DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
191680 A. BUILDING __________
B. WING ______________ 		08/10/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
PASSAGES HOSPICE 2111 N CAUSEWAY BLVD, MANDEVILLE, LA, 70471
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0555      
30587 Based on record review and interview the facility failed to ensure medication was administered as ordered for 1 of 5 sampled patients (Patient #1) reviewed for pharmaceutical services. Findings: Review of Patient #1's Physician Progress Notes dated 06/09/2022 revealed Patient #1 with senile degeneration of brain and cervical (spinal cord) fractures. Further revealed titrate medications as needed; increase Fentanyl (narcotic/pain patch) patch today. Review of Patient #1's Physician Orders dated 06/09/2022 revealed Fentanyl patch 25mcg (micrograms) apply one patch transdermal (patch to the skin) every 72 hours. Review of Patient #1's Nurses Notes dated 06/09/2022 at 12:25pm revealed the nurse applied Patient #1's increased Fentanyl 25mcg patch. Review of Patient #1's MAR (Medication Administration Record) for June 2022 revealed Patient #1's Fentanyl 25mcg patch was to change every 3 days with administration time ordered for 12:30pm. Further review revealed the Fentanyl patch was changed on 06/09/2022 and then changed on 06/12/2022 by SRN (a night shift nurse). Review of Patient #1's Nurses Notes dated 06/12/2022 at 8:00pm revealed Patient #1's Fentanyl 25mcg patch was applied. In an interview on 08/10/2022 at 3:38pm, S2ADON (Assistant Director of Nursing) stated with the review of Patient #1's MAR and the facility's Controlled Substance Sheets the facility was able to confirm Patient #1 did not have her Fentanyl patch replaced during the day shift as ordered.
L0663      
30587 Based on record review and interview the facility failed to have evidence of staff competencies for staff providing direct patient care for 5 of 5 sampled direct care staff (S4RN (Registered Nurse), S5RNAuditor, S6CNA (Certified Nursing Assistant), S7RN, and S8RN) reviewed for staff competency. Findings: Review of S4RN's Personnel File revealed a date of hire of 08/22/2017. Further review revealed no documented evidence and, the facility presented no documented evidence of S4RN had professional skills competency assessed. Review of S5RN/Auditor's Personnel File revealed a date of hire of 04/16/2021. Further review revealed no documented evidence and, the facility presented no documented evidence of S5RN/Auditor had professional skills competency assessed. Review of S6CNA's Personnel File revealed a date of hire of 04/06/2022. Further review revealed no documented evidence and, the facility presented no documented evidence of S6CNA had professional skills competency assessed. Review of S7RN's Personnel File revealed a date of hire of 05/24/2022. Further review revealed no documented evidence and, the facility presented no documented evidence of S7RN had professional skills competency assessed. Review of S8RN's Personnel File revealed a date of hire of 11/19/2021. Further review revealed no documented evidence and, the facility presented no documented evidence of S8RN had professional skills competency assessed. In an interview on 08/10/2022 at 3:06pm, S3Assistant Administrator stated the facility had no documented evidence of staff competencies having been assessed.
L0671      
30587 Based on record review and interview the facility failed to ensure the facility had documented clinical notes for care and services provided by the nursing staff for 1 of 5 sampled patients (Patient #1) reviewed for care and services provided as ordered. Findings: Review of Patient #1's record revealed no documented evidence and the facility presented no documented evidence of documentation of the care and services provided to Patient #1 by nursing staff on 06/12/2022 from 7:00am to 7:00pm. In an interview on 08/10/2022 at 3:38pm, S1Administrator stated the facility had no documented evidence of the care and services provided on 06/12/2022 from 7:00am to 7:00pm.