Amedisys Hospice Care

“Based on agency policy, clinical record review, and staff interviews, the agency failed to provide effective pain management for 1 of 1 patient reporting unmanaged pain (patient #2).Findings included: A policy, Patient and Family Rights and Responsibilities (revised 7/2/25), received on 5/18/26 at 4:34 PM from the Director of Operations stated, “The patient and the family have the right to: … Receive effective pain and symptom management from the hospice…”Patient #2 was admitted on 3/19/26 with a diagnosis of malignant neoplasm (cancer) of the bladder and secondary neoplasm of unspecified lung. The plan of care (POC) for 3/19/26-6/16/26 included orders for skilled nurse visits 2 times a week for 1 week and 1 time a week for 13 weeks with 8 PRN (as needed). Review of the clinical record revealed that on 4/16/26 registered nurse (RN) #2 documented, “No medication change…Patient asked if doctor could increase pain med [medication] dosage explaining that current regime is not as effective as before…” Further review revealed that there was no documentation of a medication change until 5/6/26 (21 days after the report of unmanaged pain.)During an interview on 5/16/26 at 4:00 PM RN #2 stated, “I did speak with the Doctor and that’s when we got the new order [on 5/6/26].The Director of Operations and the Clinician Development Specialist were unable to state the agency’s expectations.During an interview conducted on 5/18/26 at 4:06 PM the Area Vice President of Clinical Operations stated, “Of course if the patient’s pain isn’t managed, we would contact the doctor and implement interventions…. We expect them to be in a manageable pain level within 24-48 hours.””

“Based on agency policy, clinical record review, and staff interviews, the registered nurses failed to include orders in the plan of care for topical medications for 1 of 1 using antifungal medications patient (patient #1); and failed to include an order for oxygen for 1 of 1 patient with an oxygen concentrator (patient #2).Findings included: 1. Patient #1 was admitted on 7/24/25 with a diagnosis of Alzheimer’s disease (progressive brain disorder). The plan of care for 3/21/26-5/19/26 included orders for skilled nurse (SN) visits 1 time a week for 8 weeks, with 8 PRN (as needed) and beginning the week of 5/4/26 2 times a week. Review of the clinical record revealed that on 5/6/26 registered nurse (RN) #9 documented, “Supplies: Chucks, antifungal cream and powder…” on 5/08/26 RN #9 documented, that the caregiver was educated on the use of antifungal cream and powder. Further review revealed that there was no order for antifungal cream or powder in the POC.An interview conducted on 5/18/26 at 3:36 PM with RN #9 revealed that they were unaware that an order needed to be documented.2. Patient #2 was admitted on 3/19/26 with a diagnosis of malignant neoplasm (cancer) of the bladder and secondary neoplasm of unspecified lung. The plan of care (POC) for 3/19/26-6/16/26 included orders for skilled nurse visits 2 times a week for 1 week and 1 time a week for 13 weeks with 8 PRN (as needed). Review of the clinical record revealed that on 3/26/36 registered nurse (RN) #2 documented that an oxygen concentrator was ordered. Further review revealed that there was no order for oxygen in the POC.The Director of Operations and the Clinician Development Specialist were unable to state the agency’s expectations.During an interview conducted on 5/18/26 at 3:35 PM the Area Vice President of Clinical Operations stated, “Once they obtain an order it should be entered into the record.””

“Based on agency policy, clinical record review, and staff interviews, the registered nurses (RN) failed to assess if the home health aides (HHA) were following the plan of care for 2 of 3 patients receiving HHA services (patients #2 & 3).Findings included: A policy, Non-Core Services- Hospice Aide and Homemaker (revised 5/24/23), received on 5/18/26 at 4:44 PM from the director of operations stated, “The supervising nurse [RN] must assess an aide’s [sic] ability to demonstrate initial and continued satisfactory performance in meeting outcomes criteria that include but not limited to: Following the patient’s POC [plan of care] for completion of task assigned to the hospice aide by the RN.”1. Patient #2 was admitted on 3/19/26 with a diagnosis of malignant neoplasm (cancer) of the bladder and secondary neoplasm of unspecified lung. The plan of care (POC) for 3/19/26-6/16/26 included orders for skilled nurse visits 2 times a week for 1 week and 1 time a week for 13 weeks with 8 PRN (as needed) and home health aide (HHA) visits 2 times a week for 12 weeks. Review of the HHA plan of care revealed that the HHA was assigned to record the patient’s temperature, blood pressure, respirations, and pulse/heart rate at each visit. Review of the clinical record revealed the following documentation:During the HHA visit on 3/24/26 HHA #3 documented, “Unable to obtain” for the temperature, blood pressure, respirations, and pulse/heart rate.During the HHA visit on 3/27/26 HHA #3 documented, “Unable to obtain” for the blood pressure and pulse/heart rate.During the HHA visit on 4/1/26 HHA #3 documented, “Unable to obtain” for the Blood pressure and pulse/heart rate.During the HHA visit on 4/3/26 HHA #3 documented, “Unable to obtain” for the temperature, blood pressure, respirations, and pulse/heart rate.During the HHA visit on 4/14/26 HHA #3 documented, “Unable to obtain” for the blood pressure and pulse/heart rate.During the HHA visit on 4/17/26 HHA #3 documented, “Unable to obtain” for the temperature, blood pressure, and pulse/heart rate.During the HHA visit on 4/24/26 HHA #3 documented, “Unable to obtain” for the temperature, blood pressure, respirations, and pulse/heart rate.During the HHA visit on 4/29/26 HHA #3 documented, “Unable to obtain” for the temperature, blood pressure, respirations, and pulse/heart rate.During the HHA visit on 5/1/26 HHA #3 documented, “Unable to obtain” for the temperature, blood pressure, respirations, and pulse/heart rate.During the HHA visit on 5/5/26 HHA #3 documented, “Unable to obtain” for the temperature, blood pressure, respirations, and pulse/heart rate.During the HHA visit on 5/15/26 HHA #3 documented, “Unable to obtain” for the temperature, blood pressure, respirations, and pulse/heart rate. Further review revealed the following documentation:During the RN visit on 4/16/26 RN #2 documented that the HHA was following the POC.During the RN visit on 5/14/26 RN #2 documented that the HHA was following the POC. 2. Patient #3 was admitted on 4/8/26 with a diagnosis of hypertensive heart disease with heart failure (high blood pressure with reduce blood pumping). The plan of care for 4/8/26-7/6/26 included orders for skilled nurse visits 2 times a week for 13 weeks with 8 PRN (as needed) and home health aide (HHA) visits 2 times a week for 12 weeks, effective 4/12/26. Review of the clinical record revealed that on 4/16/26 RN #11 conducted a HHA supervisory visit and documented, “Yes (the HHA follows the plan of care).” Further review revealed that the HHA had not completed any visits.HHA #3 was not available for an interview.RN #11 was not available for an interview.An interview conducted on 5/18/26 at 4:34 PM with RN #2 revealed that the HHA documentation was not reviewed prior to documenting the supervisory visits.The Director of Operations and the Clinician Development Specialist were unable to state the agency’s expectations.An interview conducted on 5/18/26 at 3:53 PM with the Area Vice President of Clinical Operations revealed that the RN should be talking to the family… looking at what’s being documented and what’s assigned to them while performing a supervisory visit.”

“Based on record review and staff interviews, the registered nurse included inaccurate documentation in the clinical record for 1 of 1 patient with a urostomy (artificial opening into the bladder to drain urine) (patient #2).Findings included: Patient #2 was admitted on 3/19/26 with a diagnosis of malignant neoplasm (cancer) of the bladder and secondary neoplasm of unspecified lung. The plan of care (POC) for 3/19/26-6/16/26 included orders for skilled nurse visits 2 times a week for 1 week and 1 time a week for 13 weeks with 8 PRN (as needed) and, “Hospice nurse to instruct patient/caregiver on care and management of Urostomy [artificial opening into the bladder to drain urine].” Review of the clinical record revealed the following:During the registered nurse (RN) visit on 4/1/26 RN #2 documented, Interventions Provided… Instructed patient/caregiver in self-care management of nephrostomy (tube inserted into the kidney to drain urine) tube.”During the RN visit on 4/7/26 RN #2 documented, “Genitourinary Nephrostomy tube… Instructed patient/caregiver in self-care management of nephrostomy tube.”During the RN visit on 4/30/26 RN #2 documented, “Genitourinary Nephrostomy tube…”During the RN visit on 5/14/26 RN #2 documented, “Genitourinary Nephrostomy tube…”Further review revealed that patient #2 did not have a nephrostomy tube.During an interview conducted on 5/18/26 at 3:44 PM RN #2 confirmed that the patient did not have a nephrostomy tube.The Director of Operations and the Clinician Development Specialist were unable to state the agency’s expectations.During an interview conducted on 5/18/26 at 3:50 PM the Area Vice President of Clinical Operations stated, “The documentation should be accurately documented as reflecting the device that they have…””

“Based on agency policy, clinical record review, and staff interviews the agency failed to provide pain and/or symptom management for 1 of 2 patients with shortness of breath (patient #13) and 1 of 2 patients with unmanaged pain (patient #23). Findings included: A policy, Patient and Family Rights and Responsibilities (reviewed 12/16/2024), received on 02/06/2025 at 12:53 PM from the Area Vice President stated, “;The patient and the family have the right to: ... Receive effective pain and symptom management...” A policy, Pain and Symptom Management (reviewed 08/05/2024) received on 02/03/2025 at 12:56 PM from the agency director stated, “;The nurse will notify the physician of any uncontrolled pain as soon as it is identified... The patient will be assessed at a minimum but not limited to the following symptoms each visit: dyspnea (shortness of breath) ... The IDT (interdisciplinary group) and the patients attending physician will develop a plan of care to assure patient comfort.” Patient #13 was admitted on 11/13/2024 with a diagnosis of Senile Degeneration of Brain (a progressive decline in mental function). The plan of care for 11/13/2024-01/11/2025 included orders for skilled nurse (SN) visits 1 time a week for 1 week, 2 times a week for 8 weeks, and 3 PRN (as needed), hospice nurse to assess effectiveness of cardiopulmonary symptom relief measures...and hospice nurse to instruct patient/caregiver regarding cardiopulmonary symptom relief measures.” Patient #13 was admitted to a hospital on routine hospice care. Review of the clinical record revealed that during the registered nurse (RN) visit on 12/07/2024 RN #17 documented a respiratory assessment including, BPM (breaths per minute) 31 with labored/shallow breaths on room air and “;because hes a full code unable to receive anything other than [name brand acetaminophen, treats minor aches and pain, and reduces fever] at this time.” Further review of the clinical record revealed that no interventions for shortness of breath were performed. An interview conducted on 02/04/2025 at 3:55 PM with RN #17 revealed that the hospital was managing the patient not the hospice agency and the hospital nurse would not administer medications for shortness of breath. During an interview conducted on 02/04/2025 at 4:05 PM the agency director stated, “;They [nurses] need to consult with the medical director [hospice] or attending physician for all hospice orders and we [hospice agency] manage the patients [plan of care].” 2. Patient #23 was admitted on 01/01/2025 with a diagnoses of malignant neoplasm of UNSP (unspecified) kidney (cancer of the kidney) and secondary malignant neoplasm of bone (cancer that has spread to the bone). The plan of care for 01/01/2025-0/31/2025 included orders for skilled nurse visits 2 times a week for 1 week, 3 times a week for 12 weeks, 1 time a week for 1 week, with 3 PRN (as needed), “;hospice nurse to monitor patients pain level and report ineffective pain control to the physician.” Review of the clinical record revealed the following documentation: Registered nurse (RN) #24 documented on 01/09/2025, “;Patient states that pain regime is not helping... Caregiver reports pharmacy still has no stock of morphine...” Further review revealed that a physician was not contacted for new orders. RN #17 documented on 01/11/2025, “;PT [patient] stated pain was at an 8 [assessed on a 1-10 scale] ... Starter [sic] his pain not been below 8 since diagnosis. – no medication change” Further review revealed that a physician was not contacted for new orders.” RN #15 documented on 01/20/2025, pain “;10” and “;PT is agitated today due to not having oxycodone... pharmacy is awaiting delivery of medication.” Further review revealed that a physician was not contacted for new orders. RN #24 was not available for an interview. An interview conducted on 02/06/2025 at 11:33 AM with RN #15 revealed that no education was provided about non-medication pain relief, and no physician was contacted. During an interview on 02/06/2025 at 11:37 AM the agency director stated, the nurses should, “;Review the medication regime, call the physician for new orders, and provide alternative interventions.””

“Based on agency policy, clinical record review, and staff interviews, the agency failed to include all medication orders in the plan of care for 2 of 24 patients. (patient #13 and 21). Findings included: A policy, Hospice Plan of Care (reviewed 07/25/2024) received on 02/05/2025 at 12:58 PM from the agency director stated, “;The plan of care must include ... including but not limited to: Drug and treatments necessary to meet the needs of the patient including the dose for mediation, frequency and duration” Patient #13 was admitted on 11/13/2024 with a diagnosis of Senile Degeneration of Brain (a progressive decline in mental function). The plan of care (POC) for 11/13/2024-01/11/2025 included orders for skilled nurse (SN) visits 1 time a week for 1 week, 2 times a week for 8 weeks, and 3 PRN (as needed). Review of the clinical record revealed RN #26 documented “;received metoprolol [medication that relaxes blood vessels and slow the heart rate] IV [intravenously].” Further review revealed that the medication metoprolol was not included in the POC. Patient #21 was admitted on 01/11/2025 with a diagnosis of Malignant Neoplasm of UNSP part of Right Bronchus or Lung (lung cancer). The plan of care (POC) for 01/11/2025-04/10/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 13 weeks, and 4 PRN (as needed) and “;Tramadol 50 mg (narcotic pain medication) 1 tablet every 6 hours as needed for moderate to severe pain.” Review of the clinical record revealed that registered nurse (RN) #27 documented, “;Mistakenly taking tramadol instead of trazadone [antidepressant].” Further review revealed that the medication trazadone was not included in the POC, and a medication error was not reported to the physician. An interview on 02/04/2024 at 4:05 PM with the agency director revealed that the expectation is for the medication profile to include all medications.”

“Based on agency policy, clinical record review, and staff interviews, the agency failed to include all medical supplies and appliances necessary in the plan of care for 1 of 1 patient receiving routine home care while admitted to a hospital. (patient #13) Findings included: A policy, Hospice Plan of Care, (reviewed 05/25/2024), received on 02/03/2025 at 12:58 PM from the agency director stated, “;The plan must include all services necessary for the palliation and management of the terminal illness and related conditions, including...Medical supplies and equipment necessary...” Patient #13 was admitted on 11/13/2024 with a diagnosis of Senile Degeneration of Brain (a progressive decline in mental function). The plan of care (POC) for 11/13/2024-01/11/2025 included orders for skilled nurse (SN) visits 1 time a week for 1 week, 2 times a week for 8 weeks, and 3 PRN (as needed). Review of the clinical record revealed the following documentation: Registered nurse (RN) #25 documented on 12/06/2024, “;fecal management system.” Further review of the clinical record revealed that a fecal management system was not included in the POC. RN #26 documented on 12/12/2024, “;requires suctioning.” Further review of the clinical record revealed that suction equipment was not included in the POC. During an interview on 02/04/2025 at 3:55 PM the agency director stated, “;They [nurses] need to consult with the Medical Director [hospice] or attending [physician] for all hospice orders.” During an interview on 02/06/2024 at 1:03 PM the regional area director stated, “;We failed to update the patients plan of care [hospice] to correlate to the hospitals records.””

“Based on agency policy, clinical record review, and staff interviews, that agency failed to document communication within the IDT group for 7 of 24 patients. (#, 2, 4, 3, 6, 15, 21, and 23) Findings included: A policy, Interdisciplinary Team (IDT) (reviewed 07/25/2024) received on 02/03/2025 at 12:58 PM from the agency director stated, “;The IDT maintains a system of communication and integration in order to: ... Ensure that care and services are provided in accordance with the POC [plan of care]. Ensure that care and services provided are based in all assessments of the patient and family needs. Provide for and ensuring the ongoing sharing of information between all disciplines providing care.” A policy, Clinical Records Maintenance and Confidentiality (reviewed 12/13/2024) received on 02/03/20255 at 12:56 PM from the agency director stated, “;Clinical records will include all documentation to meet state and federal regulations and includes...Evidence of coordination of care.” Patient #2 was admitted on 10/01/2024 with diagnoses of chronic kidney disease, stage 5 and type 2 diabetes mellitus (condition in where the body has trouble controlling blood sugar). The plan of care for 12/30/2024-03/29/2025 included orders for skilled nurse visits 1 time a week for 13 weeks with 3PRN (as needed), chaplain visits 2 time a month for 1 month, 2 times a month for 2 months with 3 PRN, “;Hospice nurse to assess medication response”, Humalog [insulin name brand] (U1-100) 100 unit/mL subcutaneous per instructions and, [insulin name brand] 100 unit/mL (3mL) 20 units subcutaneous daily. Review of the clinical record revealed the following documentation: Registered nurse (RN) #13 documented on 01/04/2025, “;He [patient] mentioned that his insulin does not seem to be working as good to lower his BS [blood sugar]. Further review revealed that there was no documentation that a physician was contacted about blood sugars. Chaplain #14 documented on 01/09/2025, “;Patient shares this visit that he has been very confused about the new medication changes.” Further review revealed that there was no documentation that the registered nurse case manager was notified. During an interview conducted on 02/06/2025 at 10:07 AM RN #13 stated, “;I didnt address the blood sugar issue. Yes [would normally address medication concerns].” During an interview on 02/06/2025 at 9:43 AM Chaplain #14 stated, “;Yes, I did notify the nurse after the visit. Generally, I do document that I notified the nurse.” During an interview on 02/06/2025 at 9:45 AM the area vice president of operations stated, “;It is expected that its [medication concerns] reported to the case manager [RN] and that the case manager follow-up.” During an interview on 02/06/2025 at 10:09 AM the agency director stated, the expectation for concerns with blood sugars “;is to contact the physician for more orders.” 2. Patient #3 was admitted on 01/04/2025 with diagnoses of senile degeneration of the brain (condition with progressive mental impairment) and venous insufficiency (improper functioning of the vein valves in the legs). The plan of care for 01/04/2025-04/03/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 11 weeks, 1 time a week for 1 week, with 3 PRN (as needed). A review of the clinical record revealed the following documentation: Registered nurse (RN) #25 documented on 01/07/2025, “;RLE [right lower extremity] significantly larger than LLE (left lower extremity], RLE is red and has large intact blisters... Patient may benefit from [name brand diuretic].” Further review of the clinical record revealed that there was no documentation that a physician was contacted. RN #25 was not available for an interview. Licensed practical nurse (LPN) #12 documented on 01/13/2025, “;SN [skilled nurse] contact [sic] DR [physician] waiting on response. Further review of the clinical record revealed that there was no documentation of a response from the physician. An interview on 02/06/2025 at 9:55 AM with LPN #12 revealed that there was no documented follow-up with a physician. An interview on 02/06/2025 at 10:00 AM with the regional area director revealed that all communication with the physicians should be documented. RN #5 documented on 01/29/2025, “;She [patient] has edema and cellulitis noted to right leg... SN [skilled nurse] will notify the MD [medical doctor] ...” Further review revealed that no communication with the physician was documented. During an interview on 02/06/2025 at 10:14 AM RN #5 stated, “;I did call him [physician]... I forgot to go back and put a note.” During an interview on 02/06/2025 at 10:18 AM the agency director stated the expectation is for nurses to, “;make sure that they document all follow-up [with physicians].” 3. Patient #4 was admitted on 01/06/2025 with a diagnosis of unspecified protein-calorie malnutrition (changes in the body from reduced availability of nutrition). The plan of care for 01/06/2025-04/05/2025 included orders for skilled nurse visits 2 times a week for 1 week, 2 times a week for 12 weeks, with 3 PRN (as needed), home health aide (HHA) visits 2 times a week for 1 week and 3 times a week for 12 weeks, and HHA to assess temperature, blood pressure, respirations, and heart rate at each visit. A review of the clinical record revealed the following documentation: HHA #11 documented on 01/13/2025 “;Not completed” for temperature, blood pressure, respirations, and heart rate. Further review of the clinical record revealed no documentation that a registered nurse was notified of the tasks not completed. HHA #11 documented on 01/15/2025 “;Not completed” for temperature, blood pressure, respirations, heart rate, oral care, and shampoo. Further review of the clinical record revealed no documentation that a registered nurse was notified of the tasks not completed. An interview conducted on 02/06/2025 at 10:36 AM with HHA #11 revealed that normally the registered nurse is notified and documented in the clinical record. During an interview on 02/06/2025 at 10:41AM the agency director stated, “;They [HHAs] should contact the RN case manager or clinical manager and document in the record.” 4. Patient #6 was admitted on 01/06/2024 with a diagnosis of sepsis (condition where the bodys immune system overreacts to an infection). The plan of care for 12/31/2024-02/28/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 8 weeks with 3 PRN (as needed), and “;Hospice nurse to observe and assess integumentary [skin] status to identify changes and intervene to minimize complication.” A review of the clinical record revealed the following documentation: RN #5 document on 01/31/2025, “;Small open area on right hip.” Further review of the clinical record revealed that there was no documentation of the physician being notified. During an interview on 02/06/2025 at 10:11 AM RN# 5 stated, “;I put that tidbit in there [clinical record] because she told me that at the end of it [visit]... Normally you [nurses] would assess, measure, and call the MD [medical doctor] for instruction.” During an interview conducted on 02/06/2025 at 10:14 AM the agency director stated, “;She should have assessed [the wound] and called the doctor.” 5. Patient #13 was admitted on 11/13/2024 with a diagnosis of Senile Degeneration of Brain (a progressive decline in mental function). The plan of care for 11/13/2024-01/11/2025 included orders for skilled nurse (SN) visits 1 time a week for 1 week, 2 times a week for 8 weeks, and 3 PRN (as needed), hospice nurse to assess effectiveness of cardiopulmonary symptom relief measures...and hospice nurse to instruct patient/caregiver regarding cardiopulmonary symptom relief measures.” Review of the clinical record revealed that during the registered nurse (RN) visit on 12/07/2024 RN #17 documented a respiratory assessment including, BPM (breaths per minute) 31 with labored/shallow breaths on room air. Further review revealed that there was no documentation that a physician was notified of the patients shortness of breath. An interview conducted on 02/04/2025 at 3:55 PM with RN #17 revealed that a physician was not contacted. During an interview conducted on 02/04/2025 at 4:05 PM the agency director stated, “;They [nurses] need to consult with the medical director [hospice] or attending physician for all hospice orders...” 6. Patient #15 was admitted on 12/05/2024 with diagnoses of Chronic Obstructive Pulmonary Disease (lung disease that blocks airflow) and Dependance on Supplemental Oxygen. The plan of care (POC) for 12/05/2024-03/04/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 8 weeks and 3 PRN (as needed) and oxygen via nasal cannula at 4Lmin (liters per minute) continuously. Review of the clinical record revealed the following documentation: Licensed Practical Nurse (LPN) #8 documented on 12/17/2024, “;On supplemental oxygen @2LPM [at 2 liters per minute] via nasal cannula.” Further review of the clinical record revealed that there was no documentation of the physician being notified of the medication error. Registered Nurse (RN) #9 documented on 12/27/2024, “;On supplemental oxygen @2LPM [at 2 liters per minute] via nasal cannula.” Further review of the clinical record revealed that there was no documentation of the physician being notified of the medication error. RN #9 documented on 01/03/2025, “;On supplemental oxygen @2LPM [at 2 liters per minute] via nasal cannula.” Further review of the clinical record revealed that there was no documentation of the physician being notified of the medication error. RN #9 documented on 01/07/2025, “;On supplemental oxygen @2LPM [at 2 liters per minute] via nasal cannula.” Further review of the clinical record revealed that there was no documentation of the physician being notified of the medication error. RN #9 documented on 01/09/2025, “;On supplemental oxygen @2LPM [at 2 liters per minute] via nasal cannula.” Further review of the clinical record revealed that there was no documentation of the physician being notified of the medication error. LPN #8 documented on 01/14/2025, “;On oxygen 3.5L [3.5 liters per minute].” Further review of the clinical record revealed that there was no documentation of the physician being notified of the medication error. LPN #8 documented on 01/31/2025, “;Patient is O2 [oxygen] dependent at 4L via NC [nasal cannula] ... On supplemental oxygen @ 2LPM [at 2 liters per minute] via nasal cannula. Further review of the clinical record revealed that there was no documentation of the physician being notified of the medication error. During an interview conducted on 02/06/2025 at approximately 11:45 AM LPN #8 stated, “;Yes” [normally reviews the orders] and call the physician [when oxygen is administered at the incorrect dose].” An interview conducted on 02/06/2025 at 11:57 AM with RN #9 revealed that they were not aware of the physicians order. During an interview on 02/06/2025 at 11:51 AM the agency director stated the expectation is, “;For the nurse to review the orders prior to the visit. If the order is not being followed, contact the physician...” Patient #21 was admitted on 01/11/2025 with a diagnosis of Malignant Neoplasm of UNSP part of Right Bronchus or Lung (lung cancer). The plan of care for 01/11/2025-04/10/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 13 weeks, and 4 PRN (as needed) and “;Tramadol 50 mg (narcotic pain medication) 1 tablet every 6 hours as needed for moderate to severe pain.” Review of the clinical record revealed that registered nurse (RN) #27 documented, “;Mistakenly taking tramadol instead of trazadone [antidepressant].” Further review of the clinical record revealed that there was no documentation of the physician being notified of the medication error. During an interview conducted on 02/06/2025 at 10:01 AM with RN #27 stated, “;I didnt realize that a med [medication] error not given by staff had to be reported.” During an interview on 02/06/2025 at 11:51 AM the agency director stated the expectation is, “;For the nurse to review the orders prior to the visit. If the order is not being followed, contact the physician and complete an occurrence report.” 7. Patient #23 was admitted on 01/01/2025 with diagnoses of malignant neoplasm of UNSP (unspecified) kidney (cancer of the kidney) and secondary malignant neoplasm of bone (cancer that has spread to the bone). The plan of care for 01/01/2025-0/31/2025 included orders for skilled nurse visits 2 times a week for 1 week, 3 times a week for 12 weeks, 1 time a week for 1 week, with 3 PRN (as needed), “;hospice nurse to monitor patients pain level and report ineffective pain control to the physician.” Review of the clinical record revealed the following documentation: Registered nurse (RN) #24 documented on 01/09/2025, “;Patient states that pain regime is not helping... Caregiver reports pharmacy still has no stock of morphine...” Further review revealed that a physician was not contacted for new orders. RN #17 documented on 01/11/2025, “;PT [patient] stated pain was at an 8 [assessed on a 1-10 scale] ... Starter [sic] his pain not been below 8 since diagnosis. – no medication change” Further review revealed that a physician was not contacted for new orders.” RN #15 documented on 01/20/2025, pain “;10” and “;PT is agitated today due to not having oxycodone... pharmacy is awaiting delivery of medication.” Further review revealed that a physician was not contacted for new orders. RN #24 was not available for an interview. An interview conducted on 02/06/2025 at 11:33 AM with RN #15 revealed that no education was provided about non-medication pain relief, and no physician was contacted. During an interview on 02/06/2025 at 11:37 AM the agency director stated, the nurses should, “;Review the medication regime, call the physician for new orders, and provide alternative interventions.””

“Based on agency policy, direct observation, and staff interviews the skilled nurse failed to follow acceptable infection control practices when completing wound care for 1 of 2 patients receiving a home visit for wound care (#9). Findings included: Policy PCP-001 Hand Hygiene (reviewed 6/26/24), received on 02/06/2025 at 8:18am from the agency director stated: “The agency must follow accepted standards of practice, including the use of standard precautions (includes hand hygiene), to prevent the transmission of infections and communicable diseases....Perform hand hygiene as follows: ...After contact with body fluids or excretions, mucous membranes, nonintact skin,and wound dressings” Policy WC-001 The Provision of Wound and Skin Care (reviewed 12/12/24, received on 02/06/2025 at 8:18am from agency director stated: “Wound care provision consists of hand hygiene before and after the actual care and at various times during wound care...To maintain proper infection control protection, wounds should be treated individually. Soiled dressings may be removed all at once, but one wound should be cleansed, treated and dressed at a time with proper hand hygiene and glove changes occurring in between each wound even if the wounds are in the same general areas of the body.” Patient #9 was admitted to hospice care on 08/18/2023 with diagnoses of senile degeneration of the brain (gradual decline in cognitive function that occurs with aging) and a stage 4 pressure ulcer (most severe stage of tissue damage extending beyond the skin layers, reaching underlying muscle and/or bone) on sacrum (connects the spine and pelvis). Review of the Plan of Care for the certification period of 1/16/25-3/16/25 included orders for SN (skilled nursing) 2 times a week for 1 week, 3 times a week for 8 weeks, and 3 prn (as needed) visits for symptom management and emergency visits and “;Skilled nurse to perform/teach patient/caregiver wound care to stage 4 Sacrum. 1 Cleanse wound with wound cleaner. 2 Pat dry. 3 Apply calcium alginate dressing to affected area. 4 Place gauze and ABD pads to site. 5 Apply Tegaderm or Duoderm dressing to site. 6 Secure with tape. 7 Change dressing daily and as needed for soiled.” A joint home visit was conducted with SN #18 on 2/4/2025 at approximately 9:15 am. Nurse #18 cleaned her hands with hand sanitizer and applied clean gloves. Nurse #18 then removed wound dressing from patient #9s sacral wound and disposed of dirty dressing in waste basket. Hands were again cleaned with hand sanitizer and clean gloves were applied. Nurse #18 then began cleaning drainage from the wound bed with gauze she had laid out on clean barrier prior to beginning wound care. After using all the gauze pads on the barrier, Nurse #18 reached back into bulk 4x4 gauze pack without removing gloves and continued wound care. A phone interview conducted on 2/6/2025 at approximately 11:00 am with Nurse #18 revealed that hand hygiene was not performed before re-entering bulk gauze pack. When asked what the expectation is, the area vice president of operations stated “;The expectation is to clean hands anytime you go from a dirty field to a clean field”.”

“Based on agency policy, observation, clinical record review, and staff interviews, the nurse failed to assess and document a wound for 1 of 7 (#6) patients with wounds (patient #6) and failed to follow a physicians order for wound care for 1 of 7 patients with wounds. (#9) Findings included: Patient #9 was admitted to hospice care on 08/18/2023 with diagnoses of senile degeneration of the brain (gradual decline in cognitive function that occurs with aging) and a stage 4 pressure ulcer (most severe stage of tissue damage extending beyond the skin layers, reaching underlying muscle and/or bone) on sacrum (connects the spine and pelvis). Review of the Plan of Care for the certification period of 1/16/25-3/16/25 included orders for SN (skilled nursing) 2 times a week for 1 week, 3 times a week for 8 weeks, and 3 prn (as needed) visits for symptom management and emergency visits and “;Skilled nurse to perform/teach patient/caregiver wound care to stage 4 Sacrum. 1 Cleanse wound with wound cleaner. 2 Pat dry. 3 Apply calcium alginate dressing to affected area. 4 Place gauze and ABD pads to site. 5 Apply Tegaderm or Duoderm dressing to site. 6 Secure with tape. 7 Change dressing daily and as needed for soiled.” A joint home visit was conducted with SN #18 on 2/4/2025 at approximately 9:15 am. The nurse was observed covering the wound with an adhesive bordered foam dressing instead of gauze and ABD pads and then Tegaderm or Duoderm as ordered. A phone interview was conducted on 2/6/2025 at approximately 11:00 am with Nurse #18. When asked if she felt she had followed the plan of care order for wound care, she stated “;no, I did not follow the wound care order as written”. Director was asked what the expectation was and she stated “; the expectation is to follow wound care orders and get the order changed if not appropriate.” A policy, The Provision of Wound and Skin Care (reviewed 12/12/2024) received on 02/06/2025 at 8:18 AM stated, “;DOCUMENT IN THE ELECTRONIC MEDICAL RECORD (EMR): ...Location of wound/ulcer, Thickness of wound/ulcer, Measurements, Drainage amount and type... Wound bed tissue (description), Condition of surrounding tissue...” Patient #6 was admitted on 01/06/2024 with a diagnosis of sepsis (condition where the bodys immune system overreacts to an infection). The plan of care for 12/31/2024-02/28/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 8 weeks with 3 PRN (as needed), and “;Hospice nurse to observe and assess integumentary [skin] status to identify changes and intervene to minimize complication.” Review of the clinical record revealed that registered nurse (RN) #5 documented on 01/31/2025, “;Small open area on right hip.” Further review of the clinical record revealed that there was no documentation for a wound assessment. During an interview on 02/06/2025 at 10:11 AM RN# 5 stated, “;I put that tidbit in there [clinical record] because she told me that at the end of it [visit]... Normally you [nurses] would assess, measure, and call the MD [medical doctor] for instruction.” During an interview conducted on 02/06/2025 at 10:14 AM the agency director stated, “;She should have assessed [the wound] and called the doctor.””

“Based on agency policy, clinical record review, and staff interviews, the clinical record failed to include physicians orders for Do Not Resuscitate (DNR) for 2 of 15 patients that requested a DNR order. (patients #5 and 23) Findings included: A policy, Advanced Directives (reviewed 01/10/2025) received on 02/03/2025 at 12:58 PM from the agency director stated, “;A request for a DNR order may be initiated by the agency after discussion with the patient and family... The physician must renew the DNR order every re-certification period following the initial order.” Patient #5 was admitted on 01/27/2025 with a diagnosis of malignant neoplasm of the pancreas (cancer). The plan of care for 01/27/2025-04/26/2025 included orders for skilled nurse (SN) visits 2 times a week for 13 weeks and 3 PRN (as needed). A clinical record review revealed that during the SN visit of 01/27/2025 registered nurse #28 documented, “;Code status-DNR-need [sic] golden rod [slang for DNR form].” Further review of the clinical record revealed that there was no physicians order for a DNR. Patient #23 was admitted on 01/01/2025 with a diagnosis of malignant neoplasm of UNSP kidney (kidney cancer, either right or left). The plan of care for 01/01/2025-03/31/2025 included orders for skilled nurse visits 2 times a week for 1 week, 3 times a week for 12 weeks with 3 PRN (as needed). Review of the clinical record revealed that RN #28 documented, “;DNR [do not resuscitate], golden rod [slang for DNR form] needed.” Further review of the clinical record revealed that there was no physicians order for a DNR. During an interview on 02/04/2025 at 9:49 AM the Area Director of Operations stated, “;If they [patient/family] request to be a DNR we will discuss it with the physician and get an order on the day they request it.””

“Based on agency policy, clinical record review, and staff interview, the agency failed to document wound measurements for 1 of 1 discharge clinical records reviewed. (Patient #1) Findings included: Policy WC-001, last revised 03/08/23 and titled, “;The Provision of Wound and Skin Care” was received from the agency director on 12/08/23 at 4:45 PM. This policy revealed, “;In accordance with best practice and standard of care, wounds will be measured a minimum of one time a week...” Patient #1 was admitted to the agency 10/17/23 with diagnoses including heart disease and chronic heart failure (a chronic condition where the heart does not pump blood as well as it should). Plan of Care from 10/17/23 to 01/14/24 revealed orders for skilled nursing two times per week for 13 weeks and orders for wound care to a Stage 2 (a wound with damage to either the outer or second layer of skin) sacral wound every three days and as needed. Patient #1 was discharged due to death on 11/04/23. There were no documented wound measurements in Patient #1s clinical record. In an interview on 12/4/23 at 4:40 PM, Employee #1, agency director, stated, “;...I didnt see wound measurements...””

“Based on agency policy, clinical record review, and staff interview, the agency failed to provide a hospital bed and oxygen concentrator at the time of admission and failed to provide requested wound care supplies for 1 of 3 discharge clinical records reviewed (Patient #2). Findings included: Policy TX-005, last reviewed 10/16/23, and titled, “;Professional management” was received from the agency director on 12/04/23 at 4:45 PM. This policy revealed, “;The hospice retains professional management responsibility for those services related to the terminal illness and ensures that they are furnished in a safe and effective manner... The hospice team shall ensure that all hospice services are provided in accordance with the patients plan of care at all times and in all settings...” Policy WC-001, last revised 03/08/23 and titled, “;The Provision of Wound and Skin Care” was received from the agency director on 12/08/23 at 4:45 PM. This policy revealed, “;Wound care supplies will be provided using our formulary products...” 1. Patient #2 was admitted to the agency 10/27/23 with diagnoses including hepatic (liver) failure, dependence on supplemental oxygen, and need for assistance with personal care. Plan of Care from 10/27/23 to 01/24/24 revealed orders for skilled nursing one time per week for one week, six times per week for one week, seven times per week for 11 weeks, and four times per week for one week. On call triage notes entered on 10/27/23 between 11:32 PM and 11:53 PM and on 10/28/23 between 12:06 AM and 12:09 AM revealed that Employee #3, admitting registered nurse, had contacted on-call triage requesting a hospital bed and oxygen concentrator “;STAT” (immediately or urgently). When Employee #3 was advised that on-call triage was unable to place an order using the contracted entity known to the triage nurse, she requested direction from the agencys administrator on-call. Further documentation revealed that the administrator on-call advised the triage nurse that she would contact the business office manager the following morning to order the DME (durable medical equipment). On-call triage notes entered on 10/28/23 revealed that the business office manager placed the DME orders, including an oxygen concentrator and hospital bed, for Patient #2 before 8:00 AM that day. There was no documentation that indicated what time the equipment was delivered to Patient #2s home. In an interview on 12/04/23 at 2:45 PM, Employee #3, stated, “;There was no bed in the home...I had to call the hospital to talk to the charge nurse...There was no oxygen in the home...I called my AOC [administrator on call] and [name of business office manager] ...” In an interview on 12/04/23 at 3:00 PM, Employee #1, agency director, acknowledged that Patient #2 did not receive the required medical equipment at the time of admission. 2. Employee #4, registered nurse, conducted a skilled nursing visit on 11/14/23 and identified a new wound that was reportedly not present on 11/13/23. The following day, 11/15/23, Employee #5, registered nurse, conducted a skilled nursing visit and documented, “;Family at bedside and reports they have waited for supplies to place on patients bottom. This nurse was not aware of patients needs...noted patient has excoriation to buttocks and area was bleeding...Zing [sic] paste was placed on buttocks ...”. In an interview on 12/4/23 at 3:00 PM, Employee #5 stated that she was not aware of a need for wound care supplies to be taken to the home and said, “;I didnt have any stocked in my vehicle...I talked to the family prior to getting there and they never mentioned a need for supplies.””