Every finding on record at Amedisys Hospice, LLC

Based on observations, review of medical records, policy and procedure, and Potter and Perry Nursing Fundamentals, and  interviews, it was determined the hospice agency failed to ensure: 1. Oxygen (O2) cylinders were stored appropriately. 2. "No Smoking/Oxygen in Use" signage was provided to the patient/caregiver (pt/cg).This affected two of four home visits (HV), including HV # 2, and HV # 3, and had the potential to negatively affect all patients who require O2. Findings include: Policy: PUL-001Subject: Administration of OxygenDate Revised: 9/26/24Procedure:...3. Teach or review O2 safety precautions with the client and family:...h. Keep the O2 container upright...Reference: Potter and Perry Nursing Fundamentals Eleventh EditionCopyright: 2023... page 1036...Using Home Oxygen Equipment...11. Instruct patient and family caregiver in safe home oxygen practices, including placing "No Smoking/Oxygen in Use" signs at each entrance to the home,... and storing oxygen tanks upright. --- 2. HV # 3 was admitted on 5/29/25 with a primary diagnosis of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Dominate Right Side, and recertified for care from 8/27/25 to 11/24/25.A review of the Hospice Plan of Care (POC) Report dated 8/21/25 revealed the pt/cg were instructed on indications for O2 administration, use, management, and safety.A HV was conducted on 9/29/25 at 1:20 PM to observe care provided by EI # 5, Registered Nurse.During the visit, HV # 3 was receiving O2 via NC at two L per minute. There were no "No Smoking/Oxygen in Use" signs observed in the home or outside on the doors. An interview was conducted with the cg during the HV, who stated, " We have received education regarding the use and safety of the oxygen but a sign has not been given to us to display by the agency or the Durable Medical Equipment company when the O2 equipment was delivered."An interview was conducted on 10/1/25 at 3:11 PM with EI # 1 and EI # 2, who confirmed "No Smoking/Oxygen in Use" signage was not provided to the pt/cg by the agency.   1. HV # 2 was admitted to the agency on 1/17/25 with a primary diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic Kidney Disease/End Stage Renal Disease, and recertified for care 9/14/25 to 11/12/25.Review of the Client Medication Report from 9/29/25 revealed O2 ordered continuously at two liters (L) per minute via nasal cannula (NC).A HV was conducted on 9/29/25 at 12:55 PM to observe care provided by Employee Identifier (EI) # 4, Hospice Aide. During the visit, HV # 2 was receiving O2 via NC at two L per minute. There were no "No Smoking/Oxygen in Use" signs observed in the home or outside on the doors. Three O2 cylinders were observed in the room. One tank was in a stand and the other two were leaning against the wall, unsecured, in front of the closet door.An interview was conducted with the cg during the HV who stated "I remember staff giving instructions and education on safe oxygen use, but I have never been given a sign to post."An interview was conducted on 10/1/25 at 2:20 PM with EI # 1, Director of Operations and EI # 2, Clinical Manager, who confirmed the oxygen tanks were not stored appropriately per the agency policy. EI # 1 and EI # 2 also confirmed that no oxygen signage had been provided by the agency.

Based on observations, Medical Record (MR) review, agency policy and procedure, and interviews it was determined the agency staff failed to maintain an accurate medication profile for each patient. This deficient practice affected one of three Home Visit (HV) records reviewed including HV # 1 and had the potential to affect all patients admitted to this agency. Findings include: Agency policy: Medication Management - Alabama Policy number: MM-001 AL Revised: 1/20/2023 Policy: A current medication profile will remain in the patients home folder and will be updated as modifications are made... Procedure: ...E (1). Medication Reconciliation will be done on 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... --- 1. HV # 1 was admitted to the agency on 1/20/2023 with diagnoses including Malignant Neoplasm of the Larynx, Unspecified and Acute Respiratory Failure with Hypoxia. Per the Hospice Certification and Plan of Care, Skilled Nurse (SN) visits were ordered twice weekly for week one then daily for twelve weeks with SN visits being completed on 1/20, 1/21, 1/22, and 1/23/23. A HV was conducted on 1/24/23 at 2:25 PM to observe care provided by Employee Identifier (EI) # 3, Chaplain. The surveyor reviewed the current medications with a facility nurse where patient resides. The medication list provided by the facility was compared to the Client Medication Report (CMR) and the following discrepancies were observed: a) Gaviscon Liquid 15 milliliters (ml) by mouth (po) every 4 hours as needed (prn) for indigestion, was listed on the facility medication list and was not listed on the CMR. Order date was 1/19/23 and confirmed by the facility nurse. b) Acetaminophen 500 mg tablet (tab) 1 tab po every 4 hours prn pain, was listed on the facility medication list and was not listed on the CMR. Order date was 1/19/23 and confirmed by the facility nurse. c) Albuterol Hydrofluoroalkane (HFA) 90 micrograms (mcg) Inhaler 2 puffs by mouth 3 times daily prn dyspnea, was listed on the facility medication list and was not listed on the CMR. Order date was 1/19/23 and confirmed by the facility nurse d) Milk of Magnesia Suspension 30 ml po once daily prn constipation, was listed on the facility medication list and was not listed on the CMR. Order date was 1/19/23 and confirmed by the facility nurse. e) Haloperidol Lactate 5 milligrams (mg)/ml vial injection 0.5 ml (2.5 mg) intramuscular (IM) every 12 hours prn agitation, was listed on the facility medication list and was not listed on the CMR. Order date was 1/19/23 and confirmed by the facility nurse. f) Midodrine Hydrochloride (HCL) 5 mg tablet, 1 tab po 3 times daily, was listed on the facility medication list and was not listed on the CMR. Order date was 1/19/23 and confirmed by the facility nurse. An interview was conducted on 1/26/23 at 1:32 PM with EI # 1, Director of Operations (DOO), who confirmed agency staff failed to review medications and update the CMR.

Based on review of medical records (MR), agency policy and procedure and staff interviews, it was determined the agency failed to ensure wounds were measured weekly. This deficient practice affected one of ten MR reviewed including MR # 8 and had the potential to affect all patients with wounds admitted to the agency. Findings include: Agency Policy: The Provision of Wound and Skin Care Revised date:1/20/22 Purpose: To provide general guidance on wound and skin care... General Guidance:...Measuring: In accordance with best practice and standard of care, wounds will be measured a minimum of one time a week, preferably on the first visit of the week, by the same nurse, utilizing the same tool and measurement technology. The preferred day for measuring is the first visit of each week... --- 1. MR # 8 was admitted to the agency on 11/10/22 and certified for care 11/10/22 to 2/7/23 with admitting diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4 Unspecified Chronic Kidney and Acute on Chronic Diastolic (Congestive) Heart Failure. Review of the Hospice Certification and Plan of Care (POC) dated 11/10/22 revealed SN visits two times a week for thirteen weeks. Wound Care order dated 11/11/22 revealed Venous Pressure Ulcer, Clean with Wound Cleanser, Pat Dry, with Gauze. Apply Optilock to Wound, Wrap Leg in Kerlix and then in Coban for Drainage. SN to perform weekly and PRN (as needed) if soiled. Review of the SN Visit Note Report (VNR) dated 11/15 22 revealed Wound Assessment: Measurements Taken- "No," Reason Measurements Not Taken- "Not Due." Review of the SN VNR dated 11/17/22 revealed Wound Assessment: Measurements Taken- "No," Reason Measurements Not Taken- "Not Due." Review of the SN VNR dated 11/22/22 revealed Wound Assessment: Measurements Taken- "No," Reason Measurements Not Taken- "Not Due." Review of the SN VNR dated 11/25/22 revealed Wound Assessment: Wound Assessed- "No, Not Ordered This Visit." Review of the SN VNR dated 11/29/22 revealed Wound Assessment: Measurements Taken- "No," Reason Measurements Not Taken- "Not Due." Review of the SN VNR dated 12/2/22 revealed Wound Assessment: Measurements Taken- "No," Reason Measurements Not Taken- "Not Due." Review of the SN VNR dated 12/13/22 revealed Wound Assessment: Wound Care Not Provided, "Not Ordered This Visit." Review of the SN VNR dated 12/16/22 revealed Wound Assessment: Measurements Taken- "No," Reason Measurements Not Taken- "Not Due." There were no weekly wound measurements documented for the weeks of 11/15/22, 11/22/22, 11/28/22 and 12/13/22 per agency policy. An interview conducted on 1/25/23 at 1:43 PM with EI # 1, Director of Operations confirmed the wounds were not measured weekly per agency policy.

Based on medical record (MR) review, agency policy and operational guidelines, and interview, it was determined the agency failed to ensure the skilled nurse (SN) documented accurately in the clinical record. This affected MR # 1, and MR # 3, two of seven active records reviewed, and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Clinical Records Maintenance and Confidentiality Policy Number: IM-001 Revision Date: 9/12/22 Policy: A clinical record that contains past and current information is maintained for each hospice patient....All documentation is timely, detailed, and accurate... Agency Operational Guidelines: Clinical records will include...but is not limited to: ...Responses to medication, symptom management, treatments, and services. ...Visit notes...For...Nursing --- 1. MR # 1 was admitted to the agency on 12/29/22, and certified for hospice services from 12/29/22 to 3/28/23 with diagnoses including Alzheimer's Disease, Unspecified, and Unspecified Dementia, Unspecified Severity, Without Behaviors, Psychiatric, Mood, Anxiety. Review of the SN Visit Note dated 1/5/23 revealed the SN documented oxygen was present in the home. Review of SN Visit Note dated 1/9/23 revealed the SN documented no oxygen was present in the home. Review of SN Visit Notes dated 1/11/23, and 1/13/23 revealed the SN documented oxygen was present in the home. Review of SN Visit Notes dated 1/16/23, 1/18/23, and 1/23/23 revealed the SN documented no oxygen was present in the home. Review of ordered medications in the Hospice Certification and Plan of Care dated 12/29/22 to 3/28/23 revealed no order for oxygen. An interview conducted on 1/26/23 at 1:35 PM with Employee Identifier (EI) # 1, Director of Operations confirmed there was no oxygen in the home, no order for oxygen, and the SN failed to document accurately in the clinical record. 2. MR # 3 was admitted to the agency on 12/29/22 with diagnoses including Chronic Obstructive Pulmonary Disease With Acute Exacerbation, and Chronic Respiratory Failure With Hypercapnea. Review of the Hospice Certification and Plan of Care dated 12/29/22 to 3/28/23 revealed orders for the hospice aide to provide services one time a week, beginning 1/1/23. Review of the SN Visit Note dated 12/30/22 revealed the SN documented an aide supervisory visit. There was no aide providing services on 12/30/22. An interview conducted on 1/26/23 at 2:07 PM with EI # 1 confirmed there was no aide providing services when the SN documented a supervisory visit, and the documentation was inaccurate.

Based on medical record (MR) review, agency policy and operational guidelines, and interview, it was determined the agency failed to ensure the skilled nurse (SN) wrote a verbal order at the time it was received from the physician. This deficient practice had the potential to negatively affect all patients served by the agency, and did affect MR # 7, one of ten active records reviewed. Findings include: Agency Policy: Physician Verbal Orders Policy Number: TX-002 Review Date: 01/06/22 Policy: Verbal or telephone orders...shall be immediately recorded, signed and dated by the licensed staff member receiving such an order... Agency Operational Guidelines: 1. The licensed staff members receives the verbal order from the physician...then records the verbal order electronically via the Point(of)Care device or directly into the HCHB (Home Care Home Base) system. --- 1. MR # 7 was admitted to the agency on 8/25/22, and recertified for care from 11/23/22 to 2/20/23 with diagnoses including Liver Cell Carcinoma and Unspecified Cirrhosis of Liver. Review of the 12/02/22 SN Visit Note Report Narrative (VNR) revealed the SN documented he/she spoke with the physician during the visit, and received a telephone order to increase the fentanyl dose from 75 micrograms (MCG) to 100 MCG. Review of the 12/05/22 SN VNR Narrative revealed the SN documented the caregiver was applying two 50 MCG fentanyl patches since fentanyl was increased from 75 MCG to 100 MCG. Review of physician orders revealed the order to increase the fentanyl to 100 MCG strength was written on 12/13/22, 11 days after the verbal order was received. The SN failed to write the verbal order immediately per agency policy. An interview conducted on 1/26/23 at 1:51 PM with Employee Identifier (EI) # 1, Director of Operations confirmed the verbal order was not written when received on 12/02/22, and should have been.