Every finding on record at Amedisys Hospice, LLC

Upon patient record review, 3 of 19 (Patient #1,6,8) 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: Upon observation of facility medication record, the facility had Lorazepam 2 mg/ml 0.25 ml Q 4 hrs as needed; the hospice medication record indicated Lorazepam 2mg/ml 0.5 ml Q 4 hrs. as needed. This was corrected on site by the hospice obtaining a new order for Lorazepam. Patient #6: There is evidence of an RN note "patient has not had to use O2 this week" and patient's equipment included O2 concentrator. O2 was not on the medication record. Corrected on site with an order for O2. Patient #8: There is evidence in the RN002 note "the patient is on an antibiotic for UTI" There antibiotic was not listed on the medication record.

Upon patient record review, 1 of 19 (Patient #10) 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 #10: There is evidence of an order for wound care to the sacrum. The wound has not been assessed since admission.

Upon patient record review, 1 of 19 (Patient #10) 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 #10: There is evidence in the RN admission note the patient had an indwelling urinary catheter. There was not a plan of care for a urinary catheter.

Upon patient record review, 5 of 19 (Patient #1,6,7,8,10) 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 #1: Upon observation of facility medication record, the facility had Lorazepam 2 mg/ml 0.25 ml Q 4 hrs. as needed; the hospice plan of care indicated Lorazepam 2mg/ml 0.5 ml Q 4 hrs. as needed. This was corrected on site by the hospice obtaining a new order for Lorazepam. Additionally, the nursing admission indicated the patient had a laceration of the forehead with sutures that needed removing. There was no order for suture removal that was completed. Patient #6: There is evidence of an RN note "patient has not had to use O2 this week" and patient's equipment included O2 concentrator. There was not an order for O2. Corrected on site with an order for O2. Patient #7: There was evidence of a wound order on 12/22/25. The order did not include the location of the wound. This was corrected on site by writing the order including the location of the wound. Patient #8: There is evidence in the RN002 note "the patient is on an antibiotic for UTI" There is no order for antibiotic. Patient #10: There is evidence in the RN admission note the patient had an urinary catheter. There was not an order for a urinary catheter. Corrected on site with an order for catheter.

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 was evidence of a hospice order for Volunteer stating "volunteer coordinator to recruit volunteer". However, no frequency was indicated. The patient received a volunteer visit on 12/8/25.

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. Annual volunteer cost savings for 2025 was 1.64%

Upon patient client record review, 1 of 19 (Patient #8) 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 #8: There is evidence in the nurses notes 12/24/25 and 1/7/26 of supervision of the Aide. The patient did not have an Aide.

Upon client record review, 5 of 11 (Patient #2, 4, 7, 8, 9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2 POC dated 12/17/22, SN ordered 1w1, 2w12, Week of 12/25/22 evidence of only one visit on 12/25. Week of 1/1/23 evidence of only one visit 1/6/23. Patient #4 Chaplain order as of 12/1/22 for 1m3, visits performed in excess of 1m3 on 12/2/22, 12/20/22, 1/17/23, 1/31/23. No evidence of order to change frequency. MSW order as of 12/1/22 for 1m3, visits performed in excess of 1m3 on 1/3/23, 1/6/23, 1/31/23. Patient #7 SN frequency ordered as of 12/16/22 if 1w1, 1w8, No evidence of visit on 12/16/22 (last day of first week), no evidence of visit for week of 12/18/22. Patient #8 POC dated 1/7/23, MSW ordered 1m2 plus 3 prn, Visited performed in excess of 1m2 on 1/20/23 and 1/26/23. No evidence of order to change frequency. SN ordered 1w8 and 3 prn as of 1/7/23, No evidence of visit during first week. Patient #9 Chaplain ordered effective 11/8/22 as 1m3, No evidence of visit in November. MSW ordered effective 11/8/22 1m3, No evidence of visit in November. Visits in January performed in excess of 1m3 in January. 1/5/23 and 1/11/23. No evidence of order to change frequency.

Upon patient record review 1 of 11 (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: 12/18/22 Aide was ordered 2xweek, on 12/19/22 Order was obtained to discharge aide, 12/20/22 Aide performed visit after order received to discharge aide services.

Upon personnel record review, 1 of 12 (Personnel #8) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel #8: No evidence of criminal history check being obtained.