Every finding on record at Amedisys Hospice, LLC

Based on document review, record review and staff interview, it was determined the agency failed to ensure their medication management policy was followed for controlled medications (i.e., Schedule II, III and IV) for ten (10) of ten (10) patients (patients #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10). This failure has the potential to negatively affect all patients provided care by the agency. --- Findings include: Review of policy, titled ";MM-001 WV - Medication Management Policy – West Virginia", last revised 1/20/23, revealed it stated in part: ";Section E. Medication Reconciliation, 2. A medication count of Scheduled II, III and IV controlled substance medications will be done every nursing visit ... Section F. Medication Discrepancy, 2. The hospice nurse will report the drug discrepancy back to Interdisciplinary team (IDT) and if any possible reasons were identified. The IDT will further investigate the discrepancy." Review of the medical records for patients #1 through #10 revealed there was no system for the reconciliation of controlled medications. Review of nursing notes for patient #1, dated 12/4/22 to 1/27/23, revealed controlled medication counts were being recorded on the bottom of nursing notes. When notes were cross referenced, it revealed discrepancies with the controlled medication count; however, there was no evidence of controlled medication discrepancies, nor evidence of it being discovered or reported to the IDT. Medication counts for patient #1 from 1/17/23 to 1/27/23 were: 1/17/23: Oxycodone 5, Ativan 22, Tramadol 82, Morphine 30 and Contin 42 1/18/23: Oxycodone 5, Ativan 22, Tramadol 81, Morphine 30 and Contin 42 1/19/23: Oxycodone 5, Ativan 21, Tramadol 84, Morphine 30 and Contin 42 1/20/23: Oxycodone 5, Ativan 21, Tramadol 84, Morphine 30 and Contin 42 1/21/23: Oxycodone 5, Ativan 20, Tramadol 82, Morphine 30 and Contin 42 1/22/23: Ativan 17, Tramadol 84, Morphine 30 and Contin 44 1/22/23: Oxycodone 5, Ativan 21, Tramadol 81, Morphine 29.5 and Contin 42 1/23/23: Oxycodone falls off list with no explanation. Ativan 20, Tramadol 83, Morphine 30 and Contin 42 1/24/23: Ativan 20, Tramadol 83, Morphine 30 and Contin 42 1/25/23: Ativan 18, Tramadol 82, Morphine 30 and Contin 42 1/25/23: Ativan 27, Tramadol 82, Morphine 30 and Contin 42 1/27/23: Ativan 14, Tramadol 80, Morphine 29 and Contin 40 An interview was conducted with Clinical Manager (CM) #1 on 3/22/23 at 9:58 a.m. They confirmed that the nursing notes were only reviewed if the doctor had a question regarding the medications. When asked if they were the direct supervisor of the registered nurses (RN), CM #1 stated in part: ";Yes, and the other clinical supervisor." When asked who reviews RN notes, CM #1 stated part, ";We review notes if we need to get into the chart for a reason, such as if a physician wanting to check medication count. We would review the note for medication count for refill notices or if something triggered us to review." When asked if anyone reviews narcotic sheets or notes on a regular basis, they stated, ";No." When asked what happens if there is a discrepancy, they stated, ";If a patient thinks or questions a medication refill, we will check the notes. If there is a discrepancy noted, we review the notes, call the pharmacy to see the last time medication was filled, cross reference information with notes and contact the physician. It is at the physicians discretion what happens next. We do re-educate the patient and/or family member on medication agreement if it looks like medications arent being given per order." When asked if they have a specific process for reconciliation of controlled medications, i.e., Schedule II, II and IV medications, they stated, ";No, just if there is thought to be an issue with medications." When asked if they were aware that five (5) Oxycodone medications fell off the count without any written explanation, they stated, ";No." An interview with RN #1 on 3/21/23 at 2:00 p.m. was conducted. When asked about patient #1s medications, RN #1 stated that the husband takes care of getting the medications, ";we do the counts each visit." When asked about the counts having discrepancies, RN #1 had no explanation. When asked about Oxycodone falling off the medication list, they explained that the Oxycodone was from a prior prescription and the agency didnt have anything to do with it. RN #1 stated, ";[Patient #1] rarely takes any pain medications at all, so I dont know what happened with the Oxycodone." RN #1 stated maybe it was used and not refilled. An interview with RN #2 on 3/21/23 at 4:29 p.m. was conducted. RN #2 was very familiar with patient #1 stating that they worked very closely together. RN #2 confirmed that patient #1 didnt like taking the medication and seldom took pain medications. RN #2 explained that the husband was very involved and took care of the prescriptions and getting the medications. RN #2 stated that they were not aware of the patient taking the Oxycodone at all. ";If you look at the count, you will see [patient #1] didnt take a lot of the medications. I dont know what happened with the Oxycodone or why there would be discrepancies in the medication count. Maybe someone miscounted, I dont know."

Based on record review, document review and staff interview, it was determined the agency failed to ensure the interdisciplinary team (IDT) policy was followed for ten (10) of ten (10) patients (patients #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10). This failure has the potential to negatively affect all patients provided care by the agency. --- Findings include: Medical record review completed on 3/21/22 for patient #1 revealed no evidence of the patient and/or family members attending their interdisciplinary team meetings. The record revealed no evidence of written notices or communication with patient and/or family members of date and time of meetings. Medical record revealed no evidence that patient and/or family member was afforded the opportunity to participate in their own treatment. Medical record review completed on 3/21/22 for patient #2 revealed no evidence of the patient and/or family members attending their interdisciplinary team meetings. The record revealed no evidence of written notices or communication with patient and/or family members of date and time of meetings. Medical record revealed no evidence that patient and/or family member was afforded the opportunity to participate in their own treatment. Medical record review completed on 3/21/22 for patient #3 revealed no evidence of the patient and/or family members attending their interdisciplinary team meetings. The record revealed no evidence of written notices or communication with patient and/or family members of date and time of meetings. Medical record revealed no evidence that patient and/or family member was afforded the opportunity to participate in their own treatment. Medical record review completed on 3/21/22 for patient #4 revealed no evidence of the patient and/or family members attending their interdisciplinary team meetings. The record revealed no evidence of written notices or communication with patient and/or family members of date and time of meetings. Medical record revealed no evidence that patient and/or family member was afforded the opportunity to participate in their own treatment. Medical record review completed on 3/21/22 for patient #5 revealed no evidence of the patient and/or family members attending their interdisciplinary team meetings. The record revealed no evidence of written notices or communication with patient and/or family members of date and time of meetings. Medical record revealed no evidence that patient and/or family member was afforded the opportunity to participate in their own treatment. Medical record review completed on 3/22/22 for patient #6 revealed no evidence of the patient and/or family members attending their interdisciplinary team meetings. The record revealed no evidence of written notices or communication with patient and/or family members of date and time of meetings. Medical record revealed no evidence that patient and/or family member was afforded the opportunity to participate in their own treatment. Medical record review completed on 3/22/22 for patient #7 revealed no evidence of the patient and/or family members attending their interdisciplinary team meetings. The record revealed no evidence of written notices or communication with patient and/or family members of date and time of meetings. Medical record revealed no evidence that patient and/or family member was afforded the opportunity to participate in their own treatment. Medical record review completed on 3/22/22 for patient #8 revealed no evidence of the patient and/or family members attending their interdisciplinary team meetings. The record revealed no evidence of written notices or communication with patient and/or family members of date and time of meetings. Medical record revealed no evidence that patient and/or family member was afforded the opportunity to participate in their own treatment. Medical record review completed on 3/22/22 for patient #9 revealed no evidence of the patient and/or family members attending their interdisciplinary team meetings. The record revealed no evidence of written notices or communication with patient and/or family members of date and time of meetings. Medical record revealed no evidence that patient and/or family member was afforded the opportunity to participate in their own treatment. Medical record review completed on 3/22/22 for patient #10 revealed no evidence of the patient and/or family members attending their interdisciplinary team meetings. The record revealed no evidence of written notices or communication with patient and/or family members of date and time of meetings. Medical record revealed no evidence that patient and/or family member was afforded the opportunity to participate in their own treatment. Review of policy, titled ";AA-002, Interdisciplinary Team (IDT)", last revised 10/29/21, revealed in part: ";The composition of the IDT includes at a minimum a physician, a registered nurse, a social worker, and a spiritual counselor, as well as the patient and/or caregiver." An interview was conducted with Clinical Manager (CM) #1 on 3/22/23 at 9:58 a.m. When asked how often IDT meetings were held, they stated they were split depending on location, and they have a meeting for someone every week, or fifteen (15) days. When asked who attends the IDT meetings, CM #1 stated the physician, social worker, Chaplin, nurse, and depending on availability, patients need a case manager. When asked whether the patients or their representative attend the IDT meetings, they stated in part, ";Generally not." When asked why they were not attending the meetings and how do they know when there is a meeting, CM #1 stated in part: ";We tell them and give them the date of the first meeting and the paperwork we give them at admission tells them there is a meeting every fifteen (15) days. When asked if notices are sent out, they stated, ";No." When asked how the patients know of changes to their plans of care, they stated in part: ";An email goes out after the IDT meetings to all case managers. It is their responsibility to follow up with families and pharmacy if needed."