OIG conducted an inspection at the VA Western New York Healthcare System in Buffalo NY (system) in response to allegations that staff prematurely referred critically ill intensive care unit (ICU) patients to the Hospice/Palliative Care Program for hospice care and that providers inappropriately prescribed opioid medications to sedated patients receiving hospice care. Because the system predominantly provides hospice care in the community living center (CLC), we expanded our review to include CLC patients as well as those who received hospice care in the ICU. We did not substantiate the allegations that staff prematurely referred ICU patients to palliative care or that sedated ICU patients received opioid medications that were inappropriate. However, we found that because providers in the CLC used narrative text orders for dose increase instructions, pharmacy and on-call physicians were, at times, unaware of opioid medication dose increases made by the CLC nursing staff. In addition, narrative text orders related to opioid infusions placed responsibility for dose increases solely with nursing and lacked recognition of drug pharmacokinetics. Portions of required nursing documentation of patient pain assessments and reassessments were lacking and scanning of paper opioid infusion records was inconsistent in both the CLC and ICU. We recommended that the System Director strengthen processes in the CLC to prevent the use of narrative text orders for opioid patient controlled or nurse controlled analgesia and that opioid titration orders include titration parameters. We also recommended that the System Director strengthen processes to ensure that nursing pain documentation adheres to Veterans Health Administration, Veterans Integrated Service Network, and local policies and that copies of paper records are available in electronic health records.