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

Upon patient record review, 1 of 19 (Patient #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #5: The visit frequency for the Chaplain was indicated at 1x/month on the initial assessment of 5/29/25. There was only evidence of one visit being made on 06/26/25 and no further visits.

Upon patient record review 1 of 19 (Patient #14) did not have evidence that a Registered Nurse made an on-site visit to the patient's home no less frequently 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 met the patient's needs. Patient #14: An aide supervisory visit was done on 07/15/25 and no further supervisory visits were documented.

Upon observation, there was no evidence that the annual report documented 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. The Administrator provided the calendar year 2024 report and this reflected a result on 3.13%.

Upon patient record review, 1 of 19 (Patient #11) did not have evidence that each patient record contains Advance Directives. Patient #11: Numerous areas of the clinical record reflected that the patient had an Oregon POLST but this was not attached to the chart.

Upon patient record review, 1 of 19 (Patient #18) did not have evidence that the discharge summary included all CMS-required information. Patient #18: The discharge summary dated 07/15/25 did not include the following content: • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current plan of care • The patient's latest physician orders

Based on interview and record review, it was determined the agency failed to develop an individualized care plan for each patient which reflected measurable patient and family goals for 7 of 10 current patients reviewed (Patients #1-3 and Patients #7-10). --- The review of documents titled "Hospice POC Report," the "RN Hospice Start of Care Visit Note Report," the "RN Hospice Recert [sic] Assessment" and the "RN Hospice Subsequent Visit Report" for Patients #1-3 and #7-10 revealed the same goal and intervention statements on several care plans without individualization to reflect patient and family goals and how goals will be measured. Findings: 1. The care statement "WHAT MATTERS-PATIENT PREFERENCE (HOSPICE SN)" revealed for Patients #1-3 and #7-10 a goal, "PT/FAMILY WILL EXPRESS AN INCREASE IN FEELING SUPPORTED IN IDENTIFYING WHAT MATTERS TO THEM." This statement failed to identify what matters to each individual patient and how achieving goal will be measured. 2. The care statement "NEED FOR O2 SATS-HOSPICE" revealed the goal, "PULSE OXIMETRY READING IS OBTAINED AND APPROPRIATE INTERVENTION INITIATED" for 4 of 7 care plans reviewed (Patients #1, #2, #8 and #10.) This statement failed to identify why this affects each individual patient and how achieving this goal will be measured. 3. The care statement "NEED FOR ASSESSMENT OF EFFECTIVENESS OF PAIN CONTROL MEASURES-HOSPICE" revealed the goal, "PAIN IS CURRENTLY MANAGED AT A LEVEL ACCEPTABLE TO PATIENT" for 5 of 7 care plans reviewed (Patients #2, #7, #8, #9 and #10.) The goal statement failed to identify what pain is to each individual patient and how achieving this goal will be measured. 4. The care statement "ALTERED NUTRITION/HYDRATION - HOSPICE" revealed the goal, "PATIENT/CAREGIVER UNDERSTANDS EFFECTS OF TERMINAL ILLNESS ON NUTRITION AND HYDRATION" for 3 of 7 care plans reviewed (Patients #1, #3 and #7.) The goal statement failed to reflect how this can be individualized for each patient and how achieving this goal will be measured. During an interview with the Director of Operations and the Clinical Manager on 11/3/2022 at 2:30 PM, the above findings were discussed. The Director of Operations and the Clinical Manager acknowledged the findings. The Clinical Manager stated, "It is a challenge to work with an EMR that doesn't allow for editing the 'pick-list' options in the care plan."

Based on interview and record review, it was determined the agency failed to include in the plan of care measurable outcomes anticipated from implementing and coordinating the plan of care for 7 of 10 patient records reviewed (Patients #1-3 and #7-10). --- Findings: 1. Review of the "Hospice POC Report" documentation for Patients #1, #3 and #7 revealed that for every problem related to "ALTERED NUTRITION/HYDRATION," the goal statement "PATIENT / CAREGIVER(S) UNDERSTANDS EFFECTS OF TERMINAL ILLINESS ON NUTRITION AND HYDRATION" is used. No patient specific measurable parameters were given for "UNDERSTANDS." 2. Review of the "Hospice POC Report" documentation for Patients #1, #8 and #10 revealed that for every problem related to "COPING", the goal statement "CAREGIVER WILL EXHIBIT IMPROVED COPING SKILLS" was used. No patient/caregiver specific measurable parameters of "IMPROVED COPING SKILLS" were given. 3. Review of the "Hospice POC Report" documentation for Patients #8, #9 and #10 revealed that for every problem related to "NEED FOR ASSESSMENT OF EFFECTIVENESS OF CARDIOPULMONARY MEASURES - HOSPICE," the goal statement "PATIENT EXHIBITS REDUCTION/RELIEF OF ANY CARDIOPULMONARY SYMPTOMS." No patient specific measurable parameters of "EXHIBITS REDUCTION/RELIEF" were given. In an interview with the Director of Operations and the Clinical Manager on 11/3/2022 at 2:30 PM the findings above were presented. The Director of Operations and the Clinical Manager acknowledged that the outcome statements were not measurable or specific to each patient. The Clinical Manager stated, "We have some work to do."