Amedisys Hospice Care of Kennesaw

“Upon patient record review, 1 of 14 (Patient #4) did not contain evidence that a Registered Nurse had been designated to ensure the 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 #4: The RN SOC admission visit documented, “Patient had an MRI today resulting in a diagnosis of L5 compression fracture; requiring the patient to now wear a brace”. This pertinent information was noted to not be included on the patient’s plan of care. Upon interview, the RN case manager reported that the patient is not using a back brace. There was no documented evidence that the nurse had followed up after the admission visit to ascertain the status of this indicated brace.”

“Upon patient record review, 1 of 14 (Patient #7) 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 #7: The admission consent reflected that the patient did not have any established Advance Directives. The RN SOC admission noted, “DNR preference was confirmed.” There was no D.N.R. POLST filed within the record. The two POLST forms within the record both reflected the patient to be a ‘Full Code.’ However, the 90-day, 11/02/25 SOC POC included an Advance Directive status of D.N.R. The Administrator confirmed that this patient was a Full Code.”

“Upon patient record review, 3 of 14 (Patients #2, 5, and 7) 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 the following: A detailed statement of both the ‘scope’ and ‘frequency’ of the planned care/services necessary to meet the specific patient and family needs: Patient #2: The IDG POC dated 01/02/26 did not include the ‘scope’ of planned interventions to be provided by the Social Worker. Patient #5: The IDG POC dated 01/02/26 did not include the ‘scope’ of planned interventions to be provided by the Social Worker. Patient #7: The IDG POC dated 12/29/25 did not include the ‘scope’ of planned interventions to be provided by the Chaplain.”

“Upon patient record review, 4 of 14 (Patients #1,2,3, and 6) did not contain evidence that a revised Plan of Care included information from the patient’s updated comprehensive assessment, and note the patient’s progress towards outcome/goals from the Plan of Care: Patient #1: In the CTI from 12/08/25, the Physician noted that the patient is unable to lie flat in bed, and requires to be elevated at a 45 degree angle. This pertinent information was not included in the current POC. Patient #2: The admission consent reflected that this patient had a Living Will and D.N.R. However, the current POC did not include that the patient had a Living Will. Patient #3: The 08/21/24 admission consent reflected that this patient had both a Living Will and D.N.R. for Advance Directive(s). The IDG POC dated 12/26/25 did not include Living Will in the Advance Directive section. Patient #6: The 11/16/25 admission consent reflected that this patient had a Living Will. The IDG POC dated 01/02/26 did not include this pertinent Advance Directive information.”

“Upon patient record review, 3 of 14 (Patients #1, 5, and 7) did not contain evidence that the Hospice Aide assignments and duties were: • Assigned to a specific patient by a Registered Nurse that is a member of the Interdisciplinary Group. • Written patient care instructions for a Hospice Aide must be prepared by a Registered Nurse who is responsible for the supervision of a Hospice Aide as specified under paragraph (h) of 418.76 Patient #1: In the physician’s CTI from 12/08/25, the Physician noted that the patient is unable to lie flat in bed, and requires to be elevated at a 45 degree angle. This pertinent information was not included in the current Aide Plan of Care. The Aide POC also assigned shampoo every visit. The Aide verbalized that she has not been completing that assigned task, as the patient has a bandage on her head covering an erupting/bleeding area. The Aide visit reports dated 12/16/25 through 01/02/26 all document ‘no’ for the assigned task of shampoo. The Aide POC is not current. Patient #5: The RN-established 11/07/25 Aide Plan of Care listed the patient’s Advance Directive status as, “Life Sustaining Treatment Order”. This patient was a D.N.R. This Aide POC is not current. Patient #7: The admission consent reflected that the patient did not have any established Advance Directives. The RN SOC admission noted, “DNR preference was confirmed.” There was no D.N.R. POLST filed within the record. The two POLST forms within the record both reflected the patient to be a ‘Full Code.’ However, the Aide POC established 11/04/25 listed the patient to be a D.N.R. The Administrator confirmed that this patient was a Full Code. The Aide POC is not current.”

“Upon patient record review 2 of 14 (Patients #1 and 3) did not contain evidence that the Hospice Aide provided services that were: • Ordered by the Interdisciplinary Group • Included in the Plan of Care Patient #1: The current Aide POC assigned the following tasks: 1) Report any vitals that are outside of parameters to the RN; and 2) Remind the patient to take her medications. During Surveyor-attended home visit on 01/06/26 the Aide confirmed that she does not take any patient vitals. The Aide also confirmed that she no longer reminds the patient to take her medications, as this was only done when the patient previously lived in her own home. Patient #3: The Aide POC established 12/10/25 assigned: 1) Apply Skin Barrier Cream to peri-area every visit; 2) Provide nail care every visit; and 3) Change Linens every visit. For all three of these assigned tasks the Aide documented them as not done for the following visit dates: 12/24/25, 12/29/25, 12/31/25, and 01/05/26.”