Every finding on record at Passages Hospice North-Cenla, LLC

Based on record review, observation, and interview, the agency failed to ensure the physical, psychosocial, emotional, and spiritual needs identified by the comprehensive assessment were addressed for 2 (#3 and #12) of 14 sampled patients reviewed for hospice care.  The agency failed to: Ensure Patient #3's Plan of Care/orders addressed wound care interventions including wound care orders for a pressure ulcer; and  Ensure Patient #12's Plan of Care included a psychosocial assessment by the MSW and a spiritual assessment by the Chaplain.Findings: --- Findings: Review of the agency’s undated policy titled “Interdisciplinary Team and Plan of Care” revealed in part, Purpose: To provide direction to the interdisciplinary team providing care to the patient, family, and caregiver. 5. The plan of care will include: b. psychosocial assessments and plans for interventions and expected outcomes; c. spiritual assessments and plans for interventions and expected outcomes; and d. bereavement assessments and plans for interventions and expected outcomes. Patient #12 Review of Patient #12’s clinical record revealed a start of care date for hospice services on 11/22/2025 and an expired date of 12/19/2025. The patient had an admitting diagnosis of Hepatic Failure, Unspecified without Coma. Further record review revealed Patient #12 had the following hospice service disciplines assigned: MSW and Chaplain. Review of Patient #12’s Care Plan dated 11/22/2025- 02/19/2026 revealed no documentation of a psychosocial assessment by the MSW or a spiritual assessment by the Chaplain included in the plan of care. In an interview on 04/15/2026 at 8:25 a.m. with S1 Administrator/DON confirmed there was no care plan to address Patient #12’s psychosocial, spiritual, and bereavement needs but there should have been.  Review of Patient #3's Care Plan/Physician Orders for Certification Period 02/25/2026 through 04/25/2026 revealed the patient lived in a nursing facility and had an unstageable pressure ulcer to his left lateral foot.  Further review revealed there was no care planning related to Patient #3's wound or specific wound care orders for the skilled nurse to follow when providing care. During a home visit conducted on 04/14/2026 at 11:30 a.m., S3RN performed Patient #3's wound care to his left lateral foot's 5th toe area.  S3RN stated she followed the nursing facility's wound care orders for Patient #3. In an interview on 04/14/2026 at 1:40 p.m., S1Administrator/DON reviewed the medical record and confirmed there were no wound care orders in Patient #3's Care Plan/Physician Orders, except for an order that stated to follow facility orders, which were not specified.  S3Administrator/DON confirmed the nursing facility's wound care orders were not in the Patient's chart or care plan, but should have been.

Based on record review and interview, the agency failed to ensure bereavement services were made available to the family for up to 1 year following the death of the patient for 2 (Patient #11 and Patient #12) of 2 death records reviewed.  Findings: --- Record review of the agency’s policy titled “Bereavement Assessment” dated 05/20/2025 read in part… The agency will provide bereavement services for up to one year after the patient’s death to surviving family/caregiver members. After death occurs, the hospice social worker of bereavement coordinator will complete the bereavement plan of care and follow-up. The bereavement coordinator will develop a plan for intervention, based on the findings of the bereavement assessment and input from interdisciplinary group members. The bereavement coordinator will document the interventions on the bereavement services checklist and bereavement plan of care. All bereavement documentation will be submitted for filing in the patient’s permanent clinical record and plan of care.  Patient #11Review of Patient #11’s clinical record revealed a start of care date for hospice services on 02/07/2025 and an expired date of 02/12/2025. Patient #11 had an admitting diagnosis of Hepatic Failure, Unspecified without Coma.  Further record review revealed no documented evidence of bereavement services made available to the family after Patient #11 expired. Interview with S2RN/ClinicalOperations on 04/14/2026 at 2:54 p.m. confirmed no bereavement steps were carried out after death for Patient #11, but should have been. Patient #12 Review of Patient #12’s clinical record revealed a start of care date for hospice services on 11/22/2025 and an expired date of 12/19/2025. Patient #12 had an admitting diagnosis of Hepatic Failure, Unspecified without Coma.  Further record review revealed no documented evidence of bereavement services made available to the family after Patient #12 expired. Interview with S1Administrator/DON on 04/15/2026 at 1:30 p.m. confirmed Patient #11 and Patient #12’s medical records did not contain bereavement services that was made available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patients, but should have.

Based on record review and interview, the Hospice agency failed to ensure that volunteers provided administrative and patient care services in an amount that at a minimum equaled 5 percent of the total patient care hours of all paid hospice employees as evidenced by failing to utilize volunteers.  Findings: --- Interview with S2RN/Clinical Operations on 04/15/2026 at 10:05 a.m. revealed the agency was trying to get a volunteer program started, but did not have one at this time. Interview with S1Administrator/DON and S2RN/Clinical Operations on 04/15/2026 at 1:30 p.m. confirmed the agency did not have any volunteers, but should. S1Administrator/DON and S2RN/Clinical Operations confirmed a minimum of 5% of total patient care hours paid should be provided by volunteers, but was not.

Based on interview and record review the agency failed to provide services to patients in accordance with an individualized written plan of care. The agency failed to ensure Hospice Aide visits were not missed for 1 (Patient #2) of 11 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10 and Patient #11) sampled patients. Findings: --- Review of the closed record revealed Patient #2 was admitted to services on 12/23/2022 with diagnoses that included Senile Degeneration of the Brain. Review of Patient #2s Individualized Plan of Care for certification period 01/01/2023-01/24/2023 revealed Patient #2 was to receive Hospice Aide visits 3 times a week for 11 weeks. Review of Patient #2s scheduled visit calendar for the week 01/01/2023 through 01/07/2023 revealed Patient #2 had missed HA (Hospice Aide) visits on 01/02/2023 and 01/06/2023. Review of a missed visit note dated 01/02/2023 revealed the visit was missed due to holiday. Review of a missed visit note dated 01/06/2023 revealed the visit was cancelled by the agency. Interview on 06/21/2023 at 11:54 a.m. with S1 Admin/DON revealed the agency was closed on 01/02/2023. S1 Admin/DON also revealed the visit on 01/06/2023 was cancelled by the agency and she was not sure why. S1 Admin/DON confirmed Patient #2 did not receive HA visits according to the Individualized Plan of Care for the week 01/01/2023 through 01/07/2023 and should have.

Based on record review and interview the agency failed to use volunteers to provide administrative and/or direct patient care services in an amount that, at a minimum equals 5 percent of total patient care hours of all paid hospice employees and contract staff. Findings: --- Review of the agencys Volunteer Policies revealed the following including: ";Purpose: The Volunteer Program is designed to meet Federal regulations for the provision of volunteer services to hospice patients and their caregivers. The Volunteer Program is monitored on a continuous basis to ensure it is functioning as intended and meeting the needs of the hospice program and its patients". ";Purpose: All volunteers are required to provide timely, accurate and appropriate documentation of any patient-related contact". Interview on 06/21/2023 at 11:21 a.m. with S1 Admin/DON revealed the agency did not try to recruit volunteers. S1 Admin/DON stated recruiting volunteers had not been at the forefront of things to do at this agency. S1 Admin/DON revealed she was aware use of volunteers was a federal requirement. Interview on 06/21/2023 at 11:29 a.m. with S1 Admin/DON revealed she had talked to S3 VP of Hospice Operations, and she (S3 VP of Hospice Operations) informed S1 Admin/DON that there had been no volunteers used by the agency since the agency started. S1 Admin/DON stated there had been no volunteers used at this agency since she started in 03/2020. Review of the agencys Governing Body Minutes dated 01/16/2023 & 04/24/2023 revealed no mention of recruitment of volunteers for the agency. Interview with S1 Admin/DON on 06/21/2023 at 12:05 p.m. confirmed this information. Review of 11 sampled patients electronic health records revealed no documentation of volunteer services. Review of email received on 06/22/2023 at 10:07 a.m. from S3 VP of Hospice Operations revealed no documentation concerning volunteers hired for this agency.