Every finding on record at Amedia Hospice, LLC

It is required that the documented comprehensive assessment include a drug profile that contains the patient's current prescription and over the counter (OTC) drugs, supplements, herbal remedies, other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) home visit observations, the agency did not ensure the patient's medication profile included the patient's current medications. HOME VISIT 2: The patient elected the hospice benefit on 09/27/2023 and resided at a nursing facility. During the home visit observation on 06/26/2025 with the Registered Nurse (RN) (Personnel Record 3), a medication review was completed by comparing the nursing facility's medication list to the patient's hospice medication profile. The nursing facility's medication list included Bexarotene 75mg capsules - five capsules by mouth twice a day, as per the order dated 05/09/2025. The patient's hospice medication profiles dated 04/19/2025 to 06/17/2025 and 06/18/2025 to 08/16/2025 included Bexarotene 75mg capsules - one capsule by mouth three times daily, dated 09/05/2023. The facility medication list ordered a dosage of 750mg per day, and the hospice medication profile ordered a dosage of 225mg per day. During a joint review of the facility's and hospice's medication lists and an interview on 06/26/2025, the Director of Clinical Services (DCS) (Personnel Record 2) confirmed that there was a dosage discrepancy between the two medication lists. The DCS obtained an order from the hospice Medical Director to correct the error.

It is required that each patient’s individualized written plan of care reflects the patient and family goals and identify planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure the individualized plan of care identified planned interventions and goals based on problems identified during assessments. CLINICAL RECORD 11: The patient elected the hospice benefit on 10/09/2024 and was recertified for multiple episodes of care. Clinical record review revealed a communication note was documented for a call made on 11/02/2024 at 10:50 a.m. by the patient who reported they were experiencing some nausea and vomiting. The nurse advised the patient to take his/her prescribed medication Ondansetron as needed to relieve the symptoms of nausea and vomiting. The Registered Nurse (RN) documented on the nursing visit note dated 11/25/2024, the patient reported not always taking his/her medications because he/she feels nauseous. The RN documented teaching the patient to utilize Ondansetron as needed during those periods. The plan of care dated 10/09/2024 to 12/07/2024 included an order for Ondansetron HCL 4mg by mouth every four to six hours as needed for nausea and vomiting. The plan of care did not include goal(s) and intervention(s) for the patient’s nausea and vomiting identified during nursing assessment(s). CLINICAL RECORD 13: The patient elected the hospice benefit on 12/07/2024 and was discharged as deceased on 03/10/2025. Clinical record review revealed an after-hours visit by the Licensed Vocational Nurse (LVN) on 02/27/2025, the nurse documented the patient was in bed with their eyes closed and was minimally responsive to touch. The skin was hot to touch, and the patient had a wet, nonproductive cough. The Interdisciplinary Team was notified of the change in the patient's condition, and an order was received to increase nursing visits from once a week to daily visits for the patient's decline. The RN documented on the nursing visit note dated 03/01/2025, the patient made eye contact but did not respond. The patient was refusing to eat, take meds, or wear oxygen, and was only taking in some fluids. During a call with the patient's daughter, the patient's expected prognosis was reviewed, and she verbalized agreement with the plan of care. The hospice nurse documented the patient’s death occurred on 03/10/2025. The plans of care dated from 12/07/2024 to 03/06/2025 and 03/07/2025 to 06/04/2025 were not updated to include goals and interventions related to the patient's decline in physical condition and imminent death. During a joint clinical record review and interviews on 06/26/2025 and 06/27/2025, the Director of Clinical Services (Personnel Record 2) confirmed that the patients' plans of care were not updated to include goals and interventions based on problems identified during assessments.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following: measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records reviewed, the agency did not ensure the individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 2: The patient elected the hospice benefit on 09/23/2024 with diagnoses of multiple sclerosis, major depression, and neuralgia. The patient was recertified for multiple episodes of care. The physician's recertification of terminal illness for the benefit period dated 05/21/2025 to 07/19/2025 noted that the patient exhibits symptoms of shortness of breath and uses 8 liters of oxygen per nasal cannula continuously. The plan of care dated 05/21/2025 to 07/19/2025 included the goal that the patient's shortness of breath would be managed within the limits of the disease progression. The goal was not measurable when it did not describe how the patient’s shortness of breath would be managed within the limits of the disease progression. CLINICAL RECORD 4: The patient elected the hospice benefit on 09/29/2024 with diagnoses of cerebral vascular disease, bipolar, major depressive disorder, and chronic pain syndrome. The patient was recertified for multiple episodes of care. The Nurse Practitioner's face-to-face visit for the benefit period dated 05/24/2025 to 07/25/2025 included documentation that the patient experienced ongoing management of shortness of breath with a history of oxygen use. The plan of care dated 05/27/2025 to 07/25/2025 included the goal that the patient's shortness of breath would be managed within the limits of the disease progression. The goal was not measurable when it did not describe how the patient’s shortness of breath would be managed within the limits of the disease progression. CLINICAL RECORD 6: The patient elected the hospice benefit on 02/21/2025 with diagnoses of malignant neoplasm of the parathyroid gland, malignant neoplasm of the face, head, and neck, and unspecified protein-calorie malnutrition. The plan of care dated 05/22/2025 to 08/19/2025 included a pain goal for the patient that documented an acceptable level of pain for the patient was "_/10." The patient's acceptable level of pain was left blank, and the goal was not measurable. The goal for anorexia documented the patient would be monitored/managed for anorexia, but did not describe how the anorexia would be monitored and managed and was not measurable. CLINICAL RECORD 8: The patient elected the hospice benefit on 09/27/2023 with diagnoses of congestive heart failure and vascular dementia. The physician's recertification of terminal illness for the benefit period 04/19/2025 to 06/17/2025 included that the patient exhibited worsening orthopnea and increased shortness of breath with progressive dyspnea [shortness of breath] and increased oxygen dependency, now requiring continuous supplemental oxygen at two liters per minute nasal cannula. The plan of care dated 04/19/2025 to 06/17/2025 included a goal that the patient's shortness of breath would be managed within the limits of the disease progression. The goal was not measurable when it did not describe how the patient’s shortness of breath would be managed within the limits of the disease progression. CLINICAL RECORD 14: The patient elected the hospice benefit on 03/31/2025 with diagnoses of malignant neoplasm of the bladder and pulmonary embolism. The Registered Nurse documented that the patient had severe generalized pain and documented teaching to the patient and caregiver on Morphine Sulfate administration for pain relief. The nurse also documented that the patient was short of breath at rest and had diminished breath sounds in all lobes. The plan of care dated 03/31/2025 to 06/28/2025 included a respiratory goal to increase the patient's level of respiratory comfort and decrease their level of shortness of breath and a pain goal that the patient would experience a pain level of none or set a comfortable level of pain to promote quality of life. The goals were not measurable when they did not describe what respiratory comfort would be for the patient and the patient’s acceptable level of pain. During a joint clinical record review and interviews on 06/25/2025 and 06/26/2025, the Director of Clinical Services (Personnel Record 2) confirmed that the patients' goals listed in the plans of care were not measurable.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. The agency did not ensure the hospice volunteer program included documentation of efforts to recruit and retain volunteers. Review of the hospice Volunteer Program revealed no documented evidence that the hospice had documented ongoing efforts to recruit and retain volunteers for 2024 and the first quarter of 2025. During review of the program and interview on 06/26/2025, the Director of Clinical Services (Personnel Record 2) and the Volunteer Coordinator (Personnel Record 5) confirmed that there was no documentation of volunteer recruitment or retention efforts. However, they were able to verbalize ongoing activities, such as one-on-one discussions and introductions to current volunteers, as well as the pursuit of various recruitment avenues, including flyers, colleges, and online platforms. During a review of the Volunteer Program's recruitment and retention documentation for 2024 and the first quarter of 2025, it was revealed that despite volunteer percentages at 5%, there was no documentation of recruitment or retention efforts for either 2024 or 2025. Interviews were conducted on 06/26/2025 with the Director of Clinical Services (Personnel Record 2), hired on 12/16/2024, and the Volunteer Coordinator (Personnel Record 5), who was hired on 03/17/2025. They confirmed that there was no evidence of any recruitment or retention efforts; however, they were able to verbalize ongoing activities, such as one-on-one discussions and introductions to current volunteers, as well as the pursuit of various recruitment avenues, including flyers, colleges, and online platforms.

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the Medical Director documented the certification of terminal illness. CLINICAL RECORD 2: The patient elected the hospice benefit on 09/23/2024. There was no documented evidence in the clinical record that the physician had completed the certification of terminal illness form for the initial hospice benefit period dated 09/23/2024 to 11/21/2024. The findings were confirmed during a joint clinical record review and interview on 06/27/2025 with the Director of Clinical Services (Personnel Record 2) and the Administrator (Personnel Record 1) on 06/27/2025.

It is required that the hospice medical director or physician-designee provide written and signed recertification of the terminal illness to meet the hospice care benefit requirement. The recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 5 of 12 (42%) clinical records reviewed with recertification of services, the agency did not ensure the hospice Medical Director completed and signed the recertification of terminal illness. CLINICAL RECORD 2: The patient elected the hospice benefit on 09/23/2024. The patient was recertified for a second benefit period dated 11/22/2024 to 01/20/2025. The recertification of terminal illness dated 11/06/2024 was not signed by the hospice Medical Director and was dated 16 days before the start of the benefit period. CLINICAL RECORD 4: The patient elected the hospice benefit on 09/29/2024 and recertified for a second benefit period dated 11/28/2024 to 01/26/2024. The recertification of terminal illness dated 11/14/2024 was not signed by the hospice Medical Director. CLINICAL RECORD 10: The patient elected the hospice benefit on 04/21/2025 and was recertified for a second benefit period dated 06/21/2025 to 09/18/205. The clinical record did not include a recertification of terminal illness form for the benefit period dated 06/21/2025 to 09/18/2025. CLINICAL RECORD 11: The patient elected the hospice benefit on 10/09/2024 and recertified multiple episodes of care. For the hospice benefit period dated 12/08/2024 to 01/09/2025, there was no recertification of terminal illness documented in the clinical record. CLINICAL RECORD 12: The patient elected the hospice benefit on 09/23/2023 and recertified for multiple episodes of care. For the hospice benefit period dated 11/16/2024 to 01/14/2025, the physician certification of terminal illness dated 11/16/2024 did not include a narrative and physician signature. The evidence was confirmed during a joint clinical record review and interview with the Director of Clinical Services (Personnel Record 2) and the Administrator (Personnel Record 1) on 06/27/2025.

It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: the most recent hospice plan of care, hospice election form and any advance directives, physician certification and recertification of the terminal illness, names and contact information for hospice staff involved in the patient’s care, instructions on how to access the hospice’s 24-hour on-call system, hospice medication information, and hospice physician and attending physician (if any) orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) home visit observations where the patient resided in a nursing facility, the agency did not ensure the nursing facility was provided with the most recent hospice plan of care, the physician's recertifications of the terminal illness, plan of care updates, and the hospice medication information. HOME VISIT 2: The patient elected the hospice benefit on 09/27/2023 and was most recently recertified for the benefit period dated 06/18/2025 to 08/16/2025. The patient resided in a nursing facility. During the home visit observation on 06/26/2025 with the Registered Nurse (RN) (Personnel Record 3), review of the hospice facility binder revealed the facility was not provided with the most recent hospice plan of care, the physician’s recertifications of terminal illness, the interdisciplinary plan of care updates, and the hospice medication profile for the benefit period dated 06/18/2025 to 08/16/2025. The RN reviewed the facility binder and confirmed the required documents were not in the facility binder. During an interview and review of findings from the home visit on 06/26/2025, the Director of Clinical Services (Personnel Record 2) stated that the hospice agency has been experiencing an ongoing issue with documents sent to the facility not being found in the facility binder. She mentioned that she had attended a meeting at the facility recently.

It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. 6 of 13 (46%) records reviewed revealed the hospice did not ensure the plan of care included all interventions and goals identified in the initial and updated comprehensive assessments. Record #4 was reviewed and identified the patient elected hospice care on 5/17/2022. The initial comprehensive assessment completed on 5/17/2022 identified the patient's diagnosis of bone cancer, with a high level of pain. The pain goal "_/10" was left blank and no pain goal was identified on the plan of care. The completed nursing visit notes reviewed documented, "control pain to 5/10." The plan of care as of 8/03/2022 did not include an updated goal for pain control. Record #6 was reviewed and identified the patient elected hospice care on 6/15/2022. The initial comprehensive assessment completed on 6/15/2022 identified the patient's high level of pain. The pain goal "_/10" was left blank and no pain goal was identified on the plan of care. The completed nursing visit notes reviewed documented a goal of "3/10" for pain control. The plan of care as of 8/03/2022 did not include an updated goal for pain control. Record #11 was reviewed and identified the patient elected hospice care on 3/10/2022, with a primary diagnosis of "Malnutrition Protein Deficiency." The initial comprehensive assessment documented, "Foley catheter to large bag drainage....difficulty swallowing... required feeding." The nursing visit note completed on 5/31/2022 documented a wound with a Duoderm. The plans of care did not document interventions or goals for the Foley, the difficulty with swallowing and feedings, and the wound. Record #1 was reviewed and identified the patient elected hospice care on 2/25/2022. The plan of care dated 2/25/2022 identified a goal for pain. The pain goal "_/10" was left blank on the plan of care. The completed nursing visit notes reviewed documented, "control pain to 5/10." The plans of care as of the review on 8/03/2022 did not include an updated goal for pain. Record #8 was reviewed and identified the patient elected hospice care on 3/30/2022. A sacral wound was documented during the nursing visit completed on 05/02/2022. The wound care provided include cleaning of wound, the application of Medihoney and a non-adherent dressing twice a day. The plan of care was not updated with interventions or goals for the wound and the wound care. Record #10 was reviewed and identified the patient elected hospice care on 2/5/2022. The nursing visit completed on 3/22/2022, documented a wound on the left arm with wound care: cleanse wound; apply triple antibiotic ointment; and a gauze dressing. The wound was documented as healed on 04/12/2022. The plan of care dated 03/31/2022 was not updated with interventions and goals addressing the wound and the wound care. During the interview with the Director of Nursing (DON) and Quality Manager confirmed the findings and stated the plans of care were identified as a process improvement project several weeks ago and are an area of focus. Agency Policy PC.6 [revision date 05/01/2020] stated in part, "The plan of care includes, but is not limited to a revised plan of care will include information from the patients updated comprehensive assessment and will note the patients progress toward outcomes and goals specified in the plan of care."

It is required that the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. 1 of 13 (8%) records reviewed revealed the hospice did not ensure all medications taken by the patient were documented on the plan of care. Record #6 was reviewed and identified the patient elected hospice care 06/15/2022. The initial comprehensive assessment completed on 06/15/2022 documented pain controlled with lidocaine patch. The plan of care dated 06/15/2022 did not document the medication lidocaine patch. The agency's policy #PC.6 "Plan of Care Process" (revised 5/01/2020) stated in part, "The plan of care includes, but is not limited to: Drugs and treatments necessary to meet the needs of the patient." During a joint record review and an interview with the Quality Manager (QM), the finding was confirmed, the QM stated the lidocaine was not on the plan of care but is on the medication profile. Agency Policy PC.6 Plan of Care Process [revised 05/01/2020] stated in part, "The plan of care includes, but is not limited to: Drugs and treatments necessary to meet the needs of the patient."

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 10 (10%) records reviewed of patients that accepted the services of an aide revealed the agency did not ensure the aide received clear and specific written instructions for the aide assignment. Record #8 was reviewed and revealed the patient elected hospice care on 3/30/22. The aide plan dated 04/05/2022 documented the assigned aide tasks of shower and bed bath, every visit. The patient experienced difficulty with anxiety and sleeping. There was no decision maker identified to determine the type of bath the aide was to provide. The aide care plan did not provide the aide with specific instructions for the patient's bath. During an interview the Administrator and Director of Nursing confirmed the patient might have been able to decide, but this was not documented on the aide plan.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes physician orders. This standard was not met as evidenced by a review of clinical records and interviews. 4 of 13 (31%) records reviewed did not provide evidence that required physician orders were documented. Record #8 was reviewed and identified the patient elected hospice care on 3/30/2022. The completed nursing visit note dated 05/02/2022, documented wound care that included cleaning, a medihoney dressing, and a non-adherent gauze covering. The record was missing a physician order for the wound care. Record #1 was reviewed and identified the patient elected hospice care on 2/25/2022. The completed nursing visit note dated 07/13/2022, documented a skin tear with "wound care" provided to the left shin. The specific wound care was not documented. In addition, subsequent nursing visit notes documented "continued wound care." The record was missing a physician order was documenting the specific wound care to be provided as of the review on 08/03/2022. Record #11 was reviewed and identified the patient elected hospice care on 3/10/2022. The completed nursing visit note dated 05/31/2022, documented, a skin opening on the right trochanter. In addition, the visit note documented starting wound care of a Duoderm dressing to be changed every 3 days. As of the record review on 08/03/2022, no physician order was documented. During an interview and a joint review of the record, the Administrator and the Director of Nursing confirmed they were not able to provide evidence of the physician order for the wound care as of 8/3/2022. Record #10 was reviewed and identified the patient elected hospice care on 2/5/2022. The completed nursing visit note dated 03/22/2022, documented, "a wound on the left arm... cleansed with NS, applied triple antibiotic ointment and gauze dressing." The record was missing a physician order for the wound care as of review 08/03/2022. An interview with the quality manager confirmed the physician orders were not documented.

It is required that drugs and biologicals are labeled and stored in accordance with state law and regulation, as well as accepted standards of practice. At a minimum, labels include the expiration date and cautionary instructions. This standard was not met as evidenced by a review of documents, interviews, and observations. The hospice did not ensure drugs and biologicals were labeled with the expiration date. During the office tour conducted on 8/4/2022, observation and inspection of the medication refrigerator revealed an open vial of Tubersol that had no evidence of the date opened. The Tubersol package insert read in part, "A vial of TUBERSOL which has been entered and in use for 30 days should be discarded." During the interview with the Quality Manager (QM), the QM stated the vial was opened on 7/1/2022 and that the agency disposes of the bottle when expired. The observed vial was entered and in use for 34 days, 4 days after recommended disposal date. Tuberculosis serum package insert stated in part, "A vial of TUBERSOL which has been entered and in use for 30 days should be discarded."

It is required that organization policy and procedure define a process for ensuring the implementation of additional precautions intended to mitigate the transmission and spread of COVID-19 for individuals who are not fully vaccinated for COVID-19. This standard was not met as evidenced by a review of personnel records, interviews, and document reviews. 1 of 1 (100%) records reviewed of individuals with an exemption revealed the agency failed to follow their policy for testing and tracking individuals who are not fully vaccinated and have patient contact. Staff #12: The personnel record for the Nurse Practitioner (NP) hired on 10/12/2017 revealed a documented exemption was signed and approved. The NP provided patient face to face visits in 2022. The record did not include documented evidence of testing or additional precautions to mitigate the transmission and spread of COVID-19 per the agency's policy The agency policy "Staff Vaccination Requirements for COVID-19" which referenced, "Title 42 Part 484, 484.70(d)" stated in part, "Requiring at least weekly testing for exempted staff and staff who have not completed their primary vaccination series, until the regulatory requirement is met, regardless of whether the facility or service site is located in a county with low to moderate community transmission, in addition to following CDC recommendations for testing unvaccinated in facilities located in counties with substantial to high community transmission." The agency failed to follow their HR policy"Staff Vaccination Requirements for COVID-19." The policy references the final rule, Title 42 Part 484, 484.70(d) that states "Requiring at least weekly testing for exempted staff and staff who have not completed their primary vaccination series, until the regulatory requirement is met, regardless of whether the facility or service site is located in a county with low to moderate community transmission, in addition to following CDC recommendations for testing unvaccinated in facilities located in counties with substantial to high community transmission.