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

Upon patient record review, 1 of 19 (Patient #13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #13: There is evidence on the medication record for the medication "pharmacy compounded medication" and the dose states "per instruction every 6 hours". The instructions indicate the "ABH cream". The medication record did not have the correct medication or dosage listed. (Corrected on site by correcting the ABH documentation on the medication record.)

Upon patient record review, 2 of 14 (Patient #5,6) did not have evidence that a Registered Nurse is designated to ensure 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 #5: There is evidence in the medical record of a wound order on 7/9/25 for skin tear to left upper arm. The wound was assessed on 7/9/25 and 7/21/25. There was no wound assessment/measurement the week of 7/14/25. Hospice policy WC-001 states: "wounds will be measured a minimum of one time a week". Patient #6: There is evidence in the medical record of a wound order on 6/28/25 for stage II sacral wound. The wound was assessed on 6/28/25 and 7/8/25. There was no wound assessment/measurement documented again until 8/1/25. Hospice policy WC-001 states: "wounds will be measured a minimum of one time a week".

Upon patient record review, 3 of 19 (Patient #2,5,10) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #2: There is evidence in the medical record on 7/17/25 the patient was experiencing agitation and started on Depakote 500 mg BID for agitation. The plan of care was not updated to include problem/interventions/goals for agitation. (Corrected on site by adding Agitation to the plan of care.) Patient #5: There is evidence in the medical record on 6/9/25 the patient requested to decline further chaplain services. The chaplain did not update the plan of care to delete chaplain specific intervention and goals. (Corrected on site by deleting chaplain specific interventions and goals on the plan of care.) Patient #10: There is evidence in the medical record on 6/2/25 the patient requested to decline further chaplain services. The chaplain did not update the plan of care to delete chaplain specific intervention and goals. (Corrected on site by deleting chaplain specific interventions and goals on the plan of care.)

Upon patient record review, 1 of 14 (Patient #11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #11: There is evidence in the medical record of an order on 6/10/25 for Oxygen 4L via NC as needed for shortness of breath. On 7/11/25 the nursing visit narrative documents patient is using "O2 5/L NC". On 7/30/25 the vital signs indicate "continues on oxygen 3L at rest". (Corrected on site by getting an order for Oxygen 3-5L via NC as needed for shortness of breath.)

Upon observation, there was no evidence the annual report documents 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. No evidence that the agency utilized volunteers for at least 5% of the total patient care hours in 2024. The total usage of volunteers for 2024 was 1.4%

Upon personnel record review, 1 of 13 (Personnel # 2) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Personnel #2: There is no evidence in the personnel file of an alternate administrator's signed job description.

Upon patient record review, 1 of 19 (Patient #10) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #10: There is evidence in the medical record on 7/9/25 and 7/23/25 the RN documented a supervisory visit for the LPN. The patient does not have an LPN.

Based on review of clinical records, it was revealed that Registered Nurse (RN), failed to complete the initial assessment within 48 hours after the election of hospice care for two (2) of thirteen (13) sampled patients (P#10, and P#11). --- The Findings Include: Review of the clinical record for (P#11), who was admitted on 7/1/22, with a diagnosis of Malignant Melanoma of left lower limb including hip, revealed that the referral was sent to hospice agency on 6/8/22, and the initial skilled nurses comprehensive assessment was done on 7/1/22. The clinical record lacked documentation regarding the staff delay on the admission, for 22 days. In an interview on 10/26/22 at 9:50 a.m., the Clinical Manager (CM) confirmed that the assessment was late. The CM also confirmed that the surveyors have been provided with all available documentation about the patients record. Review of the clinical record for (P#10), who was admitted on 3/30/22, with a diagnosed of Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, revealed that the referral was sent to hospice agency on 2/15/22, and the initial skilled nurse comprehensive assessment was completed on 3/20/22. The clinical record lacked documentation regarding the staffs delay in completing the assessments. In an interview on 10/26/22 at 10:30 a.m., the Clinical Manager (CM) confirmed that the assessment was late; moreover, the surveyors have been provided with all available documentation for the patients record.

Based on review of clinical records, it was determined that the interdisciplinary group failed to ensure that the initial comprehensive assessment was completed within 5 days of admission for one (1) of thirteen (13) sampled patients (P#11). --- The Findings include: Review of the clinical record for (P#11), who was admitted on 7/1/22, with a diagnosis of Malignant Melanoma of left lower limb including hip, revealed that the initial psychosocial assessment was completed on 7/6/22. But the clinical record lacked documentation because of staff delay in completing the assessments. In an interview on 10/26/22 at 9:50 a.m., the Clinical Manager (CM) confirmed that the assessment was late. The CM also confirmed that the surveyors have been provided with all available documentation about the patients record.