Passages Hospice

“Based on interview and record reviews, the Hospice agency’s IDG failed to ensure the completion of the Chaplain’s Initial Comprehensive Assessment within 5 days after the Election of Hospice Benefits for 1 (#13) of 18 (#6 through #23) live patients reviewed in the sample. Review of Patient #13’s Clinical Record revealed he was admitted to the agency and signed his Election of Hospice Benefits on 03/19/2025. Further review revealed a current Certification Period of 03/19/2025 through 06/16/2025. Review of Patient #13’s Physician Orders and Plan of Care for the Certification Period of 03/19/2025 through 06/16/2025 revealed, in part, an order written on 03/19/2025 for Chaplain Visits once a week and 10 as needed. Review of Patient #13’s RN Admission Assessment, dated 03/19/2025, revealed, in part, Services Needed: Chaplain. Review of Patient #13’s Chaplain Visit Calendar and Chaplain Service Notes, dated 03/19/2025 through 03/23/2025, revealed no documented evidence of the visit being attempted, refused or performed within the required timeframe. An interview was conducted on 05/05/2025 at 5:12 p.m. with S2DON. S2DON confirmed the Chaplain was a Core Service and was required to perform an Initial Visit/Assessment for newly admitted patients within 5 days of their admission to the Hospice agency. S2DON reviewed Patient #13’s Clinical Record and confirmed he did not receive an initial Chaplain Visit for assessment within the required timeframe and should have.”

“Based on interview and record reviews, the Hospice agency’s IDG failed to ensure the completion of the Initial Spiritual Assessment within 5 days after the Election of Hospice Benefits for 1 (#13) of 18 (#6 through #23) live patients reviewed in the sample. Review of Patient #13’s Clinical Record revealed he was admitted to the agency and signed his Election of Hospice Benefits on 03/19/2025. Further review revealed a current Certification Period of 03/19/2025 through 06/16/2025. Review of Patient #13’s Physician Orders and Plan of Care for the Certification Period of 03/19/2025 through 06/16/2025 revealed an order written on 03/19/2025 for Chaplain Visits once a week and 10 as needed. Review of Patient #13’s RN Admission Assessment, dated 03/19/2025, revealed, in part, the following: Services Needed: ChaplainHospice SN Mini Spiritual Assessment: Are you part of a faith based or Spiritual Community: No. Do you have any spiritual beliefs that need to be in the care we provide? Blank. What is important to you at end of life? Blank. Further review revealed no documented evidence of any additional Spiritual Assessment information. Review of Patient #13’s MSW Admission Assessment, dated 03/20/2025, revealed, in part, no documented evidence of a Spiritual Assessment. Review of Patient #13’s Chaplain Visit Calendar and Chaplain Service Notes, dated 03/19/2025 through 03/23/2025, revealed no documented evidence of the visit being attempted and refused or performed within the required timeframe. Further review revealed no documented evidence of the Spiritual Assessment within the required timeframe. An interview was conducted on 05/05/2025 at 5:12 p.m. with S2DON. S2DON confirmed she expected all required sections of a patient’s Initial Comprehensive Assessment to be completed within 5 days of admission to the Hospice agency. S2DON reviewed Patient #13’s Clinical Record and confirmed his Initial Spiritual Assessment was not completed within the required timeframe and should have been.”

“Based on interview and record reviews, the Hospice agency failed to ensure the completion of the Initial Bereavement Assessment within 5 days after the Election of Hospice Benefits for 1 (#13) of 18 (#6 through #23) live patients reviewed in the sample. Review of the Hospice agency’s undated Bereavement Assessment Policy, as of 05/05/2025, revealed, in part, the following: Purpose: To provide guidance for the assessment and reassessment of the bereavement needs of family/caregivers. Procedure: 1. On admission, the MSW or RN will complete a Bereavement Risk Assessment that will be given to the Bereavement Coordinator. Review of Patient #13’s Clinical Record revealed he was admitted to the agency and signed his Election of Hospice Benefits on 03/19/2025. Further review revealed a current Certification Period of 03/19/2025 through 06/16/2025. Review of Patient #13’s Physician Orders and Plan of Care for the Certification Period of 03/19/2025 through 06/16/2025 revealed in part, the following:Care Need: Bereavement (added 03/20/2025 by the RN);Goal: Family/caregiver will grieve appropriately; and Intervention: Establish Bereavement Plan of Care.Review of Patient #13’s Assessments by the RN, MSW and Chaplain, dated 03/19/2025 through 03/23/2025, revealed, in part, no documented evidence of an Initial Bereavement Assessment. An interview was conducted on 05/05/2025 at 5:12 p.m. with S2DON. S2DON confirmed she expected all required sections of a patient’s Initial Comprehensive Assessment to be completed within 5 days of admission to the Hospice agency and per their policy, the Initial Comprehensive Assessment included an Initial Bereavement Assessment. S2DON reviewed Patient #13’s Clinical Record and confirmed his Initial Bereavement Assessment was not completed within the timeframe and should have been.”

“Based on record reviews and interviews, the Hospice agency failed to ensure licensed professionals actively participated in all aspects of the patient’s hospice care in accordance with current professional standards. The agency failed to ensure a patient’s medical pronouncement of death by a coroner was based on personal observation or information and statements obtained from a qualified professional for 2 (#3 and #4) of 3 (#3, #4 and #5) death records reviewed. Review of Louisiana Revised Statute (LA RS) 9:111 revealed, in part, the following: A. A person will be considered dead if in the announced opinion of a physician, duly licensed in the state of Louisiana based on ordinary standards of approved medical practice, the person has experienced an irreversible cessation of spontaneous respiratory and circulatory functions….B. The medical pronouncement of death by a coroner may also be based on personal observation, information, or statements obtained from coroner investigators, Registered Nurses, physician assistants, or emergency medical technicians at the scene who are reporting from firsthand observation of the physical condition of the deceased. …Review of the Hospice agency’s undated Death Policy, as of 05/05/2025, revealed, in part, the following: Procedure: 4. The nurse will notify the attending physician of the patient’s death. It will be the attending physician’s responsibility to pronounce death (depending on state regulations coroner). 5. All deaths will be reported to the medical coroner or appropriate legal entity per state regulations. 11. The nurse will document all of the above interventions and any other significant information regarding the death in the patient’s record. Patient #3Review of Patient #3’s Clinical Record revealed a Start of Care Date of 08/20/2024 with a Certification Period of 08/20/2024 through 11/17/2024 and a date of death of 09/04/2024. Review of Patient #3’s LPN Death Visit, dated 09/04/2024, revealed, in part, the following: Death Visit Performed by: S3LPNTime In: 3:25 p.m.Time Out: 4:25 p.m.Death Pronounced by: S3LPNNarrative: No signs of life on assessment. Patient pronounced deceased at 3:30 p.m. Phone call to the local Coroner with release number received. Review of Patient #3’s Clinical Record, dated 08/20/2024, revealed no documentation indicating an RN or other qualified professional was present to perform the death assessment.Patient #4Review of Patient #4’s Clinical Record revealed a Start of Care Date of 05/13/2024 with a Certification Period of 05/13/2024 through 08/10/2024 and a date of death of 05/23/2024. Review of Patient #4’s LPN Death Visit, dated 05/23/2024, revealed, in part, the following: Death Visit Performed by: S4LPNTime In: 8:55 p.m.Time Out: 9:45 p.m.Death Pronounced by: S4LPNNarrative: Physical Assessment Findings: Pupils fixed, respirations ceased, no palpable pulse, no palpable blood pressure. Patient pronounced deceased at 3:30 p.m. Phone call to the local Coroner. Review of Patient #4’s Clinical Record, dated 05/23/2024, revealed no documentation indicating an RN or other qualified professional was present to perform the death assessment.An interview was conducted on 05/05/2025 at 5:12 p.m. with S2DON. S2DON confirmed the agency’s process upon death was for a nurse, either LPN or RN, to perform a death assessment to ensure the absence of vital signs then contact the coroner or the patient’s physician by phone to receive pronouncement of death and release of the body. S2DON confirmed she was not aware of LA RS 9:111 which prevented an LPN from performing a patient’s death visit assessment on behalf of the coroner or the patient’s physician. S2DON reviewed Patient #3 and #4’s Clinical Records and confirmed an LPN performed their death assessments and should not have.”

“Based on interviews and record reviews, the Hospice agency failed to ensure nursing services met the needs of the patients for 1 (#9) of 4 (#9, #15, #18, and #19) patients reviewed for pressure wounds. The Hospice agency failed to follow acceptable standards of practice for wound care specifically for complete wound assessments and weekly wound measurements by an RN, including the size and stage of the wounds for Patient #9. 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 conditionsinvolves 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.Review of the Hospice agency’s undated Wound and Skin Care Management Policy, as of 05/05/2025, revealed, in part, the following: Documentation: Accurately document all wound assessments, interventions, and patient response to treatment in the medical record and weekly measurements. Review of the Hospice agency’s Current Wound Log, as of 04/28/2025, revealed, in part, Patient #9 was receiving treatment for active wounds. Review of Patient #9’s Clinical Record revealed she was admitted to the Hospice agency on 11/01/2024 with a current Certification Period of 01/30/2025 through 04/29/2025. Further review revealed she was currently receiving treatment for a Stage 2 Pressure Wound to the Coccyx (identified on 01/03/2025) and an Unstageable Pressure Wound to the Left Calf (identified on 01/03/2025). Review of Patient #9’s Physician’s Orders and Plan of Care for the current Certification Period revealed, in part, the following:01/30/2025 - SNV once weekly for one week;02/02/2025 - SNV twice weekly for twelve weeks; and 04/27/2025 – SNV once weekly for one week. Review of Patient #9’s SNV Assessment and Coordination Notes for the current Certification Period revealed, in part, the following:Wound #1: Stage2 Pressure Wound to the Coccyx:02/03/2025 – No measurements and description documented by RN;02/17/2025 – No measurements and description documented by RN;03/03/2025 – No measurements and description documented by RN;03/10/2025 – No measurements and description documented by RN;03/17/2025 – No measurements and description documented by RN;03/31/2025 – No measurements and description documented by RN;04/14/2025 – No measurements and description documented by RN; and 04/22/2025 – No measurements and description documented by RN.Wound #2: Unstageable Pressure Wound to the Left Calf:02/03/2025 – No measurements and description documented by RN;02/17/2025 – No measurements and description documented by RN;03/03/2025 – No measurements and description documented by RN;03/10/2025 – No measurements and description documented by RN;03/17/2025 – No measurements and description documented by RN;03/31/2025 – No measurements and description documented by RN;04/14/2025 – No measurements and description documented by RN; and 04/22/2025 – No measurements and description documented by RN.An interview was conducted on 04/30/2025 at 9:45 a.m. with S5RN. S5RN stated wounds should be measured and documented by an RN every week. S5RN confirmed wound measurements and descriptions were only documented within the RN’s SNV Assessment and would not be located anywhere else within the Clinical Record. An interview was conducted on 05/05/2025 at 5:12 p.m. with S2DON. S2DON confirmed she expected wounds to be measured, assessed and documented by an RN every 7 days and it was not for Patient # 9.”

“Based on record review and interview, the Hospice agency failed to ensure the RN conducted an on-site HA Supervisory visit at least every 14 days to assess the quality of care and services provided by the HA for 1 (#12) of 18 (#6 through #23) live patients in the sample. Review of the Hospice agency’s undated HA Services Policy, as of 05/05/2025, revealed, in part, HA services will be supervised by the RN every 14 days to assess relationships and goals. Review of Patient #12’s Clinical Record revealed he was admitted to the agency on 10/24/2023. Review of Patient #12’s Physician’s Orders and Plan of Care revealed, in part, the following: Certification Period: 02/15/2025 through 04/15/2025 – HA Visits to be performed three times weekly for 8 weeks then once a week for one week; and Certification Period: 04/16/2025 through 06/14/2025 – HA Visits to be performed three times a week for 1 week then 5 times weekly for 8 weeks. Review of Patient #12’s Visit Calendar and HA Service Notes, dated 02/15/2025 through 05/05/2025, revealed, in part, HA Visits were conducted from 02/15/2025 through 05/05/2025. Further review revealed 54 HA Visits were conducted by S6HA on the following dates: 02/17/2025, 02/18/2025, 02/19/2025, 02/20/2025, 02/21/2025, 02/24/2025, 02/25/2025, 02/26/2025, 02/27/2025, 02/28/2025; 03/03/2025, 03/05/2025, 03/06/2025, 03/07/2025, 03/10/2025, 03/11/2025, 03/12/2025, 03/13/2025, 03/14/2025, 03/17/2025, 03/18/2025, 03/19/2025, 03/20/2025, 03/21/2025, 03/24/2025, 03/25/2025, 03/26/2025, 03/27/2025, 03/28/2025, 03/31/2025; 04/01/2025, 04/02/2025, 04/03/2025, 04/04/2025, 04/07/2025, 04/08/2025, 04/09/2025, 04/10/2025, 04/11/2025, 04/14/2025, 04/15/2025, 04/16/2025, 04/17/2025, 04/21/2025, 04/22/2025, 04/23/2025, 04/24/2025, 04/25/2025, 04/28/2025, 04/29/2025, 04/30/2025; and 05/01/2025, 05/02/2025, 05/05/2025. Review of Patient #12’s RN Service Notes, dated 02/15/2025 through 05/05/2025, revealed, in part, no documented evidence of on-site HA Supervisory Visits performed by the RN from 02/19/2025 through 04/01/2025 and/or 04/03/2025 through 05/05/2025. An interview was conducted on 05/05/2025 at 5:12 p.m. with S2DON. S2DON confirmed she expected HA Supervisory Visits to be performed by an RN every 14 days. S2DON reviewed Patient #12’s Clinical Record and confirmed there were no HA Supervisory Visits performed from 02/19/2025 through 04/01/2025 and/or 04/03/2025 through 05/05/2025 and should have been.”

“Based on record review and interview, the Hospice Agency failed to ensure volunteers provided day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equaled 5% of the total patient care hours of all paid hospice employees. Review of the Hospice agency’s Volunteer Services Cost Savings Report, dated 01/01/2024 through 05/05/2025, revealed they did not meet the annual volunteer requirements of 5% of the total patient care hours of all paid hospice employees. An interview was conducted on 05/06/2025 at 3:45 p.m. with S1ADM. S1ADM provided documentation for the Hospice agency’s volunteer service hours performed from 01/01/2024 through 05/05/2025 and confirmed the hours did not meet the 5% requirement and should have.”

“Based on interviews and record review, the Hospice agency failed to ensure Discharge Orders were obtained from the Medical Director prior to the discharge of a patient for 2 of 2 (#1 and #2) patients reviewed for discharge. Patient #1Review of Patient #1’s Clinical Record revealed he was admitted to the Hospice agency on 12/13/2024 and discharged for cause on 01/17/2025. Review of Patient #1’s Physician Orders and Plan of Care, dated 12/13/2024 through 01/17/2025, revealed no order written by the Medical Director to discharge the patient. Patient #2Review of Patient #2’s Clinical Record revealed he was admitted to the Hospice agency on 01/09/2025 and discharged for cause on 03/28/2025. Review of Patient #2’s Physician Orders and Plan of Care, dated 01/09/2025 through 03/28/2025, revealed no order written by the Medical Director to discharge the patient. An interview was conducted on 04/29/2025 at 3:23 p.m. with S2DON. S2DON confirmed prior to a patient’s discharge, she expected the patient’s nurse to obtain an order from their Medical Director to discharge the patient then add the order to the patient’s EHR. S2DON reviewed Patient #1 and #2’s Clinical Record and confirmed neither contained written discharge orders by the Medical Director to discharge the patients from the Hospice agency and should have.”