Every finding on record at Amedisys Hospice, L.L.C.

Upon patient record review, 1 of 14 (Patient #4) did not contain evidence that a Registered Nurse had been designated to ensure the continuous assessment of the patient and family's needs, and to coordinate activities with other members of the Interdisciplinary Group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family: Patient #4: The RN SOC admission visit documented, "Patient had an MRI today resulting in a diagnosis of L5 compression fracture; requiring the patient to now wear a brace". This pertinent information was noted to not be included on the patient's plan of care. Upon interview, the RN case manager reported that the patient is not using a back brace. There was no documented evidence that the nurse had followed up after the admission visit to ascertain the status of this indicated brace.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #7: The admission consent reflected that the patient did not have any established Advance Directives. The RN SOC admission noted, "DNR preference was confirmed." There was no D.N.R. POLST filed within the record. The two POLST forms within the record both reflected the patient to be a 'Full Code.' However, the 90-day, 11/02/25 SOC POC included an Advance Directive status of D.N.R. The Administrator confirmed that this patient was a Full Code.

Upon patient record review, 3 of 14 (Patients #2, 5, and 7) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including the following: A detailed statement of both the 'scope' and 'frequency' of the planned care/services necessary to meet the specific patient and family needs: Patient #2: The IDG POC dated 01/02/26 did not include the 'scope' of planned interventions to be provided by the Social Worker. Patient #5: The IDG POC dated 01/02/26 did not include the 'scope' of planned interventions to be provided by the Social Worker. Patient #7: The IDG POC dated 12/29/25 did not include the 'scope' of planned interventions to be provided by the Chaplain.

Upon patient record review, 4 of 14 (Patients #1,2,3, and 6) did not contain evidence that a revised Plan of Care included information from the patient's updated comprehensive assessment, and note the patient's progress towards outcome/goals from the Plan of Care: Patient #1: In the CTI from 12/08/25, the Physician noted that the patient is unable to lie flat in bed, and requires to be elevated at a 45 degree angle. This pertinent information was not included in the current POC. Patient #2: The admission consent reflected that this patient had a Living Will and D.N.R. However, the current POC did not include that the patient had a Living Will. Patient #3: The 08/21/24 admission consent reflected that this patient had both a Living Will and D.N.R. for Advance Directive(s). The IDG POC dated 12/26/25 did not include Living Will in the Advance Directive section. Patient #6: The 11/16/25 admission consent reflected that this patient had a Living Will. The IDG POC dated 01/02/26 did not include this pertinent Advance Directive information.

Upon personnel record review, 1 of 13 (Personnel #8) did not contain evidence that an Aide Skills Competency Assessment had been conducted per CMS guidelines. Personnel#8: An Aide Skills Competency Assessment was conducted on 05/08/25. However, the following tasks/skills were not evaluated for: Normal range of motion and positioning. This section of the form used by the hospice had been left blank by the evaluating nurse.

Upon patient record review, 3 of 14 (Patients #1, 5, and 7) did not contain evidence that the Hospice Aide assignments and duties were: • Assigned to a specific patient by a Registered Nurse that is a member of the Interdisciplinary Group. • Written patient care instructions for a Hospice Aide must be prepared by a Registered Nurse who is responsible for the supervision of a Hospice Aide as specified under paragraph (h) of 418.76 Patient #1: In the physician's CTI from 12/08/25, the Physician noted that the patient is unable to lie flat in bed, and requires to be elevated at a 45 degree angle. This pertinent information was not included in the current Aide Plan of Care. The Aide POC also assigned shampoo every visit. The Aide verbalized that she has not been completing that assigned task, as the patient has a bandage on her head covering an erupting/bleeding area. The Aide visit reports dated 12/16/25 through 01/02/26 all document 'no' for the assigned task of shampoo. The Aide POC is not current. Patient #5: The RN-established 11/07/25 Aide Plan of Care listed the patient's Advance Directive status as, "Life Sustaining Treatment Order". This patient was a D.N.R. This Aide POC is not current. Patient #7: The admission consent reflected that the patient did not have any established Advance Directives. The RN SOC admission noted, "DNR preference was confirmed." There was no D.N.R. POLST filed within the record. The two POLST forms within the record both reflected the patient to be a 'Full Code.' However, the Aide POC established 11/04/25 listed the patient to be a D.N.R. The Administrator confirmed that this patient was a Full Code. The Aide POC is not current.

Upon patient record review 2 of 14 (Patients #1 and 3) did not contain evidence that the Hospice Aide provided services that were: • Ordered by the Interdisciplinary Group • Included in the Plan of Care Patient #1: The current Aide POC assigned the following tasks: 1) Report any vitals that are outside of parameters to the RN; and 2) Remind the patient to take her medications. During Surveyor-attended home visit on 01/06/26 the Aide confirmed that she does not take any patient vitals. The Aide also confirmed that she no longer reminds the patient to take her medications, as this was only done when the patient previously lived in her own home. Patient #3: The Aide POC established 12/10/25 assigned: 1) Apply Skin Barrier Cream to peri-area every visit; 2) Provide nail care every visit; and 3) Change Linens every visit. For all three of these assigned tasks the Aide documented them as not done for the following visit dates: 12/24/25, 12/29/25, 12/31/25, and 01/05/26.

Upon patient record review 1 of 14 (Patient #5) did not contain evidence that a Registered Nurse had made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the Hospice Aide and to ensure that services ordered by the Hospice Interdisciplinary Group meet the patient's needs: Patient #5: An Aide supervisory visit was made on 11/17/25, and then not again until 12/19/25.

Upon observation, there was not evidence that the annual report documented the use of Volunteers, providing day to day administrative and/or direct patient care services, in an amount that at a minimum equals 5 percent of the total patient care hours of all paid Hospice employees and contract personnel. The Administrator provided the Surveyor with the 2025 calendar year-end Volunteer Report which reflected a 1.32% result.

Based on review of clinical records, staff interview, and review of policy titled, ";Admission", it was determined that the hospice agency failed to ensure that the initial comprehensive assessment was completed within 48 hours after the election of hospice care for one patient (P) (P#1) of 13 sampled patients (P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13). The Findings Include: --- Review of the policy titled ";Admission" Policy: AA-001, Date last reviewed 11/29/21 Page 1,2 of 22 reveals: Policy: ";Eligible patients shall be admitted to the Hospice program within 24 hours of physician order for care (unless otherwise is specified by the physician or requested by the patient/family)". 7. ";The admission assessment will be scheduled within 24 hours of physicians order unless otherwise specified by the physician or the patient/family request a delay in admission. If the admission assessment is scheduled more than 24 hours after the physicians order for care at the patient/family request, documentation of such will be included in the patients record (in a written or electronic format)". Review of the document titled Patient Information Report revealed referral date of 09/17/2020. Review of the clinical record revealed P#1 admitted with a diagnosis of memory deficit following cerebral infarction (also known as a stroke) and start of care date 9/23/2020. The clinical record failed to include documentation regarding the staff's delay in completing the assessments according to their policy. In an interview on 4/10/2023 at 4:15 p.m., Licensed Practical Nurse (LPN) DD, revealed that they did not know how they missed the admission and that there was no recorded documentation in the electronic system. On 4/10/2023 at 4:28 p.m., an interview was conducted with Assistant Vice President (AVP), who also confirmed that they failed to follow their policy, and that surveyor has been provided with all available documentation on the P#1s record.

Based on review of clinical records, staff interviews, and review of policy, it was determined that the hospice agency failed to follow plan of care (POC), for daily weights for one patient (P) (P#4) of 13 sampled patients (P#1, P#2, P#3, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13). The Findings Include: --- On 4/10/2023 at 4:15 p.m., clinical records for P#4 were reviewed for certification period (duration of hospice care coverage) 3/9/2023 to 6/6/2023. Per the patient's plan of care, the patient was admitted to hospice services on 3/9/2023 with a primary diagnosis of hypertensive heart disease with heart failure (refers to heart problems that occur because of high blood pressure that is present over a long time). The clinical record, dated 3/10/2023, at 12:11 p.m., revealed the physician ordered ";daily weights at 6AM daily and record. Report weight to nurse on 11-7 shift." Nothing was documented in the hospice agency electronic system related to P#4s weights in nurses notes or coordination notes. The hospice agency failed to follow the physicians order. An interview conducted on 4/10/2023 at 4:27 p.m. with Registered Nurse (RN) AA, revealed she did not follow physicians order by not documenting P#4s daily weights in the nurses notes on each visit. On 4/10/2023 at 4:55 p.m., an interview was conducted with RN CC, revealed she did not know why RN AA failed to document the daily weights ordered by physician for implementation by the hospice agency and the facility that P#4 resides. RN CC confirmed that nothing was documented in the hospice agencys electronic system. The facility was unable to provide policy related to daily weight communication between the hospice agency and the facility where the patient resides.

Based on clinical record review, staff interview, and policy review, it was determined that the agency failed to provide drugs and biologicals related to the management and palliation of the terminal illness and related conditions identified on patients hospice plan of care. The agency failed to provide the needed medications related to the comorbidities in four patients (P) (P#2, P#4, P#7, P#9) of 13 sampled patients (P#1, P#3, P#5, P#6, P#8, P#10, P#11, P#12, P#13). The Findings include: --- 1. Clinical records for P#2 were reviewed for certification period (duration of hospice care coverage) 3/10/2023 to 5/8/2023. Per the patient's plan of care, the patient was admitted to hospice services on 8/12/2022, with a primary diagnosis of Alzheimers disease (causes the brain to shrink and brain cells to eventually die), with the following comorbidities (existence of more than one health condition in a person at the same time): dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), essential primary hypertension (high blood pressure), and unspecified convulsions (types of seizures). The record revealed the agency failed to provide coverage of payment for the following medications used to manage the comorbidities of hypertension and unspecified convulsions: Metoprolol tartrate (Lopressor) 25miligrams (MG), give 0.5mg tablet by mouth twice daily for high blood pressure; Valproic acid (Depakene) 250mg/5milliliters (ML), give 5ml by mouth every eight hours for treatment of seizure. The medications were not paid for by the hospice agency. 2. Clinical records for P#4 were reviewed for certification period 3/9/2023 to 6/6/2023. Per the patient's plan of care, the patient was admitted to hospice services on 3/9/2023 with a primary diagnosis of hypertensive heart disease with heart failure (refers to heart problems that occur because of high blood pressure that is present over a long time). The records showed the agency was not providing coverage for payment for the following medication used to manage the co morbidities of myocardial infarction (heart attack), metabolic encephalopathy (problems with your metabolism cause brain dysfunction): Stiolto Respimat (Tiotropium-olodaterol), 2.5mcg-2.5mcg/Actuation solution, give two puffs daily for respiratory distress for better breathing. The inhaler medication was not paid for by the hospice agency. 3. Clinical records for P#7 were reviewed for certification period 8/24/2022 to 9/2/2022. Per the patient's plan of care, the patient was admitted to hospice services on 8/24/2022 with a primary diagnosis of Senile degeneration of brain (disease caused by the loss or weakening of brain functions, especially memory and mental abilities). The records revealed the agency failed to provide coverage for payment for the following medication used to manage the comorbidities of dementia: Sertraline (Zoloft) 25mg give one tablet by mouth daily for 14 days then discontinue the medication used for depression due to dementia, central nervous system agent. The medication was not paid for by the hospice agency. 4. Clinical records for P#9 were reviewed for certification period 1/28/2023 to 4/27/2023. Per the patient's plan of care, the patient was admitted to hospice services on 1/28/2023 with a primary diagnosis of malignant neoplasm of brain, unspecified (a mass of abnormal cells in the brain). The records revealed the agency failed to provide coverage for payment for the following medication used to manage the comorbidities of type 2 diabetes mellitus (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel, adult onset): Basaglar Kwik pen U-100 insulin 100 unit/ml (3ml) subcutaneous (SQ) (applied under the skin), inject eight units subcutaneous at bedtime, and Metformin 500mg give one and half tablets by mouth twice daily use to lower blood sugar. The medications were not paid for by the hospice agency. On 4/11/2023, at 3:50 p.m., an interview was conducted with the Director of Operation (DOO) and Register Nurse (RN) BB, revealed that they were unaware of any basis the agency did not pay for the medications related to the listed comorbidities on the patients plan of care. The facility was unable to provide a policy for medication coverage.