Amedisys Hospice

“Based on agency policy, clinical record review, and staff interviews, the registered nurse documented an in-person home health aide (HHA) supervisory visit when the HHA was not present for 1 of 3 patients receiving HHA visits (#1).Findings included: A policy, Clinical Records Maintenance and Confidentiality (revised 7/27/26), received on 9/8/26 at 3:28 PM from the Director of Operations stated, “All documentation is timely, detailed, and accurate reflects the care, treatment, and services provided…”A policy, Safety Management (revised 10/01/25) received on 9/8/26 at 4:18 PM stated, “The registered nurse shall make a supervisory visit to the patient’s residence at least every 14 days… and determine whether goals are being met…”Patient #1 was admitted on 4/4/25 with a diagnosis of hypertensive heart disease with heart failure (high blood pressure and hearts inability to pump blood effectively). The plan of care for 7/3/25-9/30/25 included orders for skilled nurse visits 2 times a week for 12 weeks and 1 time a week for 1 week with 8 PRN (as needed) and home health aide (HHA) 1 time a week for 1 week, 2 times a week for 12 weeks, and 1 time a week for 1 week. Review of the clinical record revealed that on 8/25/25 registered nurse (RN) #10 documented, “Supervisory Functions, Indicate Discipline of Employee Being Evaluated: Hospice Aide, Is the Hospice Aide Present at the Time of Evaluation? YES…” Further review revealed that there was no documentation of an HHA visit on 8/25/25.RN #10 was not available for an interview.An interview conducted on 9/8/26 at 1:22 PM with the Clinical Manager revealed that there was no HHA visit conducted on 8/25/25.During an interview on 9/8/26 at 4:38 PM the Area Vice President of Operation stated, “The documentation should be accurate and reflect what actually happened.””

“Based on agency policy, clinical record review, and staff interviews, the registered nurses failed to provide dietary counseling and failed to include homemaker duties in the home health aide plan of care for 1 of 3 active patients (#1).Findings included: A policy, Dietary Counseling (revised 8/23/22) received on 9/8/26 at 3:35 PM from the Director of Operations stated, “Dietary counseling will be part of the IDT [Interdisciplinary Team] plan of care and based on specific nutritional needs.”Patient #1 was admitted on 4/4/25 with a diagnosis of hypertensive heart disease with heart failure (high blood pressure and hearts inability to pump blood effectively). Patient #1 was a current patient on 9/8/26. The plan of care for 7/28/26-9/25/26 included orders for skilled nurse visits 1 time a week for 9 weeks with 8 PRN (as needed), home health aide (HHA) 2 times a week for 12 weeks and 1 time a week for 1 week, and medical Social Work (MSW)2 times a month for 2 months with 3 PRN. Review of the clinical record revealed that the registered nurses failed to document dietary counseling at any of the visits with documentation of symptoms of malnutrition at each visit. Further review revealed that the registered nurses consistently documented, “unsanitary” living conditions. Review of the HHA plans of care from 10/01/25-9/25/26 revealed that homemaker services were not provided for 7 of 8 recertification periods.During an interview conducted on 9/8/26 at 2:06 PM MSW #7 stated, “The house was not clean… I don’t think it was sanitary for the patient to be there… No, we do not cover homemaker services.”During an interview conducted on 9/8/26 at 3:20 PM RN #6 stated, “No (agency does not provide dietary counseling) …”During an interview conducted on 9/8/26 at 4:34 PM the Area Vice President of Operations stated, “The home health aide would provide homemaker services in the general vicinity of the patient.” During an interview conducted on 9/8/26 at 4:37 PM the Area Vice President of Operations stated, “Dietary needs for every patient will be addressed.””

“Based on agency policy, clinical record review, and staff interviews, the agency failed to document physician’s’ orders for a medication prior to administering the medication for 1 of 5 patients. (Patient #2)Findings included: A policy Hospice Plan of Care (revised 04/18/2025) received on 09/29/2025 at 3:14 PM from the director of operations stated, “Physician orders are needed to initiate any services, disciplines or treatments for hospice patients, including all support services related to patient care, and any services requiring the administration of medication… “Patient #2 was admitted on 08/07/2025 with a diagnosis of hypertensive heart disease. The plan of care for 08/07/202-11/04/2025 included orders for skilled nurse visits 2 times a week for 13 weeks, 1 time a week for 1 week with 8 PRN (as needed) and “hyoscyamine 0.25 MG disintegrating tablet place 1 tablet under the tongue every 6 hours as-needed for excess secretions.” Review of the clinical record revealed that on 08/16/2025 registered nurse (RN) #3 documented, “Hycosamine [sic] and oxycodone 2.5 MG crushed and given SL [under the tongue], demonstrated to CG/family [care giver] on how to administer meds [medications] syringe method…” Further review revealed that there was no documentation of a physician’s order for oxycodone 2.5mg.During an interview conducted on 09/29/2025 at 2:03 PM RN #3 stated, “They had comfort meds in the home. Yes [completes a medication review at each visit] … At that time, I didn’t see the order.”During an interview conducted on 09/29/2025 at 2:05 PM the director of operations stated, “They should be reconciling the meds [medications] every visit and reach out to the provider [physician] to get an order.””

“Based on agency policy, clinical record review, and staff interview, the agency failed to report concerns regarding verbal abuse and neglect for 1 of 1 patient with documented concerns regarding patient safety in the home environment (Patient #19). Findings included: Policy AA-010, titled “;Assessment and Reporting of Abuse, Neglect, and Exploitation”, and last revised, 12/07/23, was received from the agency director 05/22/24 at 5:02 PM. This policy revealed, “;All cases of alleged, observed, or suspected abuse, neglect, or exploitation will be investigated by the Agency and appropriate intervention will be initiated, including mandated reporting requirements in accordance with the state regulations.” Patient #19 was admitted to the agency 12/15/23 with a principal diagnosis of idiopathic pulmonary fibrosis (scarring of the lungs of an unknown cause). Plan of Care from 03/30/24 to 05/28/24 revealed orders for skilled nursing one time per week for nine weeks and three PRN (as needed), hospice aide two times per week for eight weeks, and one time per week for one week, hospice chaplain two times per month for two months and three PRN, and medical social work two times per month for one month, four times per month for one month, and three PRN. On 04/26/24 Employee #16, hospice chaplain, conducted a visit with Patient #19 and documented that the patient complained of severe head pain during the visit, the patient did not have water in the home, and “;chaplain concerned about level of care pt [patient] is receiving”. There was no evidence that the documented concerns about the patients level of care were reported. In an interview on 05/22/24 at 4:45 PM, Employee #16 stated that the patient had a live-in caregiver but on arrival to the home that day, he noted that the house was not clean, the patient was alone and in extreme pain with the television volume was very loud, and no food or water was in the home. Employee #16 also stated that during the visit, Patient #19 was crying while clutching his head and shared that his live-in caregiver had been bringing “;a girl into the home”, yelling at the patient, and accusing the patient of being able to “;get up if he wanted to”. Employee #16 stated that he reported his findings to the hospice nurse and patients daughter and that was the extent of his reporting. In an interview on 05/22/24 at 4:50 PM, Employee #1, agency director, stated, “;if were worried about safety, we need to contact the social worker.””

“Based on agency policy, observation, clinical record review, and staff interviews the Plan of Care failed to include correct medications for 1 of 4 patients with a home visit conducted. (patient #22). Findings included: The Policy Medication Management Policy-NC (Reviewed 6/15/23) was provided by the director on 5/22/24 at 1:55 PM. The policy stated, “;The medication plan of care (POC) will include all prescription and over the counter medications, oxygen, and herbal supplements both covered and not covered by the hospice benefit...Medication Reconciliation will be done at admission, recertification, a change in patients condition requiring medication changes, when a medication is discontinued, when a medication is a new order, or a change in existing medication order.” Patient #22 was admitted on 12/14/22 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) with (acute) Exacerbation (chronic inflammatory lung disease that causes obstructed airflow from the lungs). The plan of care (POC) dated 4/7/24-6/5/24 included orders for skilled nursing 2 times a week for 8 weeks, 1 time a week for 1 week, and 3 PRN (as needed) visits for symptom management. A home visit was conducted on 5/21/24 at approximately 8:30 AM with registered nurse (RN) #9. RN #9 conducted a comprehensive medication review. The POC included Aricept [treat symptoms of Alzheimers Disease] 5mg tablet at bedtime with a start date of 9/1/22; Atorvastatin [treat high cholesterol] 40mg daily with a start date of 8/1/22; Mecobalamin (vitamin B12) 1,000 mcg (mica grams) daily with a start date of 12/1/21; metoprolol succinate ER [blood pressure] 100mg daily with a start date of 12/1/21; Mirtazapine [antidepressant] 15mg daily with a start date of 3/1/22; multivitamin tablet daily with a start date of 12/1/21; Namenda [treat symptoms of Alzheimers Disease] 5mg daily with a start date of 7/1/22; olanzapine [antipsychotic] 2 times a day with a start date of 12/1/21; tamsulosin [treat enlarged prostate] 0.4mg at bedtime with a start date of 1/6/22; trazodone [antidepressant] 100mg daily with a start date of 7/1/22; and vitamin D3 50 mcg 2,000 units daily with a start date of 12/1/21 as active medications. The patients caregiver stated that the patient is not taking any of these medications. The caregiver provided a bottle of Tadalafil [erectile dysfunction] 5mg daily with a start date of 5/1/24. An interview with patient # 22s caregiver revealed that the patient has been taking this medication as ordered. An interview was conducted with RN #9 on 5/22/24 at 4:01 PM. The RN stated, “;I try to do it [comprehensive medication review and medication profile update] every visit. His medications are not correct, it appears that someone put another patients medications in his chart because he has never been on most of those medications, especially the ones for Alzheimers Disease and the mental health medications. He has never had those diagnosis or been on those medications.” An interview was conducted with the agency director on 5/22/24 at 4:18 PM. The agency director stated, “;I would expect the medications to be reviewed and updated with each visit.””

“Based on agency policy, clinical record review, and staff interview the agency home health aide failed to notify the registered nurse about assigned task not being performed for 1 of 16 patients with home health aide services (Patient # 21) and the agency chaplain failed to document notifying the registered nurse regarding the patient having a severe cough for 1 of 16 patients receiving chaplain services (Patient #6). Findings included: A policy Non-Core Services-Hospice Aide and Homemaker Services was received on 05/22/2024 at 2:00 from the agency director. The policy stated, “Hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and social needs, as the changes relate to the plan of care... The hospice aide provides services... included in the patient’s plan of care.” Patient #21 was admitted on 10/21/2022 with a diagnosis of Other Frontotemporal Neurocognitive disorder (brain impairment). The plan of care for 04/13/2024-06/11/2024 included orders for skilled nurse visits 1 time a week for 9 weeks, 3 PRN (as needed), Home Health Aide (HHA) visits 2 times a week for 8 weeks and 1 time a week for 1 week, and HHA to obtain vital signs: blood pressure, respirations, and pulse/heartrate every visit. For the HHA visit of 04/25/2024 HHA # (serenity) stated, “;Nurse will obtain” for the blood pressure, respirations, and pulse/heartrate. For the HHA visit of 05/09/2024 HHA #12 stated, “;Not Completed” for blood pressure. For the HHA visit of 05/14/2024 HHA #12 stated, “;Not Completed” for blood pressure. For the HHA visit of 05/16/2024 HHA #12 stated, “;Not completed” for the blood pressure, respirations, and pulse/heartrate. There was no evidence in the clinical record of the nurse case manager or physician being notified that the task on the plan of care had not been completed. An interview was conducted with HHA #12 on 05/22/2024 at approximately 1:15 P.M. HHA #12 stated, “;I did not [notify anyone] its just in the visit. Yes, [I would usually call them or send it through the chat] if unable to perform.” An interview was conducted with the clinical manager on 05/22/2024 at approximately 1:20 P.M. The clinical manager stated, “;Any activities [alterations to the POC] they normally they would communicate everything with one another.” The interview revealed that the expectation is for the aide to document coordination. Patient #6 was admitted to the agency on 10/15/23 with a principal diagnosis of hypertensive heart disease with heart failure. Plan of care from 04/12/24 to 06/10/24 revealed orders for skilled nursing two times per week for eight weeks, chaplain one time per month for one month and two times per month for one month, and medical social work one time per month for one month. On 04/16/24, Employee #15, chaplain, conducted a visit with Patient #6 and documented “;very intense cough noted”. There was no evidence in the clinical record that the intense cough was reported to anyone. In an interview on 05/22/24 at 4:34 PM, Employee #15 stated “;I probably did [report the intense cough to the nurse case manager] and didnt note it [in the clinical record] because the case manager and I work very close.” In an interview on 05/22/24 at 4:36 PM, Employee #5, area vice president, stated if support services reported anything to the nurse case manager, they “;need to put it in their note”.”

“Based on agency policy, observation, and staff interviews the agency failed to follow accepted standards of practice to prevent the transmission of infections for 2 of 2 registered nurse home visits. (patients #22 and 27). Findings included: A policy, Hand Hygiene (reviewed 6/20/23) was received from the agency director on 5/22/24 at 1:55 PM. The policy stated, “;Perform hand hygiene as follows: ... after contact with inanimate objects (e.g. medical equipment) in the immediate vicinity of the patient.” A policy, Bag Technique (reviewed 6/20/23) was received from the agency director on 5/22/24 at 1:55 PM. The policy stated, “;Staff should not re-enter the bag with used gloves. Always perform hand hygiene before entering the bag. ... Keep the supply bag closed when not in use. ... Hands are cleansed prior to returning clean equipment and supplies to the bag.” 1. Patient #22 was admitted on 12/14/22 with a diagnosis of Chronic Obstructive Pulmonary Disease [COPD] with (acute) Exacerbation [chronic inflammatory lung disease that causes obstructed airflow from the lungs]. The plan of care dated 4/7/24-6/5/24 included orders for skilled nursing 2 times a week for 8 weeks, 1 time a week for 1 week, and 3 PRN (as needed) visits for symptom management. A home visit was conducted on 5/21/2024 at approximately 8:30 AM with registered nurse (RN) #9. RN #9 opened the clinical bag, removed medical equipment, and left the bag open for the duration of the visit. RN #9 performed a comprehensive medication review. RN #9 disinfected the vital sign equipment and returned it to the clinical bag. RN #9 failed to remove the contaminated gloves and failed to perform hand hygiene prior to entering the clinical bag. An interview was conducted with RN #9 on 5/22/24 at 4:01 PM. RN #9 stated, “;I clean the equipment then put it in my clean container and back in my bag. I would clean my hands with sanitizer before putting everything back in my bag. I would not typically use dirty gloves to clean the equipment. It was a mistake for me not to change gloves and clean my hands before cleaning the equipment and replacing it.” 2. Patient # 27 was admitted on 09/14/2023 with a diagnosis of senile degeneration of the brain. The plan of care (POC) for 05/11/2024-07/09/2024 included orders for skilled nurse visits 3 times a week for 8 weeks, 1 time a week for 1 week, and 3 PRN (as needed) visits. A home observation was conducted on 05/21/2024 with registered nurse (RN) #13 at approximately 9:45 A.M. RN # 13 assessed patient #27s oral temperature, removed a cell phone from her pocket, assessed patient #27s heart rate, lung sounds, oxygen saturation, and pedal (foot) pulses, and documented the assessment on the electronic tablet. RN #13 failed to perform hand hygiene before removing the phone from her pocket, after handling the phone, and before handling the electronic tablet. An interview was conducted on 05/22/2024 at approximately 2:15 P.M. with RN #13. RN #13 stated, “;I should have done hand hygiene before getting out the phone and then not touch her again until after Im done using my phone. I normally use my hand sanitizer.” An interview was conducted on 05/22/2024 at approximately 2:18 P.M. with the clinical manager. The clinical manager stated, “;They wash their hands per policy.” An interview was conducted with the director on 5/22/2024 at 4:08 PM. The director stated, “;I would expect them to keep their bag closed during the visit and clean their hands before going into their bag.””

“Based on policy review, volunteer program documentation review, and staff interview, the agency failed to meet the minimum standard for volunteer hours (5% of total patient care hours) for 2 of the 3 branches surveyed. Findings included: Policy TX-017a, titled “;Volunteers”, and last revised 01/25/24, was received from the area vice president on 05/22/24 at 2:45 PM. This policy revealed, “;The hospice will document and maintain a volunteer staff sufficient to provide direct patient care in an amount that, at a minimum, equals (5) five percent of the total patient care hours of all paid hospice personnel.” A report titled “;Hospice Volunteer Requirement Report” was received from the agency director on 05/22/24 at 3:51 PM. This report listed a tally of the total percentage of volunteer hours provided for branch locations A41, A42, and A43 through May 2024. The hospice waiver for volunteer services requirements was lifted at the end of the calendar year following the public health emergency effective in 2023. Branch A42 averaged 3.32% between January 2024 and April 2024 and did not meet the 5% requirement 4 of the same 4-month timeframe. Branch A43 averaged 0.91% between January 2024 and April 2024 and did not meet the 5% requirement 4 of the same 4-month timeframe. The agency provided a performance improvement plan titled “Corporate Performance Improvement Project [PIP]: Establishment of Action Plan” which revealed a PIP with the latest target date of 01/15/24. Additionally, the agency provided a copy of a slide presentation printout titled “;Hospice QAPI Plan 2024...Presentation for DOO [Directors of Operations] and CM [Clinical Managers]” which listed the agencys volunteer program as a national PIP and included bullet points noting “;CC [care center]-Establishment of a PIP” and “;CC-Follow Up Minutes for PIP”. The agency was unable to produce further evidence of an active PIP related to the volunteer program hours at the time of survey.”

“Based on agency policy, clinical record review, and staff interviews the agency failed to include x-ray results in the clinical record for 1 of 1 patient requiring an x-ray. (patient #20) Findings included: A policy Core Services-Nursing Service was received on 05/22/2024 at approximately 2:00 P.M. from the agency director. The policy stated, “The Case management includes... Documentation of all activities and findings.” Patient #20 was admitted on 11/20/2023 with a diagnosis of moderate protein calorie malnutrition. Patient #20 is a resident of a facility. The plan of care for 05/18/2024-07/16/2024 included orders for skilled nurse visits 1 time a week for 9 weeks, 3 PRN (as needed) visits, and an order for an x-ray of patient #20’s right shoulder. There was no evidence of the results of the x-ray in the clinical record. An interview with the clinical manager on 05/22/2024 at approximately 2:00 P.M. revealed that the expectation is to include the results of diagnostic test in the clinical record.”

“Based on agency policy, clinical record review, and staff interviews the agency failed to include care coordination with facilities providing care for the patient for 1 of 1 patient receiving respite care (patient #11) and 1 of 1 patient requiring diagnostic testing. (patient # 20) Findings included: A policy Professional Management (reviewed 10/16/23) was received on 5/22/23 at 2:00 PM from the agency director. The policy stated, “;The hospice will maintain ongoing communication with any other organization(s) providing care and/or services to a hospice patient.” 1. Patient #11 was admitted on 4/25/24 with a diagnosis of malignant neoplasm (cancerous tumors) of pancreas (organ within the abdomen that assist body with digestion). The plan of care for 4/25/24 to 7/23/24 included orders for Medical Social Worker (MSW) for 1 time a month for 1 month, 2 times a month for 3 months, Skilled Nursing (SN) for 1 time a week for 1 week, 2 times a week for 12 weeks, and 3 PRN (as needed) visits and Respite Care for 1 day of respite on 5/17/24. The MSW visit of 5/14/2024 at 4:23 PM MSW #6, stated “;SHE ALSO REQUEST [SIC] RESPITE FOR MAY 17 10 AM AND PICK UP BY FAMILY. MAY 18TH. MSW IS WORKING ON RESPITE TO [FACILITY NAME].” There was no evidence in the clinical record of communication between the hospice and the facility. The SN HOSPICE SUBSEQUENT VISIT note dated 5/17/24 at 2:39 PM completed by licensed practical nurse #8 stated, “;PATIENT IS CURRENTLY AT [FACILITY NAME] FOR A ONE DAY RESPITE.” An interview was conducted on 5/22/24 at 4:23 PM with MSW #6. MSW #6 stated “;I set up the respite care for the patient, the daughter had somewhere to go and needed just 1 day. I typically document that coordination [with the facility receiving the patient for respite care] in the narrative. I did it [spoke with someone at the facility to set up the respite care for the patient].” 2. Patient #20 was admitted on 11/20/2023 with a diagnosis of moderate protein calorie malnutrition. Patient #20 is a resident of a facility. The plan of care for 05/18/2024-07/16/2024 included orders for skilled nurse visits 1 time a week for 9 weeks and 3 PRN (as needed) visits. For the registered nurse (RN) visit of 04/03/2024 RN #12 stated, “;facility assisting, heard a pop in shoulder...reached out [to doctor] for x-ray.” There was no evidence in the clinical record of RN #12 notifying the facility staff of the patients reported incident. An interview was conducted on 05/22/2024 at approximately 1:26 P.M. with RN # 12. RN #12 stated, “;I did speak with the facility staff the day that it happened, I had notified the facility that I was getting an x-ray for her shoulder.” An interview was conducted on 5/22/24 at 4:27 PM with the area vice president (AVP). The AVP stated, “;I would expect that documentation to be done as soon as the coordination happened.””