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

Upon patient record review, 1 of 19 (Patient #10) 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 #10: There is evidence on medication list for Nystatin 100,000 units/ml QID. There are no instructions for use.

Upon patient record review, 1 of 19 (Patient #8) 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 #8: There is evidence in the medical record of a call from the patient's facility on 12/11/25 regarding agitation. There was no documentation of follow up until a visit on 12/15/25.

Upon patient record review, 1 of 19 (Patient #10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #10: There is evidence of a DME order for TED hose on 10/31/25. There is no order as to how often or when to use the hose. Additionally, there is an order for Nystatin 100,000 units/ml QID. There is no instructions for use

Upon patient record review, 2 of 19 (Patient #1,2) 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 #1: There is evidence in the medical record of an order on 11/18/25 for ASA 81 mg daily. The plan of care was not updated to include Risk of bleeding. Patient #2: There is evidence in the record the patient had physical therapy that was completed with no more scheduled visits. The plan of care was not updated to remove physical therapy problems, interventions and goals.

Upon client record review, 1 of 19 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: There is evidence of an add on order on 8/1/25 for volunteer services 4M1 (Aug); 1M1 (Sept). They received 2 volunteer visits in August.

Upon patient record review, 3 of 19 (Patient #1, 12, 14) did not have evidence in the patient record that hospice aide assignments and duties are: • 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 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: There is evidence in the medical record of an order on 11/18/25 for ASA 81 mg daily. The aide plan of care was not updated to include bleeding precautions. Patient #12: There is evidence in the medical record the RN00 note indicates the patient has recurrent aspiration pneumonia. The aide plan of care does not have aspiration precautions. Patient #14: There is evidence in the medical record the RN00 note indicates the patient has Dysphagia. The aide plan of care does not have aspiration precautions.

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. The Volunteer Cost Savings for 2024 was 1.15%.

Upon patient client record review, 1 of 19 (Patient #5) 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 #5: There is evidence in the medical record the patient was not receiving Aide services. The RN documented on 10/24/25 and 11/7/25, aide supervision.

Upon client record review, 1 of 19 (Patient #8) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #8: There is evidence of an add on order on 10/9/25 for chaplain services 1M3. In December, there were 2 chaplain visits.

Upon patient record review, 3 of 5 (Patient #1, #2, #5) 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 1: The medication profile dated 2/5/2023 included O2 2 L/NC continuous to maintain sats over 90%, RN to titrate. There was no evidence of how to determine the titration or to what level. Corrected on site. Patient 2: The medication profile dated 1/11/2023 included an order for O2 2L/NC PRN SOA. There was no evidence of an accurate indication as SOA is not an approved abbreviation per agency policy. Corrected on site. The medication profile dated 2/3/2023 included both topical and powder Remedy Phytoflex antifungal 2% topical to be applied daily to area of redness. There was no evidence of an area to apply. Corrected on site. Patient 5: The medication profile did not include O2, in use on patient per SN notes as of 2/10/2023. The medication profile dated 1/13/23 included MS 100mg/5ml, 20mg/ml, 0.5ml Q 4 hours PRN Pain/SOA. There was no evidence of clear indication for the use as SOA is not an approved abbreviation.

Upon patient record review, 3 of 5 (Patient #1, #2, #5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1: An O2 order dated 2/5/23 included O2 2L/NC to maintain Saturation >90%, RN to titrate. No specific order how or when to titrate O2. Corrected on site. Patient 2: An order dated 1/11/2023 included O2 2L/NC PRN SOA. There was no evidence of an accurate indication as SOA is not an approved abbreviation per agency policy. Corrected on site. An order dated 2/3/2023 included both topical and powder Remedy Phytoflex antifungal 2% topical to be applied daily to area of redness. There was no evidence of an area to apply. Corrected on site. Patient 5: There was no O2 order - notes indicated O2 initiated on 1/10/2023. An order dated 1/13/23 included MS 100mg/5ml, 20mg/ml, 0.5ml Q 4 hours PRN Pain/SOA. There was no evidence of clear indication for the use as SOA is not an approved abbreviation.

Upon patient record review, 2 of 5 (Patient #4, #5) 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 4: Nurses note on 1/30/23 include abscess rupture on abdomen occurred day prior, now closed. This occurs at times for this patient. There is no evidence of problem/interventions/goals related to skin integrity in the POC. Corrected on site. Patient 5: Nurses noted dated 1/10/23 initiated O2. Noted dated 1/11/2023 included O2 2L/M. There was no evidence of a problem/goal/interventions for O2 use.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 2 of 13 (Patient #8, #12) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #8: This patient admitted 07/06/2022 however, the spiritual assessment was not completed until 07/12/2022. Patient #12: This patient admitted 12/09/2021 however, the spiritual assessment was not completed until 12/15/2021.

Upon patient record review, 8 of 13 (Patient #1, #4, #5, #7, #9, #10, #11, #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 #1: The medication profile contained remedy calazine paste topical to coccyx daily and PRN without evidence of indication for PRN. corrected on site Patient #4: The medication profile contained clotrimazole topical without evidence of specific area, miralax oral powder without evidence of directions for mixing, nitro SL PRN without evidence of indication for PRN, and acetaminophen and hydrocodone combined potentially exceeding 3K mg without evidence of maximum allowable dose. corrected on site Patient #5: The medication profile contained miralax oral powder without evidence of directions for mixing and silvadene topical without evidence of specific area. corrected on site Patient #7: The nurse note indicated on 12/11/2022 that miralax was started for constipation however, this was not listed on medication profile. corrected on site Patient #9: The nurse note indicated on 12/21 and 12/19/2022 that zofran and meclizine were given via g-tube however, these were not listed on medication profile corrected on site Patient #10: The medication profile contained oxygen at 3lpm continuous without evidence of route. corrected on site In addition, the nurse documented on 12/12/2022 the patient was using melatonin however, this was not listed on med profile. corrected on site Patient #11: The medication profile contained gavilox 17gm oral powder without evidence of directions for mixing and oxygen at 2lpm continuous without evidence of route. Patient #13: The medication profile contained acetaminophen without specific dosing and polyethylene glycol and gavilox oral powders without evidence of directions for mixing.

Upon patient record review, 1 of 13 (Patient #8) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #8: This patient admitted 07/06/2022 however, the bereavement assessment was not completed until 07/12/2022.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 4 of 13 (Patient #1, #5, #9, #12) 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 #1: Patient admitted for respiratory failure and with catheter however, there was no evidence of problems/interventions/goals for respiratory or catheter care/education. Corrected on site. In addition, spiritual care initiated visits for spiritual support however, there was no evidence of problems/interventions/goals. Corrected on site. Patient #5: The social work and spiritual care initiated visits for emotional and spiritual support however, there was no evidence of problems/interventions/goals. Corrected on site. Patient #9: Patient admitted for ALS however, there was no evidence of problems/interventions/goals for neurological. Corrected on site. Patient #12: Patient admitted for CVA however, there was no evidence of problems/interventions/goals for neurological. In addition, social work and spiritual care initiated visits for emotional and spiritual support however, there was no evidence of problems/interventions/goals.

Upon patient record review, 8 of 13 (Patient #1, #4, #5, #7, #9, #10, #11, #13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: The order on 6/8/2022 for remedy calazine paste topical to coccyx daily and PRN did not contain evidence of indication for PRN. corrected on site Patient #4: The order on 11/2/2021 for clotrimazole topical did not contain evidence of specific area, 01/24/2022 for miralax oral powder did not contain evidence of directions for mixing, 01/24/2022 for nitro SL PRN did not contain evidence of indication for PRN, and 06/02/2022 for acetaminophen 325mg twice a day and 11/29/2021 for hydrocodone 1 tab three times a day without evidence of maximum allowable dose. corrected on site Patient #5: The order on09/21/2022 for miralax oral powder did not contain evidence of directions for mixing and 09/27/2022 for silvadene topical did not contain evidence of specific area. corrected on site Patient #7: The nurse note indicated on 12/11/2022 that miralax was started for constipation however, there was no evidence of an order for this medication. corrected on site Patient #9: The nurse note indicated on 12/21 and 12/19/2022 that zofran and meclizine were given via g-tube however, there was no evidence of an order for these medications. corrected on site Patient #10: The order on 02/13/2022 for oxygen at 3lpm continuous did not contain evidence of route. corrected on site In addition, the nurse documented on 12/12/2022 the patient was using melatonin however, there was no evidence of an order for this medication. corrected on site In addition, the nurse notes indicated the patient was using a biPap however, there was no order for this treatment. corrected on site. Patient #11: The order on 12/17/2021 for gavilox 17gm oral powder did not contain evidence of directions for mixing and 12/29/2021for oxygen at 2lpm continuous did not contain evidence of route. Patient #13: The order on 04/26/2022 for acetaminophen 325mg per instructions every 4 hours for fever did not contain specific instruction for dose or maximum allowable dose. In addition, the order on 03/16/2022 polyethylene glycol and on 04/26/2022 gavilox oral powders did not contain evidence of directions for mixing.

Upon patient record review, 9 of 13 (Patient #1, #2, #3, #5, #6, #10, #11, #12, #13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1: The home visit and nurse notes indicated patient had a hospital bed, oxygen, and over the bed table however, there was no evidence of these on plan of care. corrected on site Patient #2: The notes indicated patient had walker and wheelchair however, there was no evidence of these on plan of care. corrected on site Patient #3: The home visit and notes indicated patient had hospital bed, rollator, and oxygen however, there was no evidence of these on plan of care. corrected on site Patient #5: The notes indicated patient had hospital bed, hoyer lift, and wheelchair however, there was no evidence of these on plan of care. corrected on site Patient #6: The notes indicated patient had walker, lift chair, and electric scooter however, there was no evidence of these on plan of care. corrected on site Patient #10: The notes indicated patient had bipap, bedside commode, oxygen, walker, and wheelchair however, there was no evidence of these on plan of care. corrected on site Patient #11: The notes indicated patient had walker, oxygen, and hospital bed however, there was no evidence of these on plan of care. corrected on site Patient #12: The notes indicated patient had hospital bed, hoyer lift, and bedside commode however, there was no evidence of these on plan of care. corrected on site Patient #13: The notes indicated patient had hoyer lift and wheelchair however, there was no evidence of these on plan of care. corrected on site

Upon patient record review, 5 of 13 (Patient #2, #3, #5, #8, #11) 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: The patient was ordered on macrobid in November for a UTI and nystatin in December for thrush however, here was no evidence that problems/interventions/goals were added to the plan of care for these infections. Patient #3: The patient was ordered on keflex in November for cellulitis however, there was no evidence that problems/interventions/goals were added to the plan of care for this infection. Patient #5: The patient was placed on respite twice in the month of December and need for potential long term placement however, here was no evidence that problems/interventions/goals were added to the plan of care. Corrected on site. Patient #8: The patient developed a wound in November with treatment however, there was no evidence that problems/interventions/goals were added to the plan of care. Patient #11: The patient had several bouts of nausea and vomiting throughout January with treatment however, there was no evidence that problems/interventions/goals were added to the plan of care.

Upon client record review, 9 of 13 (Patient #1, #2, #3, #4, #5, #6, #7, #10, #11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The nursing visit frequency was 2w8 however, one of the visits the week of 12/04/2022 was a phone visit (12/7) versus in person. No evidence of an order for phone visit. corrected on site Patient #2: The nursing visit frequency was 5w1 however, there was only evidence of 3 visits the week of 11/20/2022. The week of 11/27/2022 the frequency was 6w1 however, there was only evidence of 5 visits this week. both corrected on site. In addition, the speech therapy visit frequency on 10/30/2022 was 1w2, 1every2w4 however, there was no evidence of any visits in November. Patient #3: The nursing visit frequency ordered 11/23/2022 was 2w1, 3w8, 3 PRN however, the week of 11/23 there was only evidence of one visit on 11/25. In addition the week of 12/04, one of the three visits was a phone visit. all corrected on site Patient #4: The nursing visit frequency was ordered on 11/20/2022 2w8, 1w1, 3 PRN however, the first visit in each week was a phone visit versus in person. corrected on site Patient #5: The nursing visit ordered 9/8/2022 was 3w1, 2w12, 1w1, 3 PRN however, the week of 11/20/22 one visit was a phone visit versus in person. In addition, the social worker visit frequency written 09/09/2022 was 1m3, 6 PRN however, there was evidence of 9 PRN visits and in the narrative note of the PRN visits stated the visits were "subsequent". The nurse filled medi planner on 12/20/2022 visit however, there was no order to fill medi planner. Patient #6: The social worker visit frequency written on 10/06 is 4m1, 1m1 however there was only evidence of one visit in October. Patient #7: The nursing visit frequency 11/2/2022 1w1, 2w8, 3 PRN however, the week of 11/06/2022 there was only evidence of one visit. corrected on site Patient #10: The social work PRN visit on 12/07/2022 stated in narrative it was a subsequent visit. corrected on site Patient #11: The nursing visit frequency 01/02/2022 was 3w1, 7w1, 3w1, 2w9, 1w1 however, the week of 01/09 there was only evidence of 6 visits. In addition, the social worker was ordered 4m1, 1m2 on 01/01 however there was no evidence of visits in January.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Upon chart review there was no evidence of fall report for Patient #7 on 12/19/22 and Patient #9 for 12/12. Corrected on site.

Upon patient record review 1 of 13 (Patient #2) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #2: The week of 12/11/2022 the visit frequency as 3w8 however, there was no evidence of any visits this week and only 2 documented missed visits. corrected on site

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. It was observed the agency was not providing their written policies and procedures for the management and disposal of controlled drugs. corrected on site

Upon client record review, 2 of 13 (Patient #4, #13) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #4: There was no evidence of problems/interventions/goals for coordination of care with facility. corrected on site Patient #13: The patient admitted for Parkinson's however, there was no evidence of problems/interventions/goals for neuro. In addition, patient was noted with anxiety and behaviors in several nursing visits with treatments/meds put in place however, no evidence of problems/interventions/goals.

Upon patient record review, 1 of 13 records (Patient #4) did not have evidence that the hospice provided the following information to the SNF: • Hospice election form • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice's 24-hour on-call system corrected on site