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

Upon patient record review, 3 of 5 (Patient #1, #2, #5) 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: SW SOC assessment notes referral needed for care giver assistance to area on aging, there was no problem/intervention/goals for caregiving assistance on the POC. Corrected on site. Patient #2: Patient has evidence of a wound, there was no evidence on the POC of problems, interventions or goals for the wound care. Corrected on site. Patient #5: SOC terminal diagnosis CA rectum with Liver mets. Per SN SOC assessment patient has dependent edema in extremities and abdominal tenderness There was no problem, goals or interventions related to the liver diagnosis on the plan of care. Corrected on site.

Upon patient record review, 3 of 5 (Patient #1, #2, #4) 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: Per SN notes on several visits "son gives Maalox with pain meds x1 in am", there is no evidence of an order for Maalox. Order dated 8/7/23 Lactulose 10GM/15ml, 30ml 2x day po prn constipation. Order dated 8/16/2023 Mineral oil 30 ml 2x day po prn constipation. There was no evidence of specifics when one to be given over the other or if both were intended to be utilized. Order dated 8/7/23 for Drain chest tube 3x week/prn symptoms such as pain or sob, change dressing every time pt gets drained or prn soiled. There was no evidence as to who, SN or family/caregiver were to drain tube and change dressing, and no inclusion of dressing specifics on the POC. SN note 8/6/2023 notes included "son stated he would be draining chest tube". Corrected on site. Patient #2: Orders for wound care are not consistent as to who will perform the wound care. Orders dated 8/13/23, 8/17/2023 and 8/21/2023 include "SN to perform/teach pt/caregiver wound care. On order dated 8/17/2023 include "wound care by HSN". SN notes included 8/13/23 "client completed wound care". Corrected on site. Patient #4: Per SN notes 8/20/2023 "family holding all regular medications". There was no evidence of an order to hold regular medications. Corrected on site.

Upon client record review, 1 of 5 (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: SOC 8/12/2023, SN visits to be 7xweek, there was no evidence of a visit or missed visit for 8/14/2023.

Upon patient record review, 14 of 19 (Patient #1-14) 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 #1: The profile listed acetaminophen 650mg suppository insert one Q4 hrs PRN and hydrocodone 5/325mg one tablet BID without evidence of maximum allowable dosing, diclofenac gel and Aspercreme without evidence of specific area for application, oxygen without evidence of a route, and morphine 0.25-1.0 mL PRN without evidence of specific directions. #2: The profile listed TAO ordered 01/22/23 to skin tear L forearm and 03/23/2023 for wound that were no longer being used, oxygen without evidence of a route, and morphine 0.25-1.0 mL PRN without evidence of specific directions. #3: The profile listed ABH gel without evidence of specific area for application and morphine 0.25-1.0 mL PRN without evidence of specific directions. #4: The profile listed ABH gel without evidence of specific area for application, morphine 0.25-1.0 mL PRN without evidence of specific directions, acetaminophen 650mg suppository insert one Q4 hrs PRN, Tylenol 325mg 2 tablets Q6 hrs PRN, and hydrocodone 5/325mg one tablet TID without evidence of maximum allowable dosing. #5: The profile listed acetaminophen 650mg suppository insert one Q4 hrs PRN and hydrocodone 5/325mg 1-2 tablets Q4 hrs PRN without evidence of maximum allowable dosing, oxygen without evidence of a route, and morphine 0.25-1.0 mL PRN without evidence of specific directions. #6: The profile listed morphine 0.25-1.0 mL PRN without evidence of specific directions. #7: The profile listed morphine 0.25-1.0 mL PRN without evidence of specific directions, acetaminophen 650mg suppository insert one Q4 hrs PRN and Tylenol 325mg 2 tablets Q6 hrs PRN without evidence of maximum allowable dosing. #8: The profile listed hydrocortisone cream without evidence of specific area for application, morphine 0.25-1.0 mL PRN without evidence of specific directions, acetaminophen 650mg suppository insert one Q4 hrs PRN and acetaminophen/codeine 300/30 take one every 4-5 hrs without evidence of maximum allowable dosing. #9: The profile listed morphine 0.25-1.0 mL PRN without evidence of specific directions, hydrocortisone lotion, mupirocin ointment, and venelex ointment without evidence of specific area for application. #10: The profile listed morphine 0.25-1.0 mL PRN without evidence of specific directions, acetaminophen 650mg suppository insert one Q4 hrs PRN and acetaminophen 325mg 2 tablets Q4 hrs PRN without evidence of maximum allowable dosing. COS #11: The profile listed acetaminophen 650mg suppository insert one Q4 hrs PRN and acetaminophen ER 650mg one tablet Q4 hrs PRN without evidence of maximum allowable dosing, Aspercreme without evidence of specific area for application, and morphine 0.25-1.0 mL PRN without evidence of specific directions. #12: The profile listed acetaminophen 650mg suppository insert one Q4 hrs PRN, acetaminophen 325mg two tabs every 6 hrs PRN, hydrocodone 5/325mg one-tab Q4 hrs PRN, and hydrocodone 5/325mg one tablet BID without evidence of maximum allowable dosing, and morphine 0.25-1.0 mL PRN without evidence of specific directions. #13: The profile listed NSS for wound care which was no longer active, oxygen without evidence of a route, and morphine 0.25-1.0 mL PRN without evidence of specific directions. #14: The profile listed morphine 0.25-1.0 mL PRN without evidence of specific directions, brimonidine, tetrahydrozoline and latanoprost ED without evidence of specific directions for which eye(s). ALL ABOVE COS

Upon patient record review, 2 of 19 (Patient #4, #13) 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 #4: The patient admitted 06/25/2021 however, there was evidence that bereavement assessment was completed 11/11/2022. Patient #13: The patient admitted 07/17/2022 however, there was evidence that bereavement assessment was completed 07/25/2022.

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

Upon patient record review, 5 of 19 (Patient #3, #4, #6, #12, #14) 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 #3: There was no evidence wound had been assessed or measured since 06/12/2023. Assessment and measurements per DOO/DON are to be taken weekly. Patient #4: There was no evidence wound had been assessed or measured since 06/12/2023. Patient #6: There was no evidence wound had been assessed or measured from 05/25 until 06/20 and not again until 7/03/2023. Patient #12: There was no evidence wound had been assessed or measured from 05/09 until 06/26/2023. Patient #14: The patient admitted with head wound 01/25/2023. There was no evidence wound had been assessed or measured until 07/03/2023.

Upon patient record review, 8 of 19 (Patient #1, #2, #3,#4, #5, #6, #8, #14) 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: The initial social work assessment indicated patient required assistance with funeral planning and housing/utility funding however, there was no evidence of problems/interventions/goals to assist with these needs. In addition, plan of care listed patient as a full code however, there was evidence of a DNR on file. COS Patient #2: The initial social work assessment indicated social work to assist with funeral planning however, there was no evidence of problems/interventions/goals to assist with these needs. In addition, there was no evidence of oxygen precautions included on plan of care. COS Patient #3: The initial social work assessment indicated social work to assist with funeral planning however, there was no evidence of problems/interventions/goals to assist with these needs. In addition, there was no evidence of oxygen precautions included on plan of care. COS Patient #4: There was no evidence of oxygen precautions included on plan of care. COS Patient #5: The patient admitted for hypertensive heart however, there was no evidence of problems/interventions/goals for cardiac. In addition, there was no evidence of oxygen precautions included on plan of care. COS Patient #6: The patient admitted for Alzheimer's however, there was no evidence of problems/interventions/goals for neurological. COS Patient #8: There was no evidence of oxygen precautions included on plan of care. COS Patient #14: There was no evidence of oxygen precautions included on plan of care. COS

Upon patient record review, 14 of 19 (Patient #1-#14) 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. #1: The orders for acetaminophen 650mg suppository insert one Q4 hrs PRN and hydrocodone 5/325mg one tablet BID did not contain evidence of maximum allowable dosing, diclofenac gel and Aspercreme did not contain evidence of specific area for application, oxygen did not contain a route, and morphine 0.25-1.0 mL PRN did not contain specific directions. #2: The orders were active for TAO ordered 01/22/23 to skin tear L forearm and 03/23/2023 for wound that were no longer being used, oxygen did not contain a route, and morphine 0.25-1.0 mL PRN did not contain specific directions. #3: The orders for ABH gel did not contain evidence of specific area for application and morphine 0.25-1.0 mL PRN did not contain specific directions. #4: The orders for ABH gel did not contain evidence of specific area for application, morphine 0.25-1.0 mL PRN did not contain specific directions, acetaminophen 650mg suppository insert one Q4 hrs PRN, Tylenol 325mg 2 tablets Q6 hrs PRN, and hydrocodone 5/325mg one tablet TID did not contain maximum allowable dosing. #5: The orders for acetaminophen 650mg suppository insert one Q4 hrs PRN and hydrocodone 5/325mg 1-2 tablets Q4 hrs PRN did not contain maximum allowable dosing, oxygen did not contain a route, and morphine 0.25-1.0 mL PRN did not contain specific directions. #6: The order for morphine 0.25-1.0 mL PRN did not contain specific directions. #7: The orders for morphine 0.25-1.0 mL PRN did not contain specific directions, acetaminophen 650mg suppository insert one Q4 hrs PRN and Tylenol 325mg 2 tablets Q6 hrs PRN did not contain maximum allowable dosing. #8: The orders for hydrocortisone cream did not contain evidence of specific area for application, morphine 0.25-1.0 mL PRN did not contain specific directions, acetaminophen 650mg suppository insert one Q4 hrs PRN and acetaminophen/codeine 300/30 take one every 4-5 hrs did not contain maximum allowable dosing. #9: The orders for morphine 0.25-1.0 mL PRN did not contain specific directions, hydrocortisone lotion, mupirocin ointment, and venelex ointment did not contain evidence of specific area for application. #10: The orders for morphine 0.25-1.0 mL PRN did not contain specific directions, acetaminophen 650mg suppository insert one Q4 hrs PRN and acetaminophen 325mg 2 tablets Q4 hrs PRN did not contain maximum allowable dosing. COS #11: The orders for acetaminophen 650mg suppository insert one Q4 hrs PRN and acetaminophen ER 650mg one tablet Q4 hrs PRN did not contain maximum allowable dosing, Aspercreme did not contain evidence of specific area for application, and morphine 0.25-1.0 mL PRN did not contain specific directions. #12: The orders for acetaminophen 650mg suppository insert one Q4 hrs PRN, acetaminophen 325mg two tabs every 6 hrs PRN, hydrocodone 5/325mg one-tab Q4 hrs PRN, and hydrocodone 5/325mg one tablet BID did not contain maximum allowable dosing, and morphine 0.25-1.0 mL PRN did not contain specific directions. #13: The order was active for NSS for wound care, which was no longer being treated, orders for oxygen did not contain a route, and morphine 0.25-1.0 mL PRN did not contain specific directions. #14: The orders for morphine 0.25-1.0 mL PRN did not contain specific directions, brimonidine, tetrahydrozoline and latanoprost ED did not contain evidence of specific directions for which eye(s). ALL ABOVE COS

Upon patient record review, 9 of 19 (Patient #2, #3, #6, #7, #8, #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 equipment and supply needs. Patient #2: The admission noted patient has over bed table and oxygen, however these were not listed on plan of care. COS Patient #3: The admission noted patient has over bed table and hospital bed, however these were not listed on plan of care. COS Patient #6: The admission noted patient has low air loss mattress, however this was not listed on plan of care. COS Patient #7: The medication listed noted patient using aerosolized albuterol , however a nebulizer was not listed on plan of care. COS Patient #8: The admission noted patient has bedside commode, wheelchair, oxygen and nursing note in July noted hospital bed, however these were not listed on plan of care. COS Patient #9: The admission noted patient has hospital bed and Hoyer and IDG noted motorized wheelchair, however these were not listed on plan of care. COS Patient #10: The admission noted patient has hospital bed, walker, and wheelchair, however these were not listed on plan of care. COS Patient #11: The admission noted patient has oxygen, however this was not listed on plan of care. COS Patient #13: The admission noted patient has hospital bed, over bed table and oxygen, however these were not listed on plan of care. COS

Upon patient record review, 3 of 19 (Patient #5, #7, #13) 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 #5: It was noted patient was having issues with constipation in June, however there was no evidence of problems/interventions/goals added to plan of care. COS Patient #7: The plan of care contained problems/interventions/goals for oxygen therapy however, the record indicated the patient was not on oxygen. COS Patient #13: The patient developed a skin tear from a fall in June, however there was no evidence the plan of care was updated with any skin integrity or wound problems/interventions/goals.

Upon client record review, 9 of 19 (Patient #2, #3, #4, #6, #7, #8, #10, #12, #13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: The nurse order 06/15/23 was 1W8, 4 PRN however, the week of 06/11 there was no evidence of a nurse visit. The spiritual order 06/15 was 1M2, 2 PRN however, there was no evidence of a visit after 06/15 through the end of the month. COS Patient #3: The nurse performed wound care 06/08 and 06/12/23 and documented "wound care rendered per MD orders". Patient #4: The nurse performed wound care on 06/12/23 and documented "wound care rendered per MD orders". Patient #6: The nurse performed wound care on 07/03, 06/20/23 and documented "wound care rendered per MD orders". Patient #7: The spiritual care order 06/12 1M2, 2 PRN however, there was no evidence of a visit on or after 06/12 through end of month. COS Patient #8: The nurse order 07/06 was 2W12, 1W2, 4 PRN however, there was only evidence of one visit on 07/06. COS Patient #10: The nurse documented filling the patient's pill box on 06/09, 06/22, and 06/26/23 however, there was no evidence of an order or problems/interventions/goals for this. In addition, nurse order 06/11 was 5W1, 1W2, 2W3, 1W1 however, there evidence of one visit on 06/12/23. COS Patient #12: The nurse performed wound care on 07/03, 06/26, and 06/12/23 and documented "tolerated well". In addition, the spiritual care order 04/25 1W3, 2 PRN however, there was no evidence of visit after 4/27 until 05/24. COS Patient #13: The social work order 05/13/23 was 1M2, 2 PRN however, there was no evidence of visits on or after that date through end of May. COS

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1 visit observed CNA washing hands, turning off faucet, entering bag with wet hands to remove paper towels, and then drying hands which does not follow agency policy #PCP-001, pg. 3 under Hand Hygiene procedure, steps under #2-g, h, i.

Upon patient record review 2 of 19 (Patient #6, #7) 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 #6: The aide order 05/18 was 2W1, 6W8 however, there was only evidence of patient receiving visits 3/week with 2 aides. COS Patient #7: The aide order 06/12 was 6W8, 4W1 however, there was only evidence of patient receiving visits 3/week with 2 aides. COS In addition, aide plan of care directed aide to perform nail care weekly however, aide documented this was performed on visits 06/26, 06/28, 06/30, 07/03, 07/05, and 07/07.

Upon personnel record review, 3 of 15 (Personnel #12, 13, 14) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements. Personnel #12, 13, 14: There was no evidence of primary verification of current licensure provided by the contracting agency or completed by the hospice.

Upon personnel record review, 1 of 15 (Personnel #14) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #14: There was no evidence of verification of qualifications as a licensed SLP provided. No primary verification of licensure or any other means of verifying qualifications.

Upon personnel record review, 1 of 15 (Personnel #13 ) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #13: There was no evidence of primary verification of licensure or other means of verifying a qualified Occupational Therapist.