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

Upon patient record review, 1 of 27 (Patient #9) did not contain evidence that a Registered Nurse was 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): Patient #9: The Physician SOC CTI noted, "Chronic wound LLE recently re-opened due to sheer and friction. Wound care ongoing." The RN 10/17/25 SOC assessment prompt for, "Is wound care ordered for this patient?, was answered as no". At the body diagram section the RN entered, "LLE pressure ulcer Stage III. Wound care not provided, as caregiver had already completed." It was not clear as to what wound care the caregiver had provided. Further along the RN documented, "LLE wound not assessed on admission. Daughter showed admitting RN a picture of wound; which had had a dressing placed prior to hospital discharge that same day. RN Case Manager to follow-up/assess for Physician wound care orders". There was no documentation located reflecting that the RN assessed or followed up on proper wound care to be provided. The next SNV dated 10/18/25 documented, "Wound care not ordered at this visit. Wound not assessed. Left leg wound dressing was recently changed." The next SNV dated 10/19/25 documented, "Wound not assessed. Caregiver has completed wound care." Not documented as to what that wound care consisted of. The next SNV dated 10/21/25 documented, "Wound was assessed. RN provided wound care". This patient was admitted 10/17/25. The Hospice nurse did not ensure continuous patient assessment, by not viewing a wound of concern until 10/21/25.

Upon patient record review, 3 of 27 (Patients #3, 12, and 17) 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 frequency and scope of all services necessary to meet the specific patient and family need: Patient #3: The IDG POC dated 11/26/25, did not include a scope of planned SW interventions. Patient #12: The IDG POC dated 11/26/25 contained a SW entry of, "Patient making progress toward goals. SW will continue to support as desired." This POC did not include a 'scope' of individualized SW interventions to meet previously identified patient needs. Patient #17: The IDG POC dated 12/04/25 did not include the 'scope' of planned Volunteer services.

Upon patient record review, 3 of 27 (Patients #4, 9, and 16) did not contain a Plan of Care which included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments: Patient #4: A verbal order was obtained on both 12/02/25 and 12/08/25 for, "Cleanse right heel area with wound cleanser, pat dry, apply Betadine twice daily, and PRN, without an indication for such PRN dressing change. A verbal order was obtained on 12/08/25 for, "Triad Paste to sacrum B.I.D." This order is not clear as to 'who' is to provide such B.I.D. treatment. An additional verbal order was obtained on 12/08/25 for, "Sacrum and right heel wounds: Cleanse with dermal wound cleanser, apply medi-honey to wound bed, cover with dry dressing. Daily and as needed; without an indication for such 'as needed' dressing change. The interim Administrator confirmed that this written wound procedure was worded incorrectly, as the listed interventions are only applicable to the patient's sacrum wound and not applicable to the patient's right heel wound. Patient #9: A verbal order was obtained on 12/09/25 for, "Clean calf wound with wound cleanser, pat dry, apply petroleum dressing, then dry gauze. Caregiver may provide wound care in absence of RN". There is no physician-ordered 'frequency' for the provision of this wound care. Patient #16: The 90-day SOC POC included, "SN to instruct on care/management of Nephrostomy. Cleanse with normal saline, apply gauze, stabilization device, transparent dressing. May change drainage bag PRN; without an indication for such PRN bag change. May flush with 10cc normal saline two times daily and PRN.; without an indication for such PRN flush. Change dressing Q week and PRN; without an indication for such PRN dressing change".

Upon patient record review, 3 of 27 (Patients #2, 5, and 6) did not contain a Plan of Care which included all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs: Patient #2: During survey home visit on 12/08/25, it was noted that the patient had the following DME: 1) Hospital Bed; and 2) Bedside Table. These DME items were not included on either the IDG POC dated 11/26/25, nor the 60-day POC beginning 10/20/25. Patient #5: The Medical Director's CTI for certification period beginning 11/17/25 documented, "Patient has fallen out of bed the past two months, now has 'fall mats' in place." Fall mats were not included on the Hospice POC. Patient #6: During survey home visit on 12/09/25, it was noted that the patient had the following DME: 1) Hospital Bed; 2) Bedside Table; 3) Air pressure mattress; and 4) Wheelchair. These DME items were not included on the POC.

Upon patient record review, 3 of 27 (Patients #2, 6, and 20) did not contain evidence that the revised Plan of Care included information from the patient's updated comprehensive assessment: Patient #2: The 60-day POC beginning 10/15/25 listed a Chaplain visit frequency of, "1 x per month x2 effective 11/01/25." However, the IDG POC dated 11/26/25 included: 1) Patient refusing Chaplain services. Will develop POC and provide services if requested; and 2) Chaplain to conduct a Spiritual Care assessment and develop POC. This 11/26/25 IDG POC not current/updated. The Chaplain was making visits which included the date of 11/07/25. Patient #6: The 11/06/25 90-day SOC POC ordered, "Chaplain 1x per month. An 11/08/25 phone call documented, "Patient/family refuse Chaplain care/services." However, the 11/28/25 IDG meeting notes, Spiritual Counselor section, continued to include, "Patient encouraged through ministry." The POC was not current/updated. Patient #20: A verbal order was obtained on 11/10/25 for, "Cleanse wound #2 on back with soap/water, pat dry, apply Barrier Cream, cover with Opti-foam. Change every 4 days and PRN soiling. This wound care treatment was not forwarded to all subsequent IDG Plans of Care. The wound did not heal until 12/05/25.

Upon patient record review 1 of 27 (Patient #9) did not contain evidence that the IDG had ensured that all care and services were provided in accordance with the Physician-ordered Plan of Care: Patient #9: The SOC Physician CTI noted, "Chronic wound LLE. Wound care ongoing." The 10/17/25 RN SOC visit documented, "RN Case Manager to follow-up/assess for Physician wound care orders". There was no subsequent documentation reflecting that the RN had contacted a Physician for such wound orders. The SNV dated 10/21/25 documented, "RN cleansed with wound wash, applied Xeroform to wound bed, then ABD, then gauze wrap." However, there was no Physician order obtained for this provided wound care until 12/09/25.

Upon patient record review, 1 of 27 (Patient #9) did not contain evidence that the IDG had documented the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement: Patient #9: The RN SOC visit documented a BP of 199/72. There was no documented evidence that the nurse had reported this potential need for Plan Of Care modification to the Medical Director.

Upon patient record review, 1 of 27 (Patient #9) did not contain evidence that 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 Patient #9: The Aide POC's assigned the task of weigh patient every visit. The patient is bedbound, with use of Hoyer Lift for any transfers. On the Aide home visit reports dated 10/20, 10/22, 10/24, 10/27/25, and multiple other visits, the Aide had documented "Not completed" for this assigned task. The task of weigh patient every visit was no longer applicable for this patient, and the RN had not maintained a current individualized Aide POC.

Upon patient record review 2 of 27 (Patients #6 and 9) did not contain evidence that the Hospice Aide had provided care/services that were: • Ordered by the Interdisciplinary Group • Included in the Plan of Care Patient #6: The Aide POC(s) effective 11/06/25 and 12/09/25, both assigned the Aide to obtain a T, P, R, and BP every visit. The Aide did not obtain/document the provision of these tasks on either the 12/08 or 12/09/25 visits. Patient #9: The Aide POC dated 12/09/25 assigned the task of weigh patient every visit. The patient is bedbound, with use of Hoyer Lift for any transfers. On the Aide home visit reports dated 10/20, 10/22, 10/24, and 10/27/25, and multiple other visits, the Aide documented "Not completed" for this assigned task.

Upon patient record review 1 of 27 (Patient #19) 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 are meeting the patient's needs: Patient #19: The first Aide visit was made on 10/30/25. There was not evidence of a documented Aide Supervisory visit on or prior to day 14 (11/13/25).

Upon observation and interview with the Alternate Administrator there was not evidence of the Hospice's 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 2024 calendar year Volunteer Report reflected a 1.57% utilization of Volunteers.

Upon patient record review, 1 of 27 (Patient #18) did not contain evidence that all entries were legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice: Patient #18: The Aide POC effective 11/24/25 assigned, "Aide to report pain", with a provided reporting parameter of >4. The Aide visit notes section, prompting the "Aide to report pain" on visit notes dated 11/25, 12/03, and 12/08/25, resulted in the Aide documenting a response of "Yes". These Aide home visit notes did not document evidence of the Aide having assessed for patient pain level, as there was no pain level documented. This is unclear documentation.

Upon patient record review, 1 of 27 (Patient #14) did not contain evidence that the Hospice had forwarded a summary, and a copy of the patient record if requested, to the Facility when transferring the patient to that Facility: Patient #14: The Hospice transitioned a patient from their home setting to an in-patient facility on 11/03/24, to receive temporary Respite services. There was no documented evidence that the Hospice had provided the facility with a summary of the patient's history and health needs while at the facility.

Upon patient record review, 1 of 27 (Patient #23) did not contain evidence that the Hospice had created a Discharge Summary which included all CMS-required information: Patient #23: Discharged 06/02/25. There was no documented evidence of the Hospice having created/established a DC Summary document to include the following CMS-required information: • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current plan of care • The patient's latest physician orders • Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility

Based on record reviews, interviews, and review of the hospice's policy and procedure, the hospice failed to ensure reconciliation of the patient's hospice medication profile with the assisted living facility's medication administration record (MAR) for 2 of 3 patients in a nursing care facility (Patient 1 and 4) and failed to reconcile the hospice's medication profile for patients with the actual medications in the patient's home that the patient takes for 2 of 2 home visits. (Patient 2 and 3) --- On 2/15/22 at 10:45 a.m., a home visit was made with Registered Nurse (RN) #1 to Patient #4's facility home. Patient #4s hospice medication profile and the facility's medication administration record (mar) were reviewed. Discrepancies between the hospice's medication profile and the facility medication lists included Zofran, Meclizine, Morphine concentrate, mucus relief tablets, Oxygen, Hyoscyamine, Ativan, Hydrocodone/Acetaminophen, Dramamine, Xanax, and Guaifenesin. RN #4 confirmed the discrepancies between the patient's hospice medication profile and the facility mar. The findings include: During an assisted living facility (ALF) on 02/15/23 at 7:10 AM to 7:55 AM, review of Patient 1s medications as written on the ALFs mar when compared with the hospice medication profile revealed: Lantus Solostar U-100 insulin 5 units at bedtime on the ALF's mar and Lantus Solostar U-100 insulin 5 units daily on the hospice's medication profile; Metoprol Tartrate 25 milligrams (mg), take 1 tablet by mouth twice a day on the ALF's mar and Metoprol Tartrate 25 mg, take 1 tablet daily on the hospice medication profile; and Hydroxyzine Pamoate capsule 25 mg, take 1 capsule by mouth twice daily as needed, Vitamin D3 50 mcg, take 1 capsule by mouth once daily and Oxygen use as directed was listed on the ALF's mar and were not listed on the hospice's medication profile. The findings were verified by Area Vice President of Operations (AVPO) on 02/17/23 at 12:20 PM. During a home visit on 02/15/23 from 8:40 AM to 9:30 AM revealed Patient 2s actual medications in the home showed the patient no longer takes Diazepam 10 mg, but the hospice medication profile showed the patient takes 0.5 mg by mouth twice a day. Patient 2 reported he/she takes Tylenol 650 mg, take 2 tablets twice a day by mouth, Dulcolax Suppository 2 suppositories rectally as needed, Zyrtec 10 mg, take 1 tablet by mouth daily, lidocaine spray use as needed, and MiraLAX suppository take 2 suppositories rectally as needed which were not listed on the hospice's medication profile. The findings were verified by the AVPO on 02/17/23 at 12:40 PM. During a home visit on 02/15/23 from 10:45 AM to 11:43 AM, review of Patient 3s actual medications in the home showed the patient takes Trazadone 50 mg, take 1 tablet at bedtime and Tobramycin ophthalmic drops 0.3% (percent), Apply 2 drops into the right eye four times a day which were not listed on the hospice's medication profile. The findings were verified by the AVPO on 02/17/23 at 12:42 PM. Facility policy, entitled, ";Medication Management Policy", revealed, ";F. Medication Reconciliation: 1. Medication Reconciliation will be done at admission, recertification, a change in patients condition requiring medication changes, when a medication is discontinued, when a medication is a new order, or a change in existing medication order...".

Based on record reviews and interviews, the hospice failed to ensure an initial bereavement risk assessment was completed on admission for 2 of 20 patient charts reviewed. (Patient 1 and 6) --- The findings include: On 02/14/23 at 3:30 PM, review of Patient 1s chart revealed the patient was admitted on 08/25/22 for Unspecified Dementia without Behavioral Disturbance. Review of the patients chart revealed there was no initial bereavement risk assessment completed with the patients initial comprehensive assessment within 5 days of the patients admission. The findings were verified by the Area Vice President of Operations (AVPO) on 02/17/23 at 12:20 PM. On 2/16/23 at 2:00 PM, Patient #6s record revealed the patient was admitted on 10/24/22, but the Bereavement Risk Assessment was not completed until 2/16/23. On 2/17/23 at 4:00 PM, the Registered Nurse Administrator (RNA) verified the findings. The RNA confirmed the patient's Bereavement Risk Assessment was completed four months after the patient was admitted to hospice.

Based on record reviews, interview, and review of the hospice's policy and procedure, the hospice failed to ensure the patient's plan of care (poc) was individualized for 8 of 20 patient charts reviewed for care and services. (Patient 6, 9, 1, 2, 3, 11, 13, and 19) --- The findings include: Observations in Patient 1's home on 02/15/23 from 07:10 AM to 07:55 AM revealed an Oxygen concentrator, portable Oxygen tank and nebulizer machine in the patient's home. There was no documentation of Oxygen or education on Oxygen safety and/or nebulizer use or education in the patient's plan of care. During an interview on 02/17/23 at 12:20 PM, the Area Vice President of Operations (AVPO) verified the findings. Observations in Patient 2s home on 02/15/23 at 8:40 AM to 9:30 AM revealed the patient had a Foley catheter and an electric power chair. There was no documentation of electric power chair safety or education in the patients plan of care and/or documentation of Foley catheter care or education for the Foley catheter. During an interview on 02/17/23 at 12:30 PM, the AVPO verified the findings. Observations in Patient 3s home on 02/15/23 at 10:45 AM to 11:50 AM revealed two wounds to the patient's buttocks. There was no documentation of wound care and/or education in the patients plan of care. During an interview on 02/17/23 at 12:45 PM, the AVPO verified the findings. On 02/16/23 at 3:20 PM, review of Patient 11s chart revealed the Registered Nurse (RN) documented a physician order on 12/19/22 for wound care supplies. There were no physician orders for the wound care, treatment, and/or education noted on the patients plan of care. During an interview on 02/17/23 at 12:55 PM, the AVPO verified the findings. On 02/17/23 at 3:45 PM, review of Patient 13s chart revealed a ";Client Coordination Note Report" dated 02/15/23 which identified continuous Oxygen at 5 LPM (Liters Per Minute). There was no documentation of Oxygen or education on Oxygen safety in the patients plan of care. During an interview on 02/17/23 at 12:33 PM, the AVPO verified the findings. On 02/16/23 at 9:00 PM, review of Patient 19s chart revealed wound assessment tool report with documentation of a left dorsum diabetic ulcer and left pretibial arterial ulcer. There were no physician orders for the wound care, treatment, and/or education on the patients plan of care. During an interview on 02/17/23 at 1:09 PM, the AVPO verified the findings. On 2/16/23 at 9:30 AM, a home visit with Registered Nurse (RN) #2 to assess Patient #6 revealed the patient was admitted on 10/24/22 with a primary diagnosis of Wegeners Granulomatosis (disease causing inflammation of the blood vessels). Patient #6s primary caregiver stated the hospice's Medical Social Worker (HMSW) was helping the patient to get a Life Alert because the patient had almost fallen a few times. On 2/16/23 at 2:00 PM, review of Patient #6s plan of care (POC) showed the POC did not include the hospice intervention of obtaining a Life Alert. On 2/17/23 at 4:00 PM, the Registered Nurse Administrator (RNA)verified the patient's plan of care did not include the patients need for a Life Alert. On 2/17/23 at 11:15 AM, review of Patient #9s record revealed the nursing visit note dated 12/22/22 indicated Patient #9 had wounds, but wounds were not included in the patient's plan of care. On 2/17/23 at 2:45 PM, the RNA confirmed the patients wounds were not included in the patient's plan of care.

Based on record review and interview, the hospice failed to ensure physician orders were obtained for 2 of 2 patients with wounds per chart review. (Patient 3 and 19). --- The findings include: Observations in Patient 3s home on 02/15/23 at 10:45 AM to 11:50 AM revealed two wounds to the patient's buttocks. Record review revealed no documentation of wound care orders by the physician for the care and/or treatment of the wounds. During an interview on 02/17/23 at 12:45 PM, the AVPO verified the findings. On 02/16/23 at 9:00 PM, review of Patient 19s chart revealed a wound assessment tool report with documentation of a left dorsum diabetic ulcer and left pretibial arterial ulcer. There were no physician orders for the wound care and/or treatment of the wounds. During an interview on 02/17/23 at 1:09 PM, the AVPO verified the findings.

Based on record reviews and interview, the hospice failed to ensure the Skilled Nurses (SN), Master of Social Worker (MSW), Chaplain, Hospice Aide (HA) and Volunteer completed home visits per the ordered frequency on the patient's plan of care for 5 of 20 patient charts reviewed. (Patient 5,16,17,19, and 20) --- The findings include: On 02/16/23 at 1:45 PM, review of Patient 5s chart revealed a visit frequency for the Skilled Nurse (SN) for 2 times a week for 13 weeks starting 12/12/22. Review of the benefit period dated 12/12/22 to 03/11/23 revealed 1 missed SN visit the week of 12/25/22, 1 missed visit the week of 01/08/23, and 2 missed visits the week of 02/05/23. During an interview on 02/17/23 at 12:47 PM, the Area Vice President of Operations (AVPO) verified the findings. On 02/16/23 at 8:50 PM, review of Patient 16s chart revealed a visit frequency for the HA for 2 times a week for 12 weeks starting 10/30/22. Review of the benefit period dated 10/25/22 to 01/22/23 revealed 1 missed HA visit the week of 11/13/22 and 1 missed visit the week of 11/20/22. During an interview on 02/17/23 at 12:56 PM, the AVPO verified the findings. On 02/16/23 at 9:15 PM, review of Patient 17s chart revealed a visit frequency for the HA for 2 times a week for 12 weeks starting on 09/04/22, a MSW (Medical Social Worker) frequency for 1 time a month for 3 months and a volunteer visit frequency for 1 time a month for 1 month. Review of the benefit period dated 09/01/22 to 11/29/22 revealed 1 missed HA visit the week of 09/11/22 and 1 missed visit the week of 09/25/22, 1 missed MSW visit for the month of 09/22, and 1 missed Volunteer visit for the month of 09/22. During an interview on 02/17/23 at 1:00 PM, the AVPO verified the findings. On 02/16/23 at 09:35 PM, review of Patient 19s chart revealed a visit frequency for the SN for 4 times a week for 1 week, 3 times a week for 1 week, and 2 times a week for 11 weeks; and a MSW visit frequency for 1 time a month for 1 month. Review of the benefit period dated 12/02/22 to 03/01/23 revealed 2 missed SN visits for the week of 12/04/22, 1 missed SN visit for the week of 12/11/22, 1 missed visit for the week of 12/25/22; and 1 missed MSW visit for the month of 12/22. During an interview on 02/17/23 at 1:09 PM, the AVPO verified the findings. On 02/16/23 at 9:45 PM, review of Patient 20s chart revealed a visit frequency for the SN for 1 time a week for 1 week and 2 times a week for 12 weeks. Review of the benefit period dated 11/14/22 to 02/11/23 revealed 1 missed SN visit the week of 12/04/22, 1 missed SN visit the week of 12/18/22, and 1 missed SN visit the week of 12/25/22. During an interview on 02/17/23 at 1:02 PM, the AVPO verified the findings.

Based on observations, interview, and review of the hospice policy, the hospice staff failed to follow accepted standards of practice for infection control by 1 of 2 Hospice Aides. (HA 1) --- The findings include: Observations in Patient 1s home on 02/15/23 at 07:10 AM to 07:47 AM revealed HA 1 donned a pair of gloves and completely bathed the patient in the shower using the same gloves. Post shower, observations showed HA 1 dried the patient off with a towel and rubbed lotion on the patient wearing the same gloves used for bathing the patient. During an interview on 02/15/23 at 7:48 AM, HA 1 stated ";I dont change my gloves while bathing." Facility policy, titled, "Hand Hygiene", revealed, "Change gloves during patient care if moving from a contaminated body site to a clean body site...".

Based on record reviews and interview, the hospice failed to ensure bereavement services were available to the family up to one year post death based on the bereavement plan of care for 3 of 3 deceased patients. (Patient 21, 23, and 24) --- The findings include: On 02/17/23 at 8:52 AM, review of Patient 21s chart revealed the patient expired on 02/24/22. Review of the patient's bereavement plan of care revealed there was no documentation that the patient's plan of care was completed based on services and frequencies outlined in the plan of care. During an interview on 02/17/23 at 1:22 PM, the Area Vice President of Operations (AVPO) verified the findings. On 02/17/23 at 9:44 AM, review of Patient 23s chart revealed the patient expired on 02/17/22. Review of the patient's bereavement plan of care revealed there was no documentation that the patient's plan of care was completed based on services and frequencies outlined in the patient's plan of care. During an interview on 02/17/23 at 1:23 PM, the AVPO verified the findings. On 02/17/23 at 9:52 AM, review of Patient 24s chart revealed the patient expired on 03/03/22. Review of the patient's bereavement plan of care revealed the 6-month bereavement letter was due to be sent to the family by 08/30/22, but the letter was not sent until 10/25/22 which was 2 months late. During an interview on 02/17/23 at 1:25 PM, the AVPO verified the findings.