Gulf South Hospice of New Orleans

“Based on interview and record reviews, the agency failed to ensure a registered nurse (RN) completed an initial assessment within 48 hours of the election of hospice care for 1 (Patient #2) of 3 (Patient #1, Patient #2, Patient #3) sampled patients reviewed admission requirements. Findings: Review of Patient #2’s Advanced Beneficiary Notice (ABN) Election Statement dated 06/06/2025 revealed, in part, Patient #2 elected hospice services on 06/06/2025. Review of Patient #2’s Hospice Initial/Comprehensive Nursing Assessment dated 06/06/2025 revealed an initial comprehensive admission assessment was completed, but was unsigned by the assessing clinician. In an interview on 06/10/2025 at 1:30PM, S2Director of Nursing (DON) indicated S7Licensed Practical Nurse, a contract nurse, completed Patient #2’s initial comprehensive nursing assessment on 06/06/2025. S2DON further indicated Patient #2 did not have an initial comprehensive assessment and/or any type assessment by a RN from admission to present.”

“Based on interviews and record reviews, the agency failed to ensure services were provided in accordance with the plan of care for 3 (Patient #1, Patient #2, Patient #3) of 3 (Patient #1, Patient #2, Patient #3) sampled patients reviewed for plan of care requirements. Findings: Patient #1Review of Patient #1’s updated comprehensive patient plan of care for the certification period of 04/11/2025 to 07/09/2025 revealed, in part, Patient #1 was to receive skilled nursing services once a week. Review of Patient #1’s record revealed the only service provided by a skilled nurse for the weeks of, 04/20/2025 through 04/26/2025 and 06/01/2025 through 06/07/2025, was a hospice aide supervisory visit. There was no documented evidence, and the agency did not present any documented evidence, a skilled nurse had provided assessments, nursing skills, or education during the weeks of 04/20/2025 through 04/26/2025 and 06/01/2025 through 06/07/2025. In an interview on 06/11/2025 at 12:52PM, S2Director of Nursing (DON) indicated the agency had no documented evidence skilled nursing visits were completed per Patient #1’s plan of care, and/or the reason as to why the visits were not completed as required. Patient #2Review of Patient #2’s updated comprehensive patient plan of care for the certification period of 04/12/2025 to 06/10/2025 revealed, in part, Patient #2 was to receive hospice aide services three times a week and skilled nursing services once a week. Review of Patient #2’s record revealed the following, in part:The week of 04/13/2025 through 04/19/2025 there was no documented evidence of hospice aide visits had been completed;The week of 04/20/2025 through 04/26/2025 there was no documented evidence of hospice aide visits and skilled nursing visits had been completed;The week of 04/27/2025 through 05/03/2025 the only hospice aide visit completed was dated 05/02/2025;The week of 05/04/2025 through 05/10/2025 the only hospice aide visits completed were dated 05/05/2025 and 05/07/2025; and,The week of 06/08/2025 through 06/14/2025 there was no documented evidence of hospice aide visits were completed. In an interview on 06/11/2025 at 12:52PM, S2DON indicated the agency had no documented evidence hospice aide and skilled nursing visits were completed per Patient #2’s plan of care, and/or the reason as to why the visits were not completed as required. Patient #3Review of Patient #3’s updated comprehensive patient plan of care for the certification period of 04/25/2025 to 06/23/2025 revealed Patient #3 was to receive skilled nursing services once a week. Review of Patient #3’s record revealed the only services which were provided by a skilled nurse for the weeks of, 04/27/2025 through 05/03/2025 and 05/11/2025 through 05/17/2025, were a hospice aide supervisory visit. There was no documented evidence, and the agency did not present any documented evidence, a skilled nurse had provided assessments, nursing skills, or education during the weeks of 04/27/2025 through 05/03/2025 and 05/11/2025 through 05/17/2025. In an interview on 06/11/2025 at 12:52PM, S2DON indicated the agency had no documented evidence skilled nursing visits were completed per Patient #3’s plan of care, and/or the reason as to why the visits were not completed as required.”

“Based on interviews and record reviews, the agency failed to communicate with the patients primary care physician to ensure coordination of care for 1 (Patient #1) of 3 (Patient #1, Patient #2, Patient #3) sampled patients reviewed for communication requirements. Findings: Review of the agency’s Coordination of Services undated policy revealed, in part, coordination of care provided by other organizations servicing the patient was conducted on an ongoing basis. The coordination may be achieved by phone calls and on-site conferences, and should be documented in the patient’s record. Review of Patient #1’s Updated Comprehensive Plan of Care for the certification period of 04/11/2025 through 07/09/2025 revealed, in part, Patient #1’s referring clinician was listed. In an interview on 06/09/2025 at 3:16PM, Patient #1 indicated she still had physician visits with her referring clinician for hypertension (elevation of the body’s blood pressure), and diabetes (elevated levels of glucose in the blood) since they were not her hospice diagnosis. In an interview on 06/09/2025 at 9:28AM, Patient #1’s referring clinician indicated she had only ever spoken with the receptionist at the agency. Patient #1’s referring clinician further indicated she had seen Patient #1 about every two weeks for her hypertension and diabetes and had never spoken with a nurse or physician from the hospice agency about coordination of care. In an interview on 06/11/2025 at 10:23AM, S6Licensed Practical Nurse (LPN) indicated she was aware Patient #1 had still been receiving care from her referring clinician. S6LPN further indicated she did not make any efforts to coordinate care and services with Patient #1’s referring clinician. In an interview on 06/11/2025 at 11:24AM, S9Medical Director indicated he was not aware Patient #1 was still seeing a primary care clinician. S9Medical Director further indicated he would have liked to have known if Patient #1 was still seeing her referring clinician to coordinate care and to know what medications were being changed. In an interview on 06/11/2025 at 12:14PM, S2Director of Nursing (DON) indicated she was aware Patient #1 was still receiving services from her referring clinician, and she had not requested records nor had she contacted the referring clinician to coordinate Patient #1’s care between the hospice agency and the referring clinician.”

“Based on interview and record reviews, the agency failed to ensure a register nurse assessed patients for a change in condition at the time of absence of life for 2 (Patient #2, Patient #3) of 2 (Patient #2, Patient #3) sampled patients reviewed for registered nurse assessments when the absence of signs of life were reported to the agency. Findings: Review of the Louisiana Administrative Code Title 48 – Public Health- Part I - General Administration Subpart 3 - Licensing and Certification Chapter 82 - Minimum Standards for Licensure of Hospice Agencies Subchapter B revealed, in part, a Licensed Practical Nurse (LPN) shall not make an assessment visit. Review of the Louisiana State Board of Medical Examiners Advisory Opinion revealed, in part, the medical pronouncement of death by a coroner may also be based on personal observation, information, or statements obtained from coroner investigators, registered nurses, physician assistants, or emergency medical technicians at the scene who were reporting from firsthand observation of the physician’s condition of the deceased. Patient #2Review of Patient #2’s Death Note dated 06/12/2025 revealed the death visit was completed by S8Licensed Practical Nurse (LPN). Patient #3Review of Patient #3’s Death Note dated 05/31/2025 revealed the death visit was completed by S8LPN. In an interview on 06/17/2025 at 3:10PM, S2Director of Nursing (DON) indicated she was not aware a LPN could not complete death visits. S2DON further confirmed a death visit was an assessment for the absence of signs of life.”

“Based on interview and record reviews, the agency failed to ensure all assessment documentation was completed for 1 (Patient #3) of 3 (Patient #1, Patient #2, Patient #3) sampled patients reviewed for documentation requirements. Findings: Review of the agency’s undated Content and Format of the Patient Record policy revealed, in part, the clinical record shall include, in part, services and treatments provided and progress toward goals/outcome of care. Review of Patient #3’s Routine Nursing Note dated 05/06/2025 revealed, in part, the following systems were documented as not assessed: pain, neurological, and cardiovascular system assessments. Review of Patient #3’s Routine Nursing Note dated 05/14/2025 revealed the following systems were documented as not assessed: pain, neurological, genitourinary, nutrition, and cardiovascular system assessments. Review of Patient #3’s Routine Nursing Note dated 05/21/2025 revealed the following systems were documented as not assessed: pain, neurological, genitourinary, nutrition, and cardiovascular system assessments. Review of Patient #3’s Routine Nursing Note dated 05/28/2025 revealed the following systems were documented as not assessed: pain, neurological, genitourinary, nutrition, and cardiovascular system assessments. In an interview on 06/17/2025 at 1:38PM, S2Director of Nursing (DON) indicated she had noticed some discrepancies with documentation not being completed for assessments of all body systems. S2DON further indicated all assessments should be completed for all routine nursing visits, and the documentation was not completed as required for the above mentioned dates.”

“Based on interviews and record reviews, the agency failed to ensure advanced directives had clear and comprehensive documentation for 2 (Patient #1, Patient #2) of 3 (Patient #1, Patient #2, Patient #3) sampled patients reviewed for advanced directive documentation. Findings: Review of the agency’s policy on Advance Directives, undated, revealed, in part, the hospice will honor a patient’s advanced directive regarding “do not resuscitate” (DNR). Further review revealed a physician’s order was required to implement a DNR or withdrawal of life-sustaining treatment by advance directive. Patient #1Review of Patient #1’s DNR/Do Not Intubate (DNI) form, undated, revealed, in part, the form was labeled with Patient #1’s name, had the signature of S9Medical Director, but was undated. Patient #2Review of Patient #2’s DNR/DNI form dated 06/06/2025 revealed the form was signed and dated by the caregiver on 06/06/2025; however, the form had S9Medical Director’s signature, but was not dated as required. In an interview on 06/11/2025 at 10:39AM, S5Business Office Manager (BOM) indicated she would often go out to the initial informational visits, and would complete the initial paperwork which include the DNR/DNI form. S5BOM further indicated she would bring a pre-signed form from S9Medical Director with her on these visits. In an interview on 06/11/2025 at 11:24AM, S9Medical Director indicated when the agency was admitting patients the agency was to get the patient and/or caregiver to sign the advanced directive and then he would review and sign the document. S9Medical Director further indicated in cases were the agency was aware of the patient’s request for DNR ahead of time, he would sign and fax a DNR on the date of admit. S9Medical Director further indicated the agency should not have a signed an undated blank form. In an interview on 06/11/2025 at 12:14PM, S2Director of Nursing indicated the agency should not have signed blank undated copies of the DNR/DNI paperwork. In an interview on 06/11/2025 at 12:16PM, S1Administrator further indicated the agency should not have any documents signed by any practitioner without a signature authenticating the documents, including but not limited to the DNR/DNI paperwork.”

“Based on interviews and record reviews, the agency failed to ensure all record entries were complete, and authenticated with the signature and/or date for 3 (Patient #1, Patient #2, Patient #3) of 3 (Patient #1, Patient #2, Patient #3) sampled patients reviewed for documentation requirements. Findings: Review of the agency’s undated Content and Format of the Patient Record policy revealed, in part, the clinical staff documentation must be signed by the staff who provided care with the first name or initial, last name, title, dated, and the time of visit. Patient #1Review of Patient #1’s Nursing Routine Note dated 04/14/2025 revealed S6Licensed Practical Nurse (LPN) had not signed, dated, or marked the note as completed. Review of Patient #1’s Nursing Routine Note dated 04/18/2025 revealed S6LPN had not signed, dated, or marked the note as completed. Review of Patient #1’s Nursing Routine Note dated 05/01/2025 revealed S6LPN had not signed, dated, or marked the note as completed. Review of Patient #1’s Nursing Routine Note dated 05/08/2025 revealed S6LPN had not signed, dated, or marked the note as completed. Review of Patient #1’s Nursing Routine Note dated 05/15/2025 revealed S6LPN had not signed, dated, or marked the note as completed. Review of Patient #1’s Nursing Routine Note dated 05/22/2025 revealed S6LPN had not signed, dated, or marked the note as completed. Review of Patient #1’s Nursing Routine Note dated 05/29/2025 revealed S6LPN had not signed, dated, or marked the note as completed. Review of Patient #1’s Nursing Routine Note dated 06/09/2025 revealed S6LPN had not signed, dated, or marked the note as completed. In an interview on 06/17/2025 at 1:38PM, S2Director of Nursing (DON) indicated the above mentioned notes were not signed, dated, and completed by the nurse or S6LPN who completed the visit as required. Patient #2Review of Patient #2’s Nursing Routine Note dated 04/18/2025 revealed S6LPN had not signed, dated, or marked the note as completed. Review of Patient #2’s Nursing Routine Note dated 05/01/2025 revealed S6LPN had not signed, dated, or marked the note as completed. Review of Patient #2’s Nursing Routine Note dated 05/08/2025 revealed S6LPN had not signed, dated, or marked the note as completed. Review of Patient #2’s Nursing Routine Note dated 05/15/2025 revealed S6LPN had not signed, dated, or marked the note as completed. Review of Patient #2’s Nursing Routine Note dated 05/22/2025 revealed S6LPN had not signed, dated, or marked the note as completed. Review of Patient #2’s Nursing Routine Note dated 05/29/2025 revealed S6LPN had not signed, dated, or marked the note as completed. Review of Patient #2’s Hospice Initial/Comprehensive Nursing Assessment dated 06/06/2025, written paper copy, revealed S7LPN had completed the initial nursing assessment. Review of Patient #2’s electronic Comprehensive Nursing Assessment dated 06/06/2025 revealed the electronic record was signed by S2Director of Nursing (DON). Review of Patient #2’s Nursing Routine Note dated 06/09/2025 revealed S6LPN had not signed, dated, or marked the note as completed. Review of Patient #3’s Death Note dated 06/12/2025 revealed S8LPN was documented as performing the death visit; however, the electronic note was signed and dated by S2DON. In an interview on 06/17/2025 at 2:09PM, S2DON confirmed the electronic documentation for Patient #2’s Initial Comprehensive Nursing Assessment dated 06/06/2025 was signed by S2DON; however, S7LPN had completed the visit. S2DON further confirmed the electronic documentation for Patient #2’s Death Note dated 06/12/2025 was signed by S2DON; however, S8LPN had completed the visit. S2DON further indicated the above mentioned notes dated 04/18/2025, 05/01/2025, 05/08/2025, 05/15/2025, 05/22/2025, 05/29/2025, and 06/09/2025 were not signed, dated, and/or completed by the nurse who completed the visit as required. Patient #3Review of Patient #3’s Nursing Routine Note dated 05/06/2025 revealed S6LPN had not signed, dated, or marked the note as completed. Review of Patient #3’s Focus Note dated 05/10/2025 revealed S8LPN had not signed, dated, or marked the note as completed. Review of Patient #3’s Nursing Routine Note dated 05/14/2025 revealed S6LPN had not signed, dated, or marked the note as completed. Review of Patient #3’s Nursing Routine Note dated 05/21/2025 revealed S6LPN had not signed, dated, or marked the note as completed. Review of Patient #3’s Nursing Routine Note dated 05/28/2025 revealed S6LPN had not signed, dated, or marked the note as completed. Review of Patient #3’s Death Note dated 05/31/2025 revealed S8LPN had not signed, dated, or marked the note as completed. In an interview on 06/17/2025 at 1:38PM, S2Director of Nursing (DON) indicated the above mentioned notes were not signed, dated, and/or completed by the nurse who completed the visit as required.”

“Based on record reviews and interviews, the facility failed ensure: 1. The interdisciplinary group completed the comprehensive assessment within 5 calendar days of election of hospice care (Patient #1, Patient #4, Patient #5, Patient #10, Patient #11, and Patient #13); and, 2. The interdisciplinary group assessed patients for the need of volunteer services (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). This deficient practice was identified for 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) 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 assessment by the interdisciplinary group. Findings: 1. Patient #1 Review of Patient #1s record revealed, in part, Patient #1 elected hospice services on 03/01/2024. Further review revealed S6Chaplain did not complete the spiritual assessment until 03/06/2024. There was no documented evidence, and the agency presented no documented evidence, of a spiritual assessment completed within 5 days of election if hospice service or the reason as to why the spiritual assessment could not be completed within 5 days. In an interview on 10/03/2024 at 1:18 p.m., S2Director of Nursing (DON) indicated the chaplain should have either completed a spiritual assessment within 5 days of election or documented the reason why the assessment could not be completed as required. Patient #4 Review of Patient #4s record revealed, in part, Patient #4 elected hospice services on 04/17/2024. Further review revealed S6Chaplain did not complete the spiritual assessment until 04/23/2024, and there was no documented evidence of a social worker assessment having been completed. Record review revealed no documented evidence, and the agency presented no documented evidence, a spiritual assessment and/or social worker assessment had been completed for Patient #4 within 5 days of election of hospice services or the reason as to why the spiritual assessment could not be completed within 5 days. In an interview on 10/03/2024 at 1:25 p.m., S2DON indicated the chaplain should have either completed a spiritual assessment within 5 days of election or documented the reason why the assessment could not be completed as required. S2DON further indicated the agency had no documented evidence the social worker assessed Patient #4 and/or any evidence Patient #4 had refused the social workers assessment Patient #5 Review of Patient #5s record revealed, in part, Patient #4 elected hospice services on 01/29/2024. There was no documented evidence, and the agency presented no documented evidence, of a spiritual assessment had been completed within 5 days of election or the reason as to why the spiritual assessment could not be completed within 5 days. In an interview on 10/03/2024 at 1:31 p.m., S2DON indicated the agency had no documented evidence of a spiritual assessment had been completed within 5 days of election of hospice services, or a reason as to why the spiritual assessment was not completed. Patient #10 Review of Patient #10s record revealed, in part, Patient #10 elected hospice services on 01/27/2024. Further review revealed S6Chaplain did not complete the initial spiritual assessment until 02/09/2024. There was no documented evidence, and the agency presented no documented evidence, a spiritual assessment had been completed within 5 days of election or the reason as to why the spiritual assessment could not be completed within 5 days. In an interview on 10/03/2024 at 1:44 p.m., S2DON indicated the agency had no documented evidence a spiritual assessment had been completed within 5 days of election of hospice services, or a reason as to why the spiritual assessment was not completed. Patient #11 Review of Patient #11s record revealed, in part, Patient #11 elected hospice services on 04/28/2024. Further review revealed S6Chaplain did not complete the initial spiritual assessment until 05/10/2024. There was no documented evidence, and the agency presented no documented evidence, a spiritual assessment had been completed within 5 days of election or the reason as to why the spiritual assessment could not be completed within 5 days. In an interview on 10/03/2024 at 1:46 p.m., S2DON indicated the agency had no documented evidence a spiritual assessment had been completed within 5 days of election of hospice services, nor a reason as to why the spiritual assessment was not completed. Patient #13 Review of Patient #5s record revealed, in part, Patient #13 elected hospice services on 12/12/2023. There was no documented evidence, and the agency presented no documented evidence, a spiritual assessment had been completed within 5 days of election or the reason as to why the spiritual assessment could not be completed within 5 days. In an interview on 10/03/2024 at 1:50 p.m., S2DON indicated the agency had no documented evidence a spiritual assessment had been completed within 5 days of election of hospice services, or a reason as to why the spiritual assessment was not completed. 2. Review of 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 #14s record revealed no documented evidence, and the agency was unable to present any documented evidence, an assessment for the patients need for volunteer services. In an interview on 10/03/2024 at 1:22 p.m., S2DON indicated the agency will offer volunteer services as available, but had not been assessing patients for their need for volunteer services during the initial comprehensive assessment which should be completed within 5 days after election of hospice services.”

“Based on record reviews and interviews, the agency failed to ensure an initial bereavement assessment of the patients family and other individuals were completed during the comprehensive assessment for 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) 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 initial bereavement assessments. Findings: Patient #1 Review of Patient #1s record revealed a start of care date of 03/01/2024. Further review of Patient #1s record revealed no documented evidence, and the agency presented no documented evidence, an initial bereavement assessment was completed with Patient #1s family and other individuals during the comprehensive assessments by the interdisciplinary group. In an interview on 10/03/2024 at 1:18 p.m., S2Director of Nursing (DON) indicated she had no documented evidence of staff having completed an initial bereavement assessment with the patients family or individuals involved in Patient #1s care. Patient #2 Review of Patient #2s record revealed a start of care date of 08/20/2024. Further review of Patient #2s record revealed no documented evidence, and the agency presented no documented evidence, an initial bereavement assessment was completed with Patient #2s family and other individuals during the comprehensive assessments by the interdisciplinary group. In an interview on 10/03/2024 at 1:22 p.m., S2DON indicated she had no documented evidence of staff having completed an initial bereavement assessment with the patients family or individuals involved in Patient #2s care. Patient #3 Review of Patient #3s record revealed a start of care date of 03/19/2024. Further review of Patient #3s record revealed no documented evidence, and the agency presented no documented evidence, an initial bereavement assessment was completed with Patient #3s family and other individuals during the comprehensive assessments by the interdisciplinary group. In an interview on 10/03/2024 at 2:06 p.m., S2DON indicated she had no documented evidence of staff having completed an initial bereavement assessment with the patients family or individuals involved in Patient #3s care. Patient #4 Review of Patient #4s record revealed a start of care date of 04/17/2024. Further review of Patient #4s record revealed no documented evidence, and the agency presented no documented evidence, an initial bereavement assessment was completed with Patient #4s family and other individuals during the comprehensive assessments by the interdisciplinary group. In an interview on 10/03/2024 at 1:25 p.m., S2DON indicated she had no documented evidence of staff having completed an initial bereavement assessment with the patients family or individuals involved in Patient #4s care. Patient #5 Review of Patient #5s record revealed a start of care date of 01/29/2024. Further review of Patient #5s record revealed no documented evidence, and the agency presented no documented evidence, an initial bereavement assessment was completed with Patient #5s family and other individuals during the comprehensive assessments by the interdisciplinary group. In an interview on 10/03/2024 at 1:31 p.m., S2DON indicated she had no documented evidence of staff having completed an initial bereavement assessment with the patients family or individuals involved in Patient #5s care. Patient #6 Review of Patient #6s record revealed a start of care date of 06/28/2022. Further review of Patient #6s record revealed no documented evidence, and the agency presented no documented evidence, an initial bereavement assessment was completed with Patient #6s family and other individuals during the comprehensive assessments by the interdisciplinary group. In an interview on 10/03/2024 at 1:32 p.m., S2DON indicated she had no documented evidence of staff having completed an initial bereavement assessment with the patients family or individuals involved in Patient #6s care. Patient #7 Review of Patient #7s record revealed a start of care date of 04/21/2023. Further review of Patient #7s record revealed no documented evidence, and the agency presented no documented evidence, an initial bereavement assessment was completed with Patient #7s family and other individuals during the comprehensive assessments by the interdisciplinary group. In an interview on 10/03/2024 at 1:36 p.m., S2DON indicated she had no documented evidence of staff having completed an initial bereavement assessment with the patients family or individuals involved in Patient #7s care. Patient #8 Review of Patient #8s record revealed a start of care date of 10/19/2023. Further review of Patient #8s record revealed no documented evidence, and the agency presented no documented evidence, an initial bereavement assessment was completed with Patient #8s family and other individuals during the comprehensive assessments by the interdisciplinary group. In an interview on 10/03/2024 at 1:37 p.m., S2DON indicated she had no documented evidence of staff having completed an initial bereavement assessment with the patients family or individuals involved in Patient #8s care. Patient #9 Review of Patient #9s record revealed a start of care date of 04/18/2024. Further review of Patient #9s record revealed no documented evidence, and the agency presented no documented evidence, an initial bereavement assessment was completed with Patient #9s family and other individuals during the comprehensive assessments by the interdisciplinary group. In an interview on 10/03/2024 at 1:42 p.m., S2DON indicated she had no documented evidence of staff having completed an initial bereavement assessment with the patients family or individuals involved in Patient #9s care. Patient #10 Review of Patient #10s record revealed a start of care date of 01/27/2024. Further review of Patient #10s record revealed no documented evidence, and the agency presented no documented evidence, an initial bereavement assessment was completed with Patient #10s family and other individuals during the comprehensive assessments by the interdisciplinary group. In an interview on 10/03/2024 at 1:44p.m., S2DON indicated she had no documented evidence of staff having completed an initial bereavement assessment with the patients family or individuals involved in Patient #10s care. Patient #11 Review of Patient #11s record revealed a start of care date of 04/30/2024. Further review of Patient #11s record revealed no documented evidence, and the agency presented no documented evidence, an initial bereavement assessment was completed with Patient #11s family and other individuals during the comprehensive assessments by the interdisciplinary group. In an interview on 10/03/2024 at 1:46 p.m., S2DON indicated she had no documented evidence of staff having completed an initial bereavement assessment with the patients family or individuals involved in Patient #11s care. Patient #12 Review of Patient #12s record revealed a start of care date of 11/29/2022. Further review of Patient #12s record revealed no documented evidence, and the agency presented no documented evidence, an initial bereavement assessment was completed with Patient #12s family and other individuals during the comprehensive assessments by the interdisciplinary group. In an interview on 10/03/2024 at 1:47 p.m., S2DON indicated she had no documented evidence of staff having completed an initial bereavement assessment with the patients family or individuals involved in Patient #12s care. Patient #13 Review of Patient #13s record revealed a start of care date of 12/12/2023. Further review of Patient #13s record revealed no documented evidence, and the agency presented no documented evidence, an initial bereavement assessment was completed with Patient #13s family and other individuals during the comprehensive assessments by the interdisciplinary group. In an interview on 10/03/2024 at 1:50 p.m., S2DON indicated she had no documented evidence of staff having completed an initial bereavement assessment with the patients family or individuals involved in Patient #13s care. Patient #14 Review of Patient #14s record revealed a start of care date of 07/29/2024. Further review of Patient #14s record revealed no documented evidence, and the agency presented no documented evidence, an initial bereavement assessment was completed with Patient #14s family and other individuals during the comprehensive assessments by the interdisciplinary group. In an interview on 10/03/2024 at 1:56 p.m., S2DON indicated she had no documented evidence of staff having completed an initial bereavement assessment with the patients family or individuals involved in Patient #14s care.”

“Based on record reviews and interview, the agency failed to ensure skilled nursing services were provided per the plan of care for 1 (Patient #10) 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. Findings: Review of Patient #10s Updated Comprehensive Plan of Care for certification period of 07/25/2024 through 09/22/2024 revealed, in part, Patient #10 was to receive skilled nursing services one to two times per week. Review of Patient #10s clinical record revealed no documented evidence, and the agency was unable to present any documented evidence, that Patient #10 received skilled nursing services the week of 07/28/2024 through 08/03/2024. In an interview on 10/03/2024 at 1:44 p.m., S2Director of Nursing (DON) indicated the agency was unable to present any documented evidence that Patient #10 received skilled nursing services the week of 07/28/2024 through 08/03/2024 as required per the plan of care.”

“Based on record review and interview, the agency failed to have documented evidence of the types of services provided by volunteers and the cost the agency would have incurred for the type of service provided if service was provided by paid employees. Findings: Review of the agencys calculation of Volunteer Service revealed the amount of volunteer hours per month for the months of January through September 2024 revealed 180 hours of volunteer services a month which was multiplied by a standard volunteer rate of $18.75. There was no documented evidence, and the agency was unable to present any documented evidence, of the type of services each volunteer provided and the cost the agency would have incurred if paid employees occupied the position for the above mentioned time frame. In an interview on 10/03/2024 at 11:03 a.m., S1Administrator indicated the agency was not keeping a log of the type of activity provided and the cost the agency would have incurred if employees had provided the service as required.”

“Based on record review and interview, the agency failed to have documented evidence of: 1. The types of services provided by volunteers and the amount of time worked; and, 2. Calculations of the level of activity of volunteers as compared to the hours of paid staff care to ensure a five percent or greater level of activity. Findings: Review of the agencys calculation of Volunteer Service revealed the amount of volunteer hours per month for the months of January through September 2024 revealed 180 hours of volunteer services a month. Further review revealed no documented evidence, the agency presented no documented evidence of the number of hours of paid services for the months of January 2024 to September 2024. There was no documented evidence, and the agency was unable to present any documented evidence, of the type of services each volunteer provided. In an interview on 10/03/2024 at 11:03 a.m., S1Administrator indicated he was compiling the information on how much time was provided by each volunteer, but was not keeping a log of the type of activity provided. S1Administrator confirmed the agency did not have any documented evidence of the amount of hours provided by paid employees to compare to volunteer hours to calculate the level of volunteer activity as required.”