Amedisys Hospice Care of Newnan

“Upon patient record review, 2 of 19 (Patients #1 and 2) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs: Patient #1: During Surveyor-attended home visit on 01/21/25 it was noted that the patient had the following DME: 1) commode; 2) walker; and 3) wheelchair. These DME were not on the Hospice POC. Patient #2: During Surveyor-attended home visit on 01/21/25 it was noted that the patient had the following DME: wheelchair. This DME was not on the Hospice POC.”

“Upon patient record review, 10 of 19 (Patients #3, 5, 7, 8, 9, 10, 11, 12, 13, and 14) did not contain evidence that the IDG had ensured that care and services were provided in accordance with the Plan of Care: Patient #3: There were no SW visits made/documented between 10/03/24 and 12/19/24. There were no interim verbal orders located between 10/03 and 12/19/24 that addressed the intended SW visit frequency. All IDG POC’s included the following statement, “SW to continue to visit at least bi-monthly.” Missed visit reports were located for 10/20/24, 11/29/24, and 12/19/24 stating, “Rescheduled for next Medicare week.” No visits were re-scheduled. Patient #5: There were no SW visits made/documented between 11/18/24 and 01/20/25. There were no interim verbal orders located that addressed the intended SW visit frequency. All IDG POC’s included the following statement, “SW to continue to visit at least bi-monthly.” Missed visit reports were located for 11/28/24, and 12/06/24 stating, “Rescheduled for next Medicare week.” No visits were re-scheduled. Patient #7: A verbal order was obtained on 10/28/24 for, “Effective 10/14/24 SW 1x per month x3 months”. No further SW visits had been made/documented. All IDG POC’s included the following statement, “SW to continue to visit at least bi-monthly.” Missed visit reports were located for 11/29/24, and 12/31/24, without a clear reason of why. Patient #8: SW visits were made on 11/12/24, 12/05/24, and 01/08/25. There was a verbal order obtained, “Effective 11/09/24, SW 1x per month x4”. However, all IDG POCs included the following statement, “SW to continue to visit at least bi-monthly.” Patient #9: SW visits were made on 12/17/24, 01/07/25. There was a verbal order obtained, “Effective 12/13/24, SW 1x per month x3”. However, all IDG POCs included the following statement, “SW to continue to visit at least bi-monthly.” Patient #10:There were no SW visits made/documented between 11/22/24 and 01/20/25. All IDG POCs included, “SW to continue to visit at least bi-monthly.” Patient #11: SW visits were made on 11/12/24 and 12/13/24. All IDG POCs included, “SW to continue to visit at least bi-monthly.” Patient #12: SW visits were made on 12/05/24 and 01/17/25. All IDG POCs included, “SW to continue to visit at least bi-monthly.” Patient #13: A Chaplain visit was made on 11/23/24. A verbal order was obtained for, “Effective 11/07/24 Chaplain 1x per month x3 months”. There was no December visit. On 12/31/24, there was a missed visit note, “Re-schedule to next Medicare week”, without a clear reason of why. Patient #14: SW visits were made on 11/18/24 and 12/19/24. All IDG POCs included, “SW to continue to visit at least bi-monthly.””

“Upon patient record review 1 of 19 (Patient #6) did not contain evidence that a Hospice Aide provided services that were: • Ordered by the Interdisciplinary Group • Included in the Plan of Care Patient #6: Aide visits were ordered at a frequency of “3x per week effective 12/22/24”. Only (1) visit was made the weeks of December 22-28, 2024 and December 29-January 4, 2025. No Aide visits were made January 5-11, 2025. There was one missed visit report during that week stating, “In-climate weather”. However it did not indicate whether this was per patient request, nor evidence of attempt to re-schedule. No Aide visits were made January 12-17, 2025. Two days this week there was a note,”Caregiver provided care”. No evidence that patient had refused the Aide visit.”

“Upon patient record review, 1 of 19 (Patient #5) did not contain evidence that all entries were clear/complete: Patient #5: The Aide Plan of Care assigned, “Report pain > 5 out of 10.” On the Aide home visit report(s), the assigned Aide(s) entered a response of “Yes”. The Aide’s were not documenting the result of each patient’s pain assessment in their individual home visit reports. It is unclear as to whether the Aides were assessing the pain and the results of such, in order to ascertain whether the Aide(s) needed to report to the RN or not.”