Every finding on record at St. Tammany Parish Hospital Service District No 1

Observed in Record Review. In 2 of 2 volunteer records reviewed, the organization had not documented ongoing education and training to volunteer staff that was consistent with their roles and responsibilities in an emergency. This was discussed with hospice leadership.

Observed in Record Review. In 2 of 14 patient records reviewed, it was noted that the organization did not ensure that the plan of care goals included outcome measures for specific care activities. For example, during a review of the medical record for HosRRNHV#10, the following goal statement was noted, “Patient will remain as independent as possible and remain safe in their environment. The goal statement did not include a method to measure the effectiveness of problem interventions. Example #2: During a review of the medical record for HosRRNHV#7, the following information was noted: Patient was scored at risk for falls and the clinician documented multiple falls with injury occurred prior to admission. The following goal statements related to patient safety were noted: Patient will remain as independent as possible and remain safe in their environment and Patient/caregiver will verbalize understanding of home safety measures, and patient will remain safe at home. The goal statement(s) did not include a method to measure the effectiveness of problem interventions. This observation was reviewed with the leadership team. Observed in Record Review. In 6 of 14 patient records reviewed, it was noted that the goals on the plan of care were not all measurable, individualized or timed. For example, in review of record for hospice home visit #3 the following goal was stated, Pt. will remain as independent as possible and remain safe in their environment. In hospice record review #4 the following goal was stated, Relief of nausea and vomiting. In review of hospice record review for hospice home visit #4 the following goals were stated, Receives appropriate emotional support and Reduce fall injury risk and frequency and symptoms of nuero deficiency will be minimized throughout hospice period. In hospice record reviews #3, #4 and #5 the pain goals were not individualized to include any patient specific pain goals and simply stated that pain would be managed and that exacerbations of pain would be relieved within 2 hours of medication administration. This was discussed with the hospice director of nursing.

Observed in Record Review. In 2 of 14 patient records reviewed, it was noted that the plan of care did not contain accurate details of scope and frequency. For example, in review of record for hospice home visit #2 it was noted that the plan of care stated that Physical Therapy was to be provided however there was no order or frequency for this service. Additionally in the same record the visit frequency for the volunteer was documented with a range of 1-12 visits PRN. In record review for hospice visit #4 the visit frequency for the volunteer was documented with a range of 1-12 visits PRN and the music therapy frequency was 1-10 visits PRN. The same visit ranges were stated for every pt having music therapy or volunteers. This was discussed with the hospice director of nursing.

Observed in Record Review. In 14 of 14 patient records reviewed, In review of all hospice records it was noted that the plan of care has standing orders for hospice which are not appropriate for all patients and/or are incomplete. For example, the following orders were part of the order set, Pluerex drainage fluid amount limits for every patient whether or not they have a Pluerex. incomplete foley insertion orders, which did not contain a catheter or balloon size. Other examples included wound care without specifics and placement of ppd or chest xray for nursing facility placement. This was discussed with the hospice director of nursing. Observed in Record Review. In 7 of 14 patient records reviewed, it was noted that the hospice plan of care was not updated or revised. For example, in review of record for hospice home visit #1 the patient developed a urinary tract infection and was treated with antibiotics twice in the last three months however the plan of care had not been updated to reflect new problems, goals or interventions. In review of record for hospice home visit #2 the care plan was not updated for a new eye infection with treatment of antibiotic eye drops. During review of hospice record #2 it was noted that the plan of care was not updated when there a change in conditions, for example the patient sustained a fall requiring sutures/staples however the plan of care was not updated until 13 days later. Additionally, the same patient developed a new wound, and the plan of care was not updated until 14 days later. In hospice record review #4 it was noted the care plan was not updated when the patient developed a herpes rash and was started on new medications. In hospice record review #5 it was noted that the plan of care was not revised when the patient refused aide visits for more than one month. In hospice record review #6 the patient had venous wounds to bilateral legs present at start of care however the interventions and goals for wound care were not added to the plan of care until on week later. This was discussed with the hospice director of nursing.

Observed in Record Review. In 1 of 12 patient records reviewed, with hospice aide services it was noted that the plan of care prepared by the RN was not appropriate to the aide's duties. For example, in review of record for hospice home visit #3 the aide care plan was noted to have the following assignment weight bearing precautions, hip/knee precautions, line precautions, and drain precautions none of which were appropriate to the patient. This was discussed with the hospice nursing director.

Observed in Record Review. In 1 of 3 patient records reviewed, where hospice aide services were provided it was noted that the aide did not provide care according to the assignment in the plan of care. For example, in the record review for hospice home visit #3 it was noted that the aide was to provide a bed bath however prior to the visit the aide stated that she would be providing a sponge bath on the commode and was observed doing the same. This was discussed with the hospice director of nursing.

Observed in Tracer Visit. In 2 of 4 home visits conducted, it was noted that the medication sheet in the home and in the record did not accurately reflect what the patient was actually taking. For example, in hospice home visit #2 the following medications were not accurate on the medication profile; Lorazepam had been discontinued, Zofran was ordered every 4-8 hours PRN but the medication profile stated every 8 hours only, Albuterol nebulizer ordered every 4 hours PRN, medication profile stated every 4-6 hours PRN, Atropine ordered 2 to 4 drops every four hours PRN, medication profile stated 2 drops every four hours PRN. Lastly, Valium was ordered as a scheduled medication BID however the wife was only giving it PRN. In review of record for hospice home visit #4 the following discrepancies were noted between the hospice medication profile and the SNF medication profile: Tylenol one table every 4-6 hours was listed on the record and 2 tabs every 6 hours was listed in the SNF record. Doxepin was listed in the hospice record as Take one by mouth every evening Administer once SBP >130 or DVP> 90, however this medication was given nightly for bipolar symptoms and no BP measurements were listed on the SNF medication profile. Lastly, Ativan was stated on the hospice medication profile as to be given by mouth however the SNF profile stated sublingual administration. This was discussed with the hospice director. Observed in Record Review. In 2 of 14 patient records reviewed, it was noted that specific notes on care, treatment or services. For example, in review of record for hospice visit #3 it was noted that the hospice aide was documenting that a bed bath was being provided however she stated and was observed performing a sponge bath on the bedside commode. with hospice aide services it was noted that the plan of care prepared by the RN was not appropriate to the aide's duties. In another example noted in the record for hospice home visit #3 the aide was noted to have documented weight bearing precautions, hip/knee precautions, line precautions, and drain precautions as tasks which were done, none of which were appropriate to the patient. This was discussed with the hospice director of nursing.

Observed in Record Review. In 1 of 2 Discharge Records reviewed, it was noted that the organization did not ensure the Discharge Summary was provided to the receiving agency. For example, a review of the medical record for HosRRDC#1, revealed that since there was no documented evidence that a discharge summary was completed; there was no documented evidence that the receiving Hospital was provided a copy of the Discharge Summary. This observation was reviewed with agency leadership. Observed in Record Review. In 1 of 2 Discharge Records reviewed, it was noted that the organization did not ensure the Discharge Summary was provided to the patient's physician. For example, since a review of the medical record for HosRRDC#1, revealed no documented evidence that a discharge summary was completed; there was no documented evidence that a discharge summary was provided to the patient's physician. This observation was reviewed with agency leadership.

Observed in Record Review. In 1 of 2 discharge records reviewed, it was noted that a discharge/transfer summary that included all required information was not completed. For example, a review of the medical records for HosRRDC#1, revealed no evidence that a discharge summary including the following information was documented: 1) A summary of the patient’s stay, including treatments, symptoms, and pain management, 2) The patient’s current plan of care, and 3) The patient’s latest physician orders. This observation was reviewed with the agency leadership team.

Observed in Record Review. In 2 of 4 patient records reviewed, who reside in a Skilled Nursing Facility, it was noted that the hospice plan of care for hospice home visit #4 did not identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. In hospice record review #6 it was noted that the plan of care for a SNF patient with a PICC line and receiving IV antibiotics did not identify the care that the facility was responsible for in terms of the infusion or PICC line care. This was discussed with the hospice director of nursing.

Based on record review and interview, the Hospice agency failed to ensure drugs and biologicals were handled in accordance with all applicable laws and regulations. This deficient practice was evidenced by failure to ensure the Hospice nurse, in the presence of a witness, documented the name and remaining counts of controlled drugs following a patient’s death for 3 of 3 (#1, #2, and #3) sampled patients. --- Review of the memo issued by the state regulatory agency, 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 regulatory agency is issuing this notice to all licensed Hospice providers. Effective 08/01/2018, Act 23 amends and reenacts LA 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 LA 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.Patient #1Review of Patient #1’s Clinical Record revealed he was admitted to the Hospice agency on 08/14/2024 and had a current Certification Period of 11/12/2024 through 12/24/2024.  Further review revealed he expired on 12/24/2024.Review of Patient #1’s Plan of Care (POC) and active Physician’s Orders at the time of his death, revealed, in part, an active order for Norco 5-325mg – Give 1 tablet by mouth every 4 hours as needed for pain.Review of Patient #1’s Death Visit Note, handwritten and electronic, dated 12/24/2024, revealed, in part, no documented evidence of the final count and/or status of Patient #1’s Norco following his death.Patient #2Review of Patient #2’s Clinical Record revealed she was admitted to the Hospice agency on 07/10/2024 and had a Certification Period of 07/10/2024 through 10/07/2024.  Further review revealed she expired on 07/20/2024.Review of Patient #2’s POC and Physician’s Orders at the time of her death, revealed, in part, an active order for MS Contin 15mg – Give 15mg via rectum twice daily for severe chronic pain.Review of Patient #2’s Death Visit Note, handwritten and electronic, dated 07/20/2024, revealed, in part, no documented evidence of the final count and/or status of Patient #2’s MS Contin following her death.Patient #3Review of Patient #3’s Clinical Record revealed he was admitted to the Hospice agency on 11/09/2023 and had a Certification Period of 09/04/2024 through 11/02/2024.  Further review revealed he expired on 10/27/2024.  Review of Patient 3’s POC and Physician’s Orders at the time of his death, revealed, in part, active orders for Norco 5-325mg – Give 1 tablet by mouth every 4 hours as needed for pain and Lyrica 150mg – Give 150mg by mouth twice daily for neuropathic pain.Review of Patient #3’s Death Visit Note, handwritten and electronic, dated 10/27/2024, revealed, in part, no documented evidence of the final count and/or status of Patient #3’s Norco and/or Lyrica following his death.An interview was conducted on 05/22/2025 at 1:25 p.m. with S1DIR.  S1DIR confirmed Norco, MS Contin and Lyrica were all controlled substances and would require compliance with LA RS 40:2191.  S1DIR reviewed the Clinical Records for Patients #1, #2, and #3 and confirmed they contained no documented evidence of the final count for the aforementioned medications and should have.

Observed in Record Review. A review of 1 of 13 patient records revealed that the organization did not ensure that initial assessments by members of the interdisciplinary group included all required information. For example, a review of the medical record for HosHV#2, revealed that the initial comprehensive assessment questions were not answered with information gathered from the comprehensive assessment. In the section of the assessment titled Safety Concerns, the question related to identification of fire safety risks was answered: no fire safety risks. However, the oxygen safety risk assessment identified smoking materials were present in the home. This observation was reviewed with the Hospice Patient Care Coordinator/Quality.

Observed in Record Review. A review of 2 of 13 patient records revealed that the organization did not ensure the information it required to be gathered during patient assessments was completed. For example, a review of the medical record(s) for HosRR#3, and HosRR#5, revealed that an initial bereavement risk assessment was not completed. This observation was reviewed with the Hospice Patient Care Coordinator/Quality.