Every finding on record at Amedisys Hospice Care

Based on agency policy, clinical record review, and staff interviews, the agency inaccurately documented licensed practical nurse (LPN) supervisory visits for 2 of 2 patients with LPN supervisory visits (patients #1 and 11).Findings included: --- Findings included:A policy, Supervision of Disciplines- RN/LPN (registered nurse/licensed practical nurse), (reviewed 08/05/2025), received on 12/03/2025 at 10:59 AM from the agency director stated, “Supervision is achieved through direction, observation, and evaluation of new and experienced staff… The on-site supervisory visit will focus on intervention consistent with the POC [plan of care], infection control… interaction with the patient/caregiver.”1. Patient #1 was admitted on 03/01/2022 with a diagnosis of Alzheimer’s disease (loss of brain function that worsens over time). The plan of care for 10/11/2025-12/09/2025 included orders for skilled nurse visits 1 time a week for 8 weeks with 8 PRN (as needed). Review of the clinical record revealed that during the RN visit on 10/30/2025 RN #9 documented, Supervisory Functions… “Licensed Practical Nurse” … POC [plan of care] can safely be implemented by the LPN “YES”… Was the patient/caregiver satisfied with the care “YES” … Further review revealed that patient #1 had not had any visits by an LPN.2. Patient #11was admitted on 07/24/2025 with a diagnosis of protein calorie malnutrition (reduced availability of nutrients leads to changes in body composition and function). The plan of care for 10/23/2025-12/21/2025 included orders for skilled nurse visits 1 time a week for 8 weeks with 8 PRN (as needed). Review of the clinical record revealed that during the RN visits on 10/27/2025, 10/29/2025, and 11/01/2025 RN #9 documented, Supervisory Functions… “Licensed Practical Nurse” … POC [plan of care] can safely be implemented by the LPN “YES”… Was the patient/caregiver satisfied with the care “YES” … Further review revealed that patient #11 had not had any visits by an LPN.RN #9 was not available for an interview.During an interview conducted on 12/03/2025 at 9:20 AM the agency director stated, “They [registered nurses] shouldn’t document a supervisory visit for an LPN if an LPN hasn’t seen the patient.”

Based on agency policy, volunteer cost savings analysis review, and staff interviews, the agency failed to provide 5% of the total patient care hours by volunteers.Findings included: --- Findings included:A policy, Volunteers (reviewed 08/11/2025) received on 12/02/2025 at 4:50 PM from the Area Vice President of Clinical Operations stated, “The hospice will document and maintain a volunteer staff sufficient to provide direct patient care in an amount that, at a minimum equals five (5) percent of the total patient care hours of all paid hospice personnel.”A review of the Hospice Volunteer Requirement Report conducted on 12/02/2025 at 9:03 AM revealed that the agency documented the monthly average of volunteer hours for 2025 as 0.81%.An interview conducted on 12/02/2025 at 3:07 PM with the Area Vice President revealed that the expectation is to meet or exceed the 5% minimum of volunteer hours.

Based on agency policy, clinical record review, and staff interviews the plan of care failed to include the formula type and rate of delivery for 1 of 1 patient receiving artificial nutrition via gastrostomy tube (G-tube), (an artificial opening in the abdomen used for tube feedings)- (#1). Findings included: --- A policy, ";Hospice Plan of Care" (revised 02/22/22), was received on 03/13/23 at approximately 10:00 A.M. from the Agency Director. The policy stated, ";The initial plan of care shall include...equipment and supplies needed...and may include diet and nutritional needs." Patient #1 was admitted on 02/19/22 with a diagnosis of Chronic Respiratory Failure. The Plan of Care for 02/14/2223-04/14/23 included orders for Skilled Nurse visits 1 time a week for 1 week, 2 times a week for 8 weeks and 3 PRN (as needed). For the skilled nurse visits of 02/24/23 and 03/10/23 included evidence that patient #1 was receiving artificial nutrition via G-tube. The was no evidence of the type of formula being administered or the flow rate in the Plan of Care. An interview was conducted on 12/06/22 at 9:35 A.M. with the Director of Operations. The Director of Operations stated, ";It [formula rate and type] should be in the chart [plan of care]."

Based on agency policy, clinical record review, and staff interviews the plan of care failed to include the formula type and rate of delivery for 1 of 1 patient receiving artificial nutrition via gastrostomy tube (G-tube), (an artificial opening in the abdomen used for tube feedings), (Patient#11), failed to include medications on the medication list for 1 of 16 records reviewed (Patient #5) and failed to include orders for the care or management of an indwelling catheter for 1 of 1 patient with indwelling catheters (Patient #15). --- A policy, ";Hospice Plan of Care" (revised 02/22/22), was received on 12/08/22 at 9:36 A.M. from the Clinical Manger. The policy stated, ";The initial plan of care shall include...equipment and supplies needed...and may include diet and nutritional needs." 3. Patient #11 was admitted on 02/19/22 with a diagnosis of Chronic Respiratory Failure. The Plan of Care for 10/17/22 – 12/15/22 included orders for Skilled Nurse visits 2 times a week for 8 weeks, 1 time a week for 1 week and 3 PRN (as needed). Fourteen of 16 skilled nurse visits include evidence of patient #11 receiving artificial nutrition via G-tube. The was no evidence of the type of formula being administered or the flow rate in the Plan of Care. An interview was conducted on 12/06/22 at 9:35 A.M. with the Director of Operations. The Director of Operations stated, ";There should be an order for type (of formula) and rate." Findings include: Policy AA-005, titled Hospice Plan of Care, reviewed 11/30/21 and revised 02/22/22, was received from the agency director on 12/622 at 4:440 PM. This policy revealed, ";...The plan must include all services necessary for the palliation and management of the terminal illness and related conditions, including but not limited to...drugs and treatments necessary to meet the needs of the patient including the dose for medications, frequency and duration..." Policy MM-001A, titled Medication Management, reviewed and revised 04/28/22, was received from the agency director on 12/08/22 at 9:30 AM. This policy revealed, ";...The medication plan of care (POC) will include all prescription and over the counter medications, Oxygen, and herbal supplements both covered and not covered by the hospice benefit..." 1. Patient #5 was admitted to the agency on 05/04/22 with a principal hospice diagnosis hypertensive heart disease with heart failure. Hospice Plan of Care (POC) from 10/31/22 to 12/29/22 included orders for skilled nursing 1 time per week for 9 weeks and 3 PRN (as needed), hospice aide 2 times per week for 9 weeks, and chaplain 4 times per month for 2 months and 3 PRN. Employee #8, Registered Nurse, conducted skilled nursing visits on 11/23/22 and 12/03/22. The narrative portion of the visit notes for both dates revealed, ";...She [Patient #5] has a dime size sore on her later lower left leg near the brace. She reports it was a bump that she had scratched, she [sic] is currently using [brand name of antibiotic ointment]..." At the time of survey, there was no evidence that antibiotic ointment was added to the POC. In an interview on 12/08/22 at approximately 9:20 AM, Employee #1, Director of Operations, stated, ";Use of [brand name of antibiotic ointment] should be on there (POC)." Employee #8 was not available for interview at the time of survey. 2. Patient #15 was admitted to the agency on 06/02/22 with a principal hospice diagnosis heart failure unspecified. Plan of Care (POC) from 11/29/22 to 01/27/23 included orders for skilled nursing services 2 times per week for 1 week, 3 times per week for 8 weeks, and 3 PRN (as needed), hospice aide 2 times per week for 9 weeks, and chaplain 1 time per month for 1 month, 4 times per month for 2 months and 3 PRN. The POC included orders for catheters and supplies and [indwelling catheter brand name] precautions. There was no evidence of an order for the care or management of Patient #15s indwelling catheter. In an interview on 12/07/22 at approximately 1:20 PM, Employee #5, Registered Nurse Case Manager, stated, ";...I know the last time it was changed by one of our nurses because he had some bleeding from the catheter...There was supposed to be an order in here for a catheter change at least once a month...It was probably in the last benefit period that I did the order...If there were no issues with it, it was always being changed once a month." Employee #1, Director of Operations, was also present during this interview and stated, ";...Im trying to look through the order history myself and I dont see it...That information should pull over each benefit period." The agency was unable to locate an order regarding the care or management of Patient #15s indwelling catheter.

Based on policy review, clinical record review, and staff interviews the nurse failed to administer oxygen according to the hospice plan of care for 1 of 16 (#11) patients with an order for oxygen and failed to obtain a physician order for tracheostomy care and suctioning for 1 of 1 patient with a tracheostomy (#11). Findings included: --- A policy, ";Hospice Plan of Care-"; (revised 02/22/22), was received on 12/08/22 at 9:36 A.M. from the Clinical Manger. The policy stated, ";When a patient resides at a nursing facility...All care provided must be in accordance with the hospice POC (Plan of Care)." 1A. Patient #11 was admitted on 02/19/22 with a diagnosis of Chronic Respiratory Failure. The Plan of Care for 10/17/22 – 12/15/22 included orders for Skilled Nurse visits 2 times a week for 8 weeks, 1 time a week for 1 week and 3 PRN (as needed) visits and oxygen to be delivered continuously at 4.5 L/min (liters per minute) via trach (artificial respiratory opening in the neck) mask. Patient #11 was a resident of a facility. For 8 of 15 skilled nurse visits, oxygen administration was inconsistent with the physicians order ranging from 2L/min to 3.5L/min. An interview was conducted with nurse #5 on 12/08/22 at approximately 9:04 A.M. Nurse #5 stated the ";order is usually 2-5Lmin PRN." Nurse #5 stated, ";The current order is 4.5Lmin via trach continuously." Nurse #5 stated that her process is to notify the facility nurse when oxygen is being administered at a rate different from the doctors order. ";Oxygen is included with medication reconciliation and the process is to write an order to match the facility when needed." An interview was conducted with nurse #9 on 12/09/22 at approximately 8:35 A.M. Nurse #9 stated that when the oxygen is being administered inconsistent with the doctors order she would ";go to the staff nurse, alert them and ask for clarification." Nurse #9 stated that she did not alert the staff nurse and ask for clarification." An interview was conducted with the director of operations on 12/09/22 at approximately 9:10 A.M. The director of operation stated that ";the order is usually 2-5Lmin PRN...I dont think the facility includes oxygen on their med (medication) list. It should be addressed with the nurses there (facility)." 1B. Patient #11 was admitted on 02/19/22 with a diagnosis of Chronic Respiratory Failure. The Plan of Care for 10/17/22 – 12/15/22 included orders for Skilled Nurse visits 2 times a week for 8 weeks, 1 time a week for 1 week and 3 PRN (as needed) visits. On the skilled nursing visit of 10/28/22 Nurse #5 stated, ";Tracheostomy patient inner cannula cleaned and suctioned..." There was no evidence of an order for tracheostomy cleaning or suctioning in the hospice plan of care. An interview was conducted with Nurse #5 on 12/09/22 at approximately 9:04 A.M. Nurse #5 stated, ";That goes along with comfort care." Nurse #5 stated, ";We should have an order." An interview was conducted with the Director of Operations on 12/09/22 at approximately 9:15 A.M. The Director of Operations stated, ";There should be an order in the Plan of Care."