Every finding on record at Amedisys Hospice, LLC

Based on record review and interviews, the hospice agency failed to ensure that the hospice staff immediately reported to the hospice administrator an alleged violation of misappropriation of patient property for 1 (Patient #2) out of 4 (Patient #1, Patient #2, Patient #3, and Patient #4) sampled patients. --- Patient #2. Review of the patients electronic clinical record revealed a start of care date of 10/30/2024. The patients admitting diagnosis was Congestive heart failure. The benefit period reviewed was 10/30/2024 to 12/28/2024. Review of the agencys complaint report dated 12/12/2024 at 4:31 PM revealed that the patients son reported that S3HA (Hospice Aide) had transported Patient #2 from her home to visit her sister, and then accepted money for transporting her in the amount greater than 100 dollars. He also reported that the patient was paying S3HA to take her laundry to S3HAS home and paying S3HA to wash them. On 03/05/2025 at 10:35 AM, an interview was conducted with S1BOM (Business Office Manager). She stated that a Marketer from the agency went to the patients home on 10/30/2024 after she returned from the hospital to screen the patient to see if she qualified to return to hospice services. She stated the patients son told the Marketer that he did not want S3HA not return back to the patients home because she had taken money from the patient to do her laundry and to provide transportation. She confirmed that the Marketer didnt inform the agency. S1BOM stated that it wasnt until 12/12/2024 they became aware when S2RN (Registered Nurse) reported that Patient #2 had voiced to her during her visits about how upset she was that S3HA had taken her to her sisters home and left her stranded at her sisters house and was charging her money to do her laundry. S1BOM stated that what S3HA had done was against agency policy. On 03/05/2025 at 12:15 PM, an interview was conducted with S2RN (Registered Nurse). S2RN stated that S3HA had approached her about transporting patients. She stated that she told S3HA that she needed to discuss it with the agency. S2RN stated that during one of her visits with Patient #2, the patient was upset and stated that S3HA had charged her to do her laundry and charged her money to take her to her sisters home. She stated that the patient stated she had given the S3HA $500.00. S2RN stated that the patient didnt want her to report this to the agency. She stated that she told the patient she would give her one week to report this or she would report it. She stated that the patient didnt report it to the agency, so she reported it. She stated that she didnt remember the date the patient informed her about what S3HA was doing and she didnt remember when she reported it to the agency. When asked if she was familiar with the agencys policy on reporting exploitation. She stated she didnt recall. When asked why she didnt report what the patient had told her immediately, she replied, ";I wanted to respect the patients wishes." When asked if what S3HA had done was a form of abuse. She replied, ";I guess it was abuse." When asked if she should have reported this immediately, she replied, ";Yes, I should have." On 03/05/2025 at 12:20 PM, an interview was conducted with S1BOM. S1BOM stated that staff are trained to immediately report any suspicion of abuse. She stated that when S2RN first became aware that S3HA had been charging Patient #2 for doing her laundry and for providing transportation, she should have reported it immediately. She stated that the agencys Marketer should have also reported this immediately when the patients informed her on 10/30/2024. She confirmed that this was a form of abuse.

Based on record review and interview, the hospice agency failed to report an alleged violation of misappropriation of property with 5 days of becoming aware of the violation for 1 (Patient #2) out of 4 (Patient #1-4) sampled patients. --- Review of the hospice agencys ";Assessment and Reporting of Abuse, Neglect and Exploitation" policy with a revised and reviewed date of 01/20/2025, read the following in part, ";Condition of participation: Patients rights. The patient has the right to be informed of his or her rights, and the hospice must protect and promote the exercise of these rights... 4) The hospice must:...(iv) Ensure that verified violations are reported to State and local bodies having jurisdiction(including to the State survey and certification agency) within 5 working days of becoming aware of the violation." Review of the agencys complaint report dated 12/12/2024 at 4:31 PM revealed that the patients son reported that S3HA (Hospice Aide) had transported Patient #2 from her home to visit her sister and accepted money for this in the amount greater than 100 dollars. He also reported that the patient was paying S3HHA to take her laundry home and paying S3HHA to wash them. Review of the SO (State Office) complaint intake revealed that the hospice agency self-reported the above incident on 01/28/2025, which was more than 5 working days after becoming aware of the incident. On 03/05/2025 at 12:20PM, an interview was conducted with S1BOM (Business Office Manager). She stated they became aware on 12/12/2024 when S2RN reported that S3HA had been taking money from Patient #2 to do her laundry and provide transportation. She stated that the agency conducted an internal investigation and did not report the incident to any outside agency within 5 working days.

Based on record review and interview, the agency failed to ensure the patient's written individualized plan of care (POC) was followed as evidenced by the agency failing to ensure hospice aide (HA) visits were made according to the POC for 1 (#1) out 4 (Patient #1-4) sampled patients. --- Review of Patient #1s electronic clinical record revealed a start of care date of 11/07/2024. The patients admitting diagnoses included in part, dysphagia post stroke, hemiplegia right side and hypertension. The benefit period reviewed was 11/07/2024 to 02/03/2025. Review of the patients POC for benefit period 11/07/2024 to 02/03/2025 revealed an order for HA effective 11/07/2024 for 5WK12, 2WK1 (five times a week for twelve weeks, two times a week for one week). Review of an email correspondence sent by S1BOM (Business Office Manager) on 12/04/2024 at 9:54 AM read in part... ";the log from the patient we spoke of, (Patient #1). The times on the log do not match the times that were put in (electronic health record). I have also attached the visit note on 12/2/2024 that has a signature however the family informed me that she does not bring her device in the home and they have never signed her tablet." Review of a phone call documentation note provided by S1BOM on 03/05/2025 at 1PM read, ";On 12/04/2024 spoke with (resident daughter), caregiver for (Patient #1), asking when they could expect their next aide visit. Through further conversation it was determined that an investigation was going to be opened regarding S4HA. Review of a correspondence sent by S1BOM on 12/06/2024 at 3:11PM revealed that Resident #1 had missed hospice aide visits on 11/20/2024, 11/26/2024, and 11/27/2024. On 03/05/2025 at 10:35 AM, an interview was conducted with S1BOM. She stated Patient #1s sister informed her that they had not seen S4HA since 11/25/2024. She confirmed S4HA did not make the home visit on 11/20/2024, 11/26/2024 and 11/27/2024. On 03/05/2025 at 11:35 AM, a phone interview was conducted with Patient #1s sister. She stated the hospice aide visits were scheduled for five times a week when the patient first started on hospice services. She stated that S4HA did not make the home visits as scheduled. She also stated that S4HA was signing her name on the visits.

Upon patient record review 1 of 19 (Patient #4) 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 #4: There is evidence in the medical record the patient was admitted on 11/7/24. The initial psychosocial assessment was completed on 11/13/24, which was greater than 5 days.

Upon patient record review, 2 of 19 (Patient #8, 11) 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 #8: Upon home visit observation, the patient was taking Pantoprazole 40 mg daily. This medication was not on the hospice medication record. Patient #11: There is evidence in the Aide care plan to apply antifungal ointment to fingernails and toenails every visit. An antifungal ointment is not on the medication record.

Upon patient record review, 1 of 19 (Patient #2) 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 #2: There is evidence in the medical record in the initial nursing assessment that the patient had a pacemaker. There is no care plan for the pacemaker. (corrected on site)

Upon patient record review, 1 of 19 (Patient #2) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #2: There is evidence in the medical record of an add on order for the MSW on 12/5/24. A care plan was opened for the MSW but there is no visit frequency. (corrected on site)

Upon patient record review, 2 of 19 (Patient #8,11) 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 #8: Upon home visit observation, the patient was taking Pantoprazole 40 mg daily. There was not an order for this medication on the plan of care. (corrected on site) Patient #11: There is evidence in the Aide care plan to apply antifungal ointment to fingernails and toenails every visit. There is not an order for antifungal ointment on the plan of care. (corrected on site)

Upon patient record review, 2 of 19 (Patient #6,8) 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 #6: There is evidence in the medical record the MSW visit frequency was 1M3. The patient refused MSW visits x3 months. The plan of care was not updated to reflect patient's progress towards goals. In addition, the Chaplain visit frequency was 1M3. The patient refused Chaplain visits x3 months. The plan of care was not updated to reflect patient's progress towards goals. Patient #8: There is evidence in the medical record the MSW visit frequency was 1M3. The patient refused MSW visits x3 months. The plan of care was not updated to reflect patient's progress towards goals. In addition, the Chaplain visit frequency was 1M3. The patient refused Chaplain visits x3 months. The plan of care was not updated to reflect patient's progress towards goals.

Upon client record review, 1 of 19 (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: There is evidence in a nurses note of 1/9/25 of a foley catheter insertion. There is no order for Foley Catheter.

Upon patient record review 1 of 19 (Patient #6) 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 meet the patient's needs. Patient #6: There is evidence in the medical record of an Aide visit on 12/10/24. The Nurse did not visit until 12/26/24 which is greater than 14 days for the Aide on site supervisory visit.