Every finding on record at Pinnacle Care Holdings, LLC

Based on interviews and record reviews, the Hospice agency failed to have a system in place to ensure the safe use, management and disposal of controlled drugs in the patient’s home in accordance with all applicable laws, regulations and accepted standards of practice.  This deficient practice was evidenced by failure to: 1.  Establish a written policy and procedure which outlined and ensured documentation of the witness’s signature for the count and disposal of unused controlled substances by the Hospice nurse immediately following a patient's death;2. Ensure immediately upon a patient’s death, the Hospice nurse, in the presence of a witness, performed the final count and disposal of all ordered controlled substances with documentation maintained of the witness’ signature for 1 of 1 (#1) death records reviewed; 3.  Establish a written policy and procedure to maintain current and accurate records of the disposition of all ordered controlled substances provided by the Hospice agency to the patient; and 4.  Ensure current and accurate records were maintained of the disposition of all ordered controlled substances provided by the Hospice agency to the patient for 3 of 3 (#1, #2, and #3) patients in the sample.  This deficient practice had the potential to affect any of the 392 patient deaths from 01/01/2025 through 08/25/2025, a current census of 127 patients and any future admissions to the agency. --- 1.  Written policy and procedure to ensure compliance with the state’s RS 40:2191.Review of the memo issued by the state’s licensing authority, dated 06/25/2018, revealed the following, in part: In accordance with Act 23 of the 2018 Regular Legislative Session, regarding the 2018 Regular Legislative Session, the state’s licensing authority is issuing this notice to all licensed hospice providers. Effective 08/01/2018, Act 23 amends and reenacts the state’s RS 40:2191 relative to disposal of controlled substances by hospice providers; to provide for ownership; to provide for written procedures; to provide for patient records; to provide for disposal; to provide for patient notification; and to provide for related matters. Review of the state’s RS 40:2191 revealed the following, in part: Disposal of deceased patient's unused controlled substances:A. Upon death of a patient receiving hospice services, ownership of the patient's unused Schedule II, III, IV, or V controlled substances under 21 CFR 1308 may transfer to the hospice for immediate disposal pursuant to the following provisions:(1) Each hospice shall establish a written procedure to ensure safe disposal of unused controlled substances by a hospice nurse at the time of a patient's death.(2) Upon the death of a patient receiving hospice services, in the presence of a witness, the hospice nurse shall record in the medical record the name and quantity of each unused controlled substance.(3)(a) The hospice nurse shall conduct immediate disposal of the controlled substance at the site of care … (b) … the hospice nurse shall perform the disposal in the presence of a witness, who shall sign a document indicating their witnessing the disposal. (5) The hospice nurse shall record the method of disposal in the medical record.Review of the agency’s policy #9118 titled “Death at Home”, last revised 10/2024, as of 08/27/2025 at 4:15 p.m., revealed, in part, the following: Procedure: The Hospice Registered Nurse (RN) shall dispose of all medications, including controlled substances, per local and state regulations.  The RN may discard all narcotics in cat litter, or dried coffee grounds, then dispose of in a double-plastic bag.  The RN documents the medications disposed in the clinical record.  Further review revealed, in part, the policy and procedure did not meet the aforementioned requirements for obtaining and maintaining documentation of the witness’s signature as required in the state’s RS 40:2191.  2.  Upon death, document the witness’s signature to the final count and destruction of all ordered controlled substances.Review of Patient #1’s Clinical Record revealed she was admitted to the Hospice agency on 06/20/2024 with an Initial Certification Period of 06/20/2024 through 09/17/2024 and a final Certification Period of 12/17/2024 through 02/12/2025.  Further review revealed, in part, she expired at home with family on 02/12/2025.Review of Patient #1’s Physician’s Orders, for the Certification Period of 12/17/2024 through 02/12/2025, revealed, in part, the following active orders for controlled substances at the time of her death: Lorazepam 2mg Tablet: Give 1 tablet by mouth every 4 hours as needed for restlessness/agitation;Dilaudid 2mg Tablet: Give 1 tablet by mouth every 8 hours as needed for pain;Morphine Sulfate Oral Concentrate 100mg/5mL: Give 0.25mL by mouth every 3 hours as needed for pain/shortness of breath; and Restoril 15mg Capsule: Give 1 capsule by mouth at bedtime for insomnia.Review of Patient #1’s Death Visit Note, performed on 02/12/2025 at 8:25 a.m. by S3RN, revealed, in part, the following: The following controlled substances were counted and disposed of per agency policy:Restoril: 14 tablets; Morphine Concentrate: 14mL; Lorazepam: 22 tablets; and Dilaudid: 45 tablets.  All controlled substances were counted and disposed of in the presence of Patient #1’s private sitter.  Further review revealed no documented evidence of the signature of the witness to the final count and disposal of Patient #1’s ordered controlled substances immediately following her death.  Review of Patient #1’s Handwritten Death Note, dated 02/12/2025 and written by S3RN, revealed, in part, the following controlled substances were counted and disposed of per agency policy: Restoril: 14 tablets; Morphine Concentrate: 14mL; Lorazepam: 22 tablets; and Dilaudid: 45 tablets.  All controlled substances were counted and disposed of in the presence of Patient #1’s private sitter.  Further review revealed no documented evidence of the signature of the witness to the final count and disposal of Patient #1’s ordered controlled substances immediately following her death.  An interview was conducted on 08/27/2025 at 11:35 a.m. with S3RN.  S3RN confirmed, during a Death Visit, she should obtain the signature of the witness to her final count and disposal of the patient’s remaining controlled substances.  S3RN confirmed the witness signature should be on the patient’s handwritten Death Note which was turned in to the agency to be added to the patient’s Clinical Record.  S3RN confirmed she did not obtain the signature of the witness to the final count and disposal of Patient #1’s remaining controlled substances.  An interview was conducted on 08/27/2025 at 3:35 p.m. with S2DON.  S2DON confirmed the RN who performed a patient’s death visit should obtain the signature of their witness to the final count and disposal of the patient’s remaining controlled substances following their death.  S2DON confirmed the witness signature should be documented on the patient’s handwritten Death Note then added the patient’s Clinical Record.  S2DON confirmed Patient #1’s Death Note did not contain a signature of the witness present for S3RN’s final count and disposal of Patient #1’s remaining controlled substances following her death and should have.3.  Written policy and procedure for the safe management, use and disposition of controlled substances in a patient’s home.Review of the United States Government Accountability Office’s (GAO) Report titled, “Preventing Drug Diversion,” published April 2020, revealed, in part, the following: Misuse of controlled substances continues to be a serious public health problem in the United States.1 National survey data from the Substance Abuse and Mental Health Services Administration show that in 2017, 53 percent of people 12 years of age and older in the United States who misused prescription pain relievers in the past year, obtained the drugs from friends and family.  The most commonly misused controlled substances include opioids (such as oxycodone), which are used to treat pain, and central nervous system depressants (such as diazepam), which are used to treat anxiety and sleep disorders. These types of drugs are prescribed for a large proportion of patients in hospice care. Patients select hospice care when they no longer want treatment for their terminal illness, but rather choose a hospice team to provide symptom management and control. In 2017, approximately 1.5 million Medicare beneficiaries received hospice services, and 56 percent of those patients received care in the patient’s home. Medicare is the largest payer for hospice services.The Controlled Substances Act regulates the manufacture, distribution, use, and disposal of controlled substances.13 In general, the Controlled Substances Act was enacted to facilitate the use of controlled substances for legitimate medical, scientific, research, and industrial purposes while preventing them from being diverted for illegal uses.What GAO Found: Best Practices for Reducing the Risk of DiversionHospice officials we spoke to identified best practices for preventing diversion of controlled substances. Best practices include prescription drug counts performed by hospice employees to determine if controlled substances are being used properly.Narcotic counts can also help ensure that unused or expired medications are properly disposed of, preventing potential misuse or accidental ingestion. Review attempted of the agency’s policy and procedure regarding the safe management, use and disposition of controlled substances in a patient’s home was attempted on 08/27/2025 with no documented evidence available for review.  4.  Ensure documentation of counts for all ordered controlled substances during Nurse Visits.Patient #1Review of Patient #1’s Ordered Frequency for Skilled Nurse Visits for the Certification Period of 12/17/2024 through 02/12/2025 revealed, in part, the following: 2 visits/week for 9 weeks effective 12/17/2025; and 6 visits/week for 1 week effective 02/09/2025.Review of Patient #1’s Physician’s Orders, for the Certification Period of 12/17/2024 through 02/12/2025, revealed, in part, the following active orders for controlled substances at the time of her death: Lorazepam 2mg Tablet: Give 1 tablet by mouth every 4 hours as needed for restlessness/agitation;Dilaudid 2mg Tablet: Give 1 tablet by mouth every 8 hours as needed for pain;Morphine Sulfate Oral Concentrate 100mg/5mL: Give 0.25mL by mouth every 3 hours as needed for pain/shortness of breath; Restoril 15mg Capsule: Give 1 capsule by mouth at bedtime for insomnia; and Tramadol HCl 50mg Tablet: Give 1 tablet by mouth every 4 hours as needed for back/hip pain.  Review of Patient #1’s Skilled Nurse Assessment and Visit Notes, for the Certification Period of 12/17/2024 through 02/12/2025, revealed, in part, the following visits contained no documented evidence of the remaining amount of the 5 aforementioned controlled substances provided to Patient #1 by the agency for a total of 24 missed opportunities to count/document: 12/18/2024;12/20/2024;12/24/2024;12/26/2024;12/31/2024;01/03/2025; 01/06/2025;01/07/2025;01/09/2025;01/14/2025;01/16/2025;01/18/2025;01/19/2025;01/20/2025;01/23/2025; 01/28/2025;01/30/2025;02/02/2025;02/04/2025;02/06/2025;02/08/2025;02/09/2025; 02/10/2025; and 02/11/2025.Patient #2Review of Patient #2’s Clinical Record revealed she was admitted to the Hospice agency on 08/04/2025 with an Initial Certification Period of 08/04/2025 through 11/01/2025.  Review of Patient #2’s Ordered Frequency for Skilled Nurse Visits for the Certification Period of 08/04/2025 through 11/01/2025 revealed, in part, 3 visits per week for 13 weeks.  Review of Patient #2’s Physician’s Orders, for the Certification Period of 08/04/2025 through 11/01/2025revealed, in part, the following active orders for controlled substances: Ativan 0.5mg Tablet: Give 1 tablet by mouth every 6 hours as needed for anxiety;Dilaudid 4mg Tablet: Give 3 to 4 tablets by mouth every 4 hours as needed for pain;Methadone HCl 10mg tablet: Give 3 tablets by mouth 3 times daily for pain; Klonopin 1mg Tablet: Give 1 tablet by mouth 3 times a day as needed for restlessness/agitation; Clonazepam 0.5mg Tablet: Give 1 tablet by mouth twice a day as needed for anxiety; andMorphine Sulfate Oral Concentrate 20mg/mL: Give 0.25mL by mouth every 3 hours as needed for pain/shortness of breath.Review of Patient #2’s Skilled Nurse Assessment and Visit Notes, for the Certification Period of 08/04/2025 through 11/01/2025, revealed, in part, the following visits contained no documented evidence of the remaining amount of the 6 aforementioned controlled substances provided to Patient #2 by the agency for a total of 8 missed opportunities to count/document: 08/04/2025;08/05/2025; 08/07/2025; 08/11/202508/13/2025;08/15/2025;08/18/2025; and 08/20/2025.Patient #3Review of Patient #3’s Clinical Record revealed she was admitted to the Hospice agency on 11/13/2024 with an Initial Certification Period of 11/13/2024 through 01/24/2025.  Review of Patient #3’s Ordered Frequency for Skilled Nurse Visits for the Certification Periods of 07/12/2025 through 08/19/2025 and 08/23/2025 through 11/20/2025 revealed, in part, 1 visit per week for 9 weeks effective 07/12/2025 and 1 visit per week for 1 week then 1 visit per week for 12 weeks effective 08/20/2025. Review of Patient #3’s Physician’s Orders for the Certification Periods of 07/12/2025 through 08/19/2025 and 08/23/2025 through 11/20/2025 revealed, in part, the following active orders for controlled substances: Ativan 0.5mg Tablet: Give 1 tablet by mouth every 6 hours as needed for anxiety;Morphine Sulfate Oral Concentrate 100mg/5mL: Give 0.25mL by mouth every 3 hours as needed for pain/shortness of breath; and Norco 5-325mg Tablet: Give 1 tablet by mouth every 6 hours as needed for pain.Review of Patient #3’s Skilled Nurse Assessment and Visit Notes, dated 07/12/2025 through 08/27/2025, revealed, in part, the following visits contained no documented evidence of the remaining amount of the 3 aforementioned controlled substances provided to Patient #3 by the agency for a total of 6 missed opportunities to count/document: 07/16/2025; 07/23/2025;07/30/2025;08/06/2025;08/13/2025; and 08/23/2025.  An interview was conducted on 08/27/2025 at 11:35 a.m. with S3RN.  S3RN confirmed she was not aware of an agency policy and procedure which would require her to document the remaining count of all of the patient’s controlled substances present in their home during her nurse visits and she did not do so.  S3RN confirmed there was not anywhere within a patient’s Electronic Health Record to document this information.  An interview was conducted on 08/27/2025 at 3:35 p.m. with S2DON.  S2DON confirmed best practice would be for her nurses to visualize and count all patient medications during every visit to ensure nothing seemed off and/or if a refill would be required prior to the nurse’s next scheduled visit.  S2DON confirmed she was not aware of a policy and procedure which would require their nurses to document the aforementioned information within the patient’s Clinical Record.  S2DON confirmed she agreed this would be key information to have documented and available for reference during future visits and/or if patient safety concerns arose.  An interview was conducted on 08/27/2025 at 4:25 p.m. with S1CEO.  S1CEO confirmed the agency did not have a policy and procedure to ensure the safe management, use and documentation within the patient’s Clinical Record of the disposition of all ordered controlled substances provided to their patients by the agency.

Based on record reviews and interviews, the hospice agency failed to ensure licensed professionals actively participated in all aspects of the patients hospice care in accordance with current professional standards. The agency failed to ensure a patients medical pronouncement of death by a coroner was based on personal observation or information and statements obtained from a qualified professional for 1 (#3) of 3 (#3, #4 and #5) bereavement records reviewed. --- Review of Louisiana Revised Statute 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 Nurse (RN)s, physician assistants, or emergency medical technicians at the scene who are reporting from firsthand observation of the physical condition of the deceased. ... Patient #3Review of Patient #3s Clinical Record revealed a Start of Care Date of 10/12/2023 with a Certification Period of 10/12/2023 through 10/15/2023 and a date of death of 10/15/2023. Review of Patient #3s On Call Visit Assessment in the Electronic Health Record (EHR) dated 10/15/2023 and written by S7LPN revealed, in part, the following: Time of Death: 6:05 p.m.Death Pronounced by S7LPN. Review of Patient #3s handwritten Death Note dated 10/15/2024 by S7LPN revealed, in part, the following: Time of Death: 6:05 p.m.Observed by Whom: S7LPN. Review of Patient #3s Nursing Visit/Clinical Notes, dated 10/15/2023, revealed no documentation indicating an RN or other qualified professional was present and performed Patient #3s death assessment. An interview was conducted on 10/17/2024 at 11:50 a.m. with S2DON. S2DON confirmed the agencys process upon death was for a nurse, either Licensed Practical Nurse (LPN) or RN, to perform a death assessment to ensure the absence of vital signs then contact the coroner by phone to receive pronouncement of death and release of the body. S2DON reviewed Patient #3s chart and confirmed S7LPN performed Patient #3s death assessment then contacted the coroner to receive pronouncement of death and release of the body independently and without an RN or other qualified professional present. S2DON confirmed she was not aware of LS RS 9.111 and was not aware an LPN could not perform the death assessment for the coroner. An interview was conducted on 10/17/2024 at 11:55 a.m. with S1ADM. S1ADM confirmed the agency allowed LPNs to perform death visits independently and she was not aware they should not. S1ADM confirmed she was not aware of LA RS 9.111.

Based on interviews and record reviews, the hospice agency failed to ensure nursing services met the needs of the patients for 2 (#6 and #9) of 3 (#6, #9, and #10) patients reviewed for pressure ulcers. The agency failed to follow acceptable standards of practice for pressure ulcer care specifically by failing to document weekly wound measurements for Patient #6 and #9. --- Review of the Louisiana State Board of Nursings Declaratory Statement Scope of Practice for Registered Nurses (RN) Wound Care Management, adapted 02/1999, revealed, in part, the following: RNs 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 conditions involves 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 RN in the practice setting. The RN 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 RN 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 2019 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. Patient #6A review of Patient #6s Clinical Record revealed a Start of Care Date of 02/22/2023 with a current Certification Period of 10/14/2024 through 12/12/2024. Further review revealed Patient #6 was currently receiving treatment for an Unstageable Pressure Ulcer to the Right Greater Trochanter. A review of Patient #6s Plan of Care, as of 10/14/2024, revealed, in part, the following: Skilled Nurse (SN) Visit Frequency: once weekly;Skin/Wound Interventions: Assess wounds and measure weekly. See assessment for measurement and wound progression; andWound Care: Right Greater Trochanter - Apply Barrier Cream and turn every 2 hours. A review of Patient #6s Weekly SN Assessments, dated 08/04/2024 through 10/14/2024, revealed, in part, the following: Unstageable Pressure Ulcer to Right Greater Trochanter: 08/07/2024 by S3RN – No wound measurements; 08/14/2024 by S3RN – No wound measurements;08/21/2024 by S3RN – No wound measurements;08/28/2024 by S3RN – No wound measurements;09/04/2024 by S3RN – No wound measurements;09/18/2024 by S3RN – No wound measurements;10/02/2024 by S3RN – No wound measurements; and 10/09/2024 by S3RN – No wound measurements. A review of Patient #6s SN Clinical Notes, dated 08/04/2024 through 10/14/2024, revealed, in part, no documented wound measurements for Patient #6s Unstageable Pressure Ulcer to the Right Greater Trochanter. An interview was conducted on 10/15/2024 at 10:40 a.m. with S3RN. S3RN confirmed he was expected to measure and document pressure ulcers in a patients chart weekly. Patient #9A review of Patient #9s Clinical Record revealed a Start of Care Date of 02/23/2024 with a current Certification Period of 08/21/2024 through 10/19/2024. Further review revealed Patient #9 was currently receiving treatment for a Stage 2 Pressure Ulcer to the Sacrum. A review of Patient #9s Plan of Care, as of 10/14/2024, revealed, in part, the following: SN Visit Frequency: twice weekly;Skin/Wound Interventions: Assess wound for location, size, stage, drainage, wound bed and periwound care; and Wound Care: Sacrum – Clean with wound cleaner and pat dry. Prepare periwound with skin protectant. Paint wound bed and periwound with gentian violet. Apply calcium alginate to wound bed and petroleum based gauze. Secure with optifioam boarder gauze. Change Daily. A review of Patient #9s Weekly SN Assessments, dated 09/01/2024 through 10/15/2024, revealed in part, the following: Stage 2 Pressure Ulcer to the Sacrum: 09/10/2024 by S4RN – No wound measurements;10/01/2024 by S4RN – No wound measurements; and 10/08/2024 by S4RN – No wound measurements. A review of Patient #9s SN Clinical Notes, dated 09/01/2024 through 10/15/2024, revealed, in part, no documentation of wound measurements for Patient #9s Stage 2 Pressure Ulcer to the Sacrum. An interview was conducted on 10/17/2024 at 10:40 a.m. with S2DON. S2DON confirmed she would expect wound measurements to be performed and documented weekly by an RN for all pressure wounds, both staged and unstageable. S2DON reviewed the above findings for Patient #6 and Patient #9 and confirmed measurements were not documented weekly 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. --- A review of the agencys 2023 Volunteer Activity Reports revealed the agency 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 10/17/2024 at 10:05 a.m. with S5VC. S5VC confirmed the agency only had 2 part time volunteers and had been struggling with getting their volunteer numbers back up since Covid. An interview was conducted on 10/17/2024 at 10:40 a.m. with S2DON. S2DON confirmed they were aware the facilitys Volunteer Program was not where it should be. An interview was conducted on 10/17/2024 at 12:30 p.m. with S1ADM. S1ADM confirmed the agency did not meet the annual volunteer requirements for the previous year, 2023, and should have.

Based on record reviews and interviews, the hospice agency failed to ensure all entries in patients death records were accurate and complete in accordance with currently accepted standards of practice for 3 of 3 (#3, #4, and #5) bereavement records reviewed. --- Review of Louisiana Revised Statute 9.111 revealed, in part, the following: Definition of Death: 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. ... Patient #3A review of Patient #3s Clinical Record revealed a Start of Care Date of 10/12/2023 with a Certification Period of 10/12/2023 through 10/15/2023 and a date of death of 10/15/2023. Review of Patient #3s On Call Visit Assessment in the Electronic Health Record (EHR) dated 10/15/2023 and written by S7LPNrevealed, in part, the following: Time of Death: 6:05 p.m.Death Pronounced by S7LPN. Review of Patient #3s handwritten Death Note dated 10/15/2024 by S7LPNrevealed, in part, the following: Time of Death: 6:05 p.m.Observed by Whom: S7LPN.Parish/Coroner Notified: Ascension. Further review of the Death Note revealed no documented evidence of the name of the physician or coroner who pronounced the death of the patient. Review of Patient #3s Nursing Visit/Clinical Notes, dated 10/15/2023, revealed no documentation of the name of the physician or coroner who pronounced the death of the patient. An interview was conducted on 10/17/2024 at 11:50 a.m. with S2DON. She reviewed Patient #3s chart and confirmed the information documented above. She confirmed the pronouncement of death was made by a coroner, not S7LPN. She confirmed Patient #3s On Call Visit Assessment in the EHR indicated the pronouncement of the patients death was made by S7LPN, not the coroner, which was not correct information. She confirmed the ";Death Pronounced by" section should have the name of the physician or coroner the nurse spoke with to obtain pronouncement of death, not the name of the nurse. She confirmed Patient #3s handwritten death note did not indicate the name of the coroner who made the pronouncement of death, and it should. Patient #4A review of Patient #4s Clinical Record revealed a Start of Care Date of 10/15/2023 with a Certification Period of 10/15/2023 through 10/16/2023 and a date of death of 10/16/2023. Review of Patient #4s On Call Visit Assessment in the EHR dated 10/16/2023 and written byS8RNrevealed, in part, the following: Time of Death: 10:16 a.m.Death Pronounced by S8RN.Further review of the Death Note revealed no documented evidence of the name of the physician or coroner who pronounced the death of the patient. An interview was conducted on 10/17/2024 at 11:50 a.m. with S2DON. She reviewed Patient #4s chart and confirmed the information documented above. She confirmed the pronouncement of death was made by a coroner, not S8RN. She confirmed Patient #4s On Call Visit Assessment in the EHR indicated the pronouncement of the patients death was made by S8RN, not the coroner, which was not correct information. She confirmed the ";Death Pronounced by" section should have the name of the physician or coroner the nurse spoke with to obtain pronouncement of death, not the name of the nurse. Patient #5A review of Patient #5s Clinical Record revealed a Start of Care Date of 09/05/2023 with a Certification Period of 09/05/2023 through 10/20/2023 and a date of death of 10/20/2023. Review of Patient #5s On Call Visit Assessment in the EHR dated 10/20/2024 and written by S3RN revealed no documentation regarding the pronouncement of death. Review of Patient #5s handwritten Death Note dated 10/20/2023 by S3RN revealed, in part, the following: Time of Death: 8:45 a.m.Observed by Whom: S3RN.Parish/Coroner Notified: EBRP. Further review of the Death Note revealed no documented evidence of the name of the physician or coroner who pronounced the death of the patient. Review of Patient #5s Nursing Visit Note dated 10/20/2023 and written by S3RN revealed, in part, the following: Arrived at 8:30 a.m.Patients death pronounced at 8:45 a.m. by absence of respirations, no palpable pulses at carotid or radial sites. No heart or breath sounds auscultated. Patient cool to touch. Cyanotic at nail beds.Coroner notified at 9:05 a.m., release of body obtained. Further review of the Nursing Visit Note revealed no documented evidence the patients death was pronounced by a physician or the coroner. An interview was conducted on 10/17/2024 at 11:50 a.m. with S2DON. She reviewed Patient #5s chart and confirmed the information documented above. She confirmed the pronouncement of death was made by a coroner, not S3RN. She confirmed the On Call Visit Assessment in the EHR was where nurses were expected to document information regarding the pronouncement of death and Patient #5s did not. She confirmed Patient #5s handwritten death note did not indicate the name of the coroner who made the pronouncement of death, and it should. She confirmed the agencys process upon death was for the nurse to perform an assessment to ensure the absence of vital signs then contact the coroner by phone to receive pronouncement of death and release of the body. She stated each patients record should have indicated the name of the physician/coroner who pronounced the death of the patient. She confirmed all patient records should have been accurate, complete, and in accordance with currently accepted standards of practice and state law. An interview was conducted on 10/17/2024 at 11:55 a.m. with S1ADM. She confirmed all patient records should be accurate, complete, and in accordance with currently accepted standards of practice and state law.

Based on interviews and record reviews, the agency failed to ensure services were provided as per the individualized written plan of care established by the hospice IDT team for 2 (#3, #5) of 13 (#1-#13) patients reviewed. The agency failed to ensure: 1.) skilled nursing staff documented wound care was provided to Patient #3 and Patient #5 as ordered in the plan of care; 2.) PT/INR labs were obtained as ordered for Patient #5. Findings: Patient #3 Review of the clinical record for Patient #3 revealed the patient was certified to receive services with the agency on 10/06/2021. The patient had diagnoses that included Chronic combined Systolic and Diastolic Congestive Heart Failure. Further review revealed the patient was ordered to receive skilled nursing services 2 times a week for 13 weeks. Review of the current plan of care for Patient #3 for the certification period of 10/06/2021-01/03/2022 revealed the following: Admit Summary- 10/06/2021: Stage 3 Wound to Buttock- Wound Care MD. Review of the wound care orders dated 10/08/2021 and 10/22/2021 for Patient #3 revealed the patient was to receive wound care dressing changes 3 times a week and as needed. Further review revealed most recent orders written on 10/22/2021 were to pack wound loosely and fill all dead space. Do not over pack wound- Pack with aquacel Ag, Apply adaptic to wound bed (if applicable) then cover with dry gauze and wrap with kerlix/conform (if applicable). Secure with tape. Avoid excessive contact of tape with skin, May substitute with border dressing. Review of the clinical notes and nursing assessments for Patient #3 revealed no documentation the skilled nurse was assessing or providing wound care to the patients wound as ordered since the beginning of receiving serviced on 10/06/2021. An interview was conducted with S1CEO on 11/10/2021 at 1:25 p.m. He reviewed the nursing assessments, clinical notes and IDT notes for Patient #3 and verified there was no documentation showing the skilled nurse was assessing and providing wound care as ordered by the MD between 10/06/2021 and 11/05/2021. He stated he would have expected to see documentation the wound care was addressed by either the nurse or the caregiver. Patient #5 Review of the clinical record for Patient #5 revealed the patient began receiving services with the agency on 06/02/2021 and had diagnoses that included Acute on Chronic Systolic Heart failure, Chronic Kidney Disease, Chronic Vascular Disorders and Abnormal Coagulation Profile. Further review revealed the patient was to receive skilled nursing services 2 times a week for 13 weeks for the certification period of 08/20/2021-11/28/2021. Review of the current care plan for Patient #5 revealed the following: Physician Order- 06/02/2021- Sacral Pressure Ulcer- SN or caregiver to clean affected area with wound cleanser, pat dry with 4x4 gauze, cover with hydrocolloid dressing every 3-5 days until healed or MD orders change. PT/INR: SN to obtain blood specimen for PT/INR in 2 weeks and report findings to MD. IDT Meeting- 06/11/2021- Nursing- Skin integrity- Patient has small Stage 1 on sacrum IDT Meeting- 06/25/2021- Nursing- Skin integrity- Patient has small Stage 1 on sacrum and its healing IDT Meeting- 07/09/2021- Nursing- Skin integrity- Patient has small Stage 1 on sacrum and its healing IDT Meeting- 07/23/2021- Nursing- Skin integrity- Patient has small Stage 1 on sacrum and its healing Further review of IDT meeting documentation revealed no documentation regarding when patient Stage 1 pressure ulcer was resolved or that PT/INRs were obtained as ordered and results reported to MD. Review of the clinical notes for Patient #5 revealed there was no documentation showing wound care was provided to the patients Stage 1 pressure ulcer as ordered. Further review revealed there was no documentation showing when the Stage 1 pressure ulcer was resolved. Review of the clinical notes and nursing assessments for Patient #5 revealed the only documentation showing SN obtained PT/INR was on 07/23/2021, 10/28/2021 and 11/04/2021. An interview was held with S2DON on 11/10/2021 at 1:20 p.m. She reviewed the record for Patient #5 and verified there was no documentation showing wound care was provided as ordered or if the wound was healed. She also verified here was no documentation a PT/INR was obtained other than on 07/23/2021, 10/28/2021 and 11/04/2021. She verified it was not obtained in 2 weeks as initially ordered on 06/02/2021.