of 19 (Patient #8) did not contain evidence that a written Hospice Plan of Care was established, and maintained in consultation with SNF/NF representatives. All Hospice care provided is in accordance with this Hospice Plan of Care: Patient #8: An 11/06/25 sacral wound order was obtained for, “Cleanse with wound cleanser, apply Dakin’s soaked gauze, cover with dry dressing. Provide wound care every day. SN to provide on days of nursing visits, and SNF staff on all other days.” The SN visit dated 11/10/25 documented, “Emily the SNF Wound Nurse did the wound care prior to my arrival.” The SN visit dated 11/17/25 documented, “Wound care not provided. SNF caregiver already completed.” The Hospice nurse documented her provision of such wound care on the 11/20/25 visit. The SN visit dated 11/26/25 documented, “Wound care not provided. SNF caregiver already completed.” There was no documentation located wherein the Hospice nurse collaborated with the SNF staff in order to ascertain that the Hospice nurse would provide the ordered wound care on her scheduled visit days.”

“Based on record review, and interview, the agency failed to review all of the patient’s medications that could affect drug therapy and ensure the accuracy of the patient’s medication for 3 (#1, #2, and #4) of 4 (#1, #2, #3, and #4) sampled patients reviewed. Findings: On 06/11/2025, a review of the agency’s policy titled, “Medication Management Policy-Louisiana” last reviewed on 07/30/2024 revealed in part…Medication Reconciliation: A medication count of Schedule II, III, and IV controlled substance medication will be done on every nursing visit. Patient #1Patient #1 was admitted to the agency on 11/20/2024 with diagnoses that included Atherosclerotic Heart Disease, Paroxysmal Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, and Chest Pain. Review of Patient #1’s SN (skilled nurse) visit notes dated 12/15/2024, 12/18/2024, 12/21/2024, and 01/02/2025 each revealed the patient was taking Tramadol for pain per the skilled nurse’s documentation. Review of Patient #1’s Client Medication List/Report revealed Tramadol was not listed as one of Patient #1’s medications. In an interview on 06/10/2025 at 1:45 p.m., S3 Clinical Manager stated she had spoken with Patient #1’s RN (Registered Nurse), S4 RN. S4 RN told S3 Clinical Manager that Patient #1 was on Tramadol when she was admitted. S3 Clinical Manager confirmed Tramadol was not listed on Patient #1’s medication list, but should have been. Patient #2Patient #2 was admitted to the agency on 10/18/2024 with diagnoses that included Hypertensive Heart Disease with Heart Failure, Hypothyroidism, Anemia, and Chronic Kidney Disease. Review of Patient #2’s physician’s orders revealed the following:10/24/2024: Xanax 0.25mg tablet one tablet by mouth two times daily as needed for anxiety. 11/30/2024: Lorazepam 0.5mg tablet one tablet by mouth every 6 hours as needed for anxiety or agitation, take if Xanax not effective. Review of the SN (Skilled Nurse) visit dated 01/08/2025 revealed the following medication count was documented by S2 RN:Ativan quantity: 30 tablets Xanax quantity: 88 tablets Review of the SN visit dated 01/13/2025 by S2 RN revealed the following medication count:Ativan quantity: 15 tabletsXanax quantity: 45 tablets Review of the SN visit dated 01/15/2025 by S2 RN revealed the following medication count:Ativan quantity: 30 tabletsXanax quantity: 20 tablets In an interview on 06/10/2025 at 9:35 a.m., S3 Clinical Manager reviewed the medication counts and confirmed they could not be correct based on Patient #2’s Physician’s orders. S3 Clinical Manager stated she called S2 RN who said she “felt like” the count of 88 Xanax was a typographical error because they do not order that many pills at a time. S3 Clinical Manager stated S2 RN said she had no idea why the Xanax count went from 45 tablets to 20 tablets from 01/13/2025 to 01/15/2025. S3 Clinical Manager stated S2 RN told her that she speaks to the medication nurse at Patient #2’s Assisted Living Facility who gives her the medication count and S2 RN said she doesn’t actually count the medications herself. S3 Clinical Manager stated that the hospice nurse should physically count the controlled medications with the nurse at the Assisted Living Facility, but did not. S3 Clinical Manager confirmed the Ativan count was incorrect and should not have decreased from 30 tablets to 15 tablets in 5 days, because the patient was only ordered to take two tablets per day.Review of Patient #2’s narcotic inventory logs at the Assisted Living Facility revealed the Ativan medication count documented on 01/13/2025 by S2 RN was incorrect and did not match the count at the Assisted Living Facility.Review of Patient #2’s narcotic inventory logs at the Assisted Living Facility revealed the Xanax medication counts documented by S2 RN on 01/03/2025, 01/06/2025, 01/08/2025, 01/13/2025, and 01/15/2025 were incorrect. In a telephone interview on 06/10/2025 at 11:40 a.m., the medication nurse for the Assisted Living Facility stated she either counts the hospice patients’ medications with S2 RN or she counts them by herself and gives the number to S2 RN on a piece of paper. The Assisted Living Facility nurse said there had been times when S2 RN would call back to the Assisted Living Facility and request the number of controlled medications after leaving the facility. In a telephone interview on 06/11/2025 at 10:25 a.m., S2 RN stated she reviews the medications with the floor nurse at the Assisted Living Facility when she visits. S2 RN stated the 88 Xanax she documented was definitely a typographical error because they don’t order that many medications at a time. S2 RN stated she discusses the medication count with the floor nurse who gives her the numbers of medications. S2 RN stated the floor nurse “may pull the drawer open at times and I look.” S2 RN stated the count may look wrong because the facility has an overflow system where they keep surplus medications elsewhere and the overflow may have not been counted. S2 RN confirmed she had never looked at the medication in the overflow area. S2 RN acknowledged the controlled medication counts for Patient #2 were incorrect and acknowledged she did not count the narcotics herself, but should have. Patient #4Patient #4 was admitted to the agency on 05/28/2024 with diagnoses that included Hypertensive Heart Disease with Heart Failure, Dyspnea, Anemia, Atrial Fibrillation, and Epilepsy. Review of Patient #4’s Physician’s orders revealed the following:05/30/2024: Lorazepam 0.5mg tablet every 6 hours by mouth as needed for anxiety. Review of Patient #4’s SN visits by S2 RN revealed the following medication counts of Lorazepam/Ativan:01/13/2025: 58 tablets01/15/2025: 30 tablets01/20/2025: 50 tablets01/24/2025: 50 tablets01/27/2025: 35 tablets01/29/2025: 41 tablets Review of Patient #4’s narcotic inventory logs at the Assisted Living Facility revealed the Ativan/Lorazepam medication count documented by S2 RN on 01/13/2025, 01/15/2025, 01/20/2025, 01/24/2025, 01/27/2025, and 01/29/2025 were incorrect. In a telephone interview on 06/10/2025 at 11:40 a.m., the medication nurse for the Assisted Living Facility stated she either counts the hospice patients’ narcotics with S2 RN or counts them by herself and gives the number to S2 RN on a piece of paper. She said there had been times when S2 RN would call back to the Assisted Living Facility and request the number of controlled medications after leaving the facility. In a telephone interview on 06/11/2025 at 10:25 a.m., S2 RN stated she reviews the medications with the floor nurse at the Assisted Living Facility when she visits. S2 RN stated she discusses the controlled medication count with the floor nurse who gives her the numbers of medications. S2 RN stated the floor nurse “may pull the drawer open at times and I look.” S2 RN stated the count may look wrong because the facility has an overflow system where they keep surplus medications elsewhere and the surplus may have not been counted. S2 RN confirmed she had never looked at the medication in the overflow area. S2 RN acknowledged the controlled medication counts for Patient #4 were incorrect and acknowledged she did not count the narcotics herself, but should have.”