Amedisys Hospice of Pa

“Based on review of clinical records (CR), agency developed plan of correction, hospice policies, hospice complaint tracking, and staff interviews, the hospice failed to follow internal policy for employee’s performance improvement for one (1) thirteen (13) PF reviewed (PF 1). Findings included:Review of Hospice policy on 7/15/25 at approximately 10:00am revealed:“1.14 CORRECTIVE ACTION PROCESS The Amedisys Corrective Action Process is designed to provide a fair, transparent and structured process, which gives employees the feedback they need to succeed, in order to: • Address misconduct and/or inadequate performance; • Prevent a recurrence of employee misconduct and/or inadequate performance; and • Improve employee performance…PERFORMANCE AND BEHAVIORAL GUIDELINES… In general, when disruptive behavior occurs, or performance issues are identified, the steps below will be followed… FEEDBACK CONVERSATION…DOCUMENTING THE FEEDBACK CONVERSATION The leader should document the discussion by emailing the individual afterwards; this serves both as a record of the conversation and as confirmation to ensure both parties understand what was discussed. Email should include: 15 • Reference to the date of the conversation • Summary of the problem(s) discussed • Summary of the expectations for the future • Approximate date of follow-up conversation to discuss progress This email should be saved the employee’s file too. While most issues can and hopefully will be resolved during these feedback conversations, the leader may also choose to alert the next level of leadership or Employee Relations (ER) for informational purposes. PERFORMANCE IMPROVEMENT PLAN Often following a feedback conversation, if an employee’s behavioral or performance concern persists, a Performance Improvement Plan (PIP) may be initiated to help formalize the efforts to help the employee succeed. Other times, this may be the first step taken when warranted…During this meeting, the leader will clarify the employee’s understanding of the workplace rules and job expectations. It should be made clear to the employee that if such misconduct continues, further disciplinary action, including termination, may result. The employee will have the opportunity to share his or her perspective. Any relevant training or resources that can be recommended or provided to improve behavior or performance should also be incorporated in the written warning. Copies of documentation in this step should be signed by both the leader, the witness, and the employee. Employees should know that their signature is intended to acknowledge the warning took place, not necessarily to admit or concede its accuracy. Signed copies, and summaries of any meetings, should be shared with the Employee Relations Consultant and saved to the employee’s file. The leader is expected to monitor the progress and follow up with the individual regarding their behavior/performance throughout. Recommendation for a documented follow-up is 30, 60 and 90 days, and notice to the employee of that follow-up timeframe should be provided at the time the warning is administered, where appropriate. Informal conversations in the meantime regarding the employee’s progress are advisable…”“1.12 RULES OF CONDUCT The following non[1]exhaustive list contains examples of behavior that may result in corrective disciplinary action, including in some instances immediate separation from employment. Common sense, good judgment and professional behavior are expected of each Amedisys employee. Allegations of the occurrence of the below behavior will be reviewed and investigated by a member of management and/or the Employee Relations team… Thereafter a recommendation regarding the appropriate corrective action to be administered will be given, which will be consistent with Company policy, our Core Values, the employee’s record of performance and behavior, and the nature of the infraction. The following list is not intended to be exhaustive, and employees may be subject to corrective disciplinary action for other reasons in addition to those set forth in this list…17. Failure to follow Amedisys written policies and procedures…”Amedisys Dress Code – Standards of Professional Appearance…PURPOSE: To outline employee and contractor standards of professional appearance as representatives of Amedisys and maintain a professional appearance to support patient/client care and a safe work environment. Any use of the term “employee” also applies to visiting and contracted staff. STANDARDS OF PRACTICE: I. Overall Standards, a) Work attire must be professional, neat, and clean…While employees are on paid time either in the workplace (meetings, educational sessions) or conducting Amedisys business elsewhere in the community (community service activities) their dress and grooming shall reflect the standards of Amedisys. Amedisys expects that all its employees and contractors will present a well-groomed and businesslike appearance to patients, clients, visitors, co-workers, and others…b) An Amedisys name badge will be worn by staff upon entering the home and during the provision of care, and by office staff during business hours, or anytime when conducting company business., c) Scrubs in company-approved colors are required to be worn by employees who provide care to patients or clients. Personal Care employees should consult with their supervisor regarding scrub requirements., d) Any clothing item is inappropriate for the workplace if: …iii) It is too casual, unkempt, or otherwise un-businesslike for an employee of a healthcare or business organization…PROCEDURE: IV. Responsibilities, b) Employees are responsible for ensuring that their dress and grooming complies with Amedisys and departmental policies, as well as pertinent safety and health considerations., c) All members of the Amedisys Management Team are responsible for ensuring that the dress and grooming of all staff comply with Amedisys and departmental policies, as well as pertinent safety and health considerations, and shall take enforcement action as appropriate., d) Employees who report to work improperly dressed or groomed: i) are sent home to change or groom. ii) The staff member clocks out and clocks back in upon their return to work. CONSEQUENCES: Team members who are found in violation of this policy or refusal to wear the designated uniform may be sent home and are subject to corrective action up to and including termination. Review of PF1 on 7/10/25 at approximately 9:30am revealed documentation of performance Improvement Plan (PIP) developed for employee dated 3/19/25. “Reason for Coaching Action: …received complaint…that [employee] was unkempt in appearance and that it took extended amount of time to arrive for visit. Coaching Action Plan: …Discussion verbally over the phone regarding concerns…ensure that appearance is neat, tidy, and follows dress code policy, [employee] to improve drive times to visits by leaving home timely...” PF revealed documentation of second PIP for complaint dated 6/27/25. “Reason for Coaching Action: Discussed regarding dress code appearance. Reference to policy HR-005-shorts are not appropriate; name badge must b worn. Prior verbal discussion regarding appearance/uniform… Coaching Action Plan: [employee] will adhere to the dress code going forward…”PIP dated 3/19/25 failed to include relevant training or resources provided to improve behavior. Both PIPs failed to include clarify the employee’s understanding of the workplace rules and job expectations and both PIPS failed to be signed by the leader/witness/employee. Both PIPS failed to include monitoring of the progress and follow up and notice to the employee of the follow-up timeframe. Review of PF14 on 7/10/25 at approximately 9:40am revealed documentation of performance Improvement Plan (PIP) developed for employee dated 7/1/25. “Reason for Coaching Action: …Late documentation of admission visit-addressed and placed on PIP in the past for same violation. Coaching Action Plan: …[Employee] will have all documentation synced back within shift and use only approved abbreviations going forward...” PIP failed to include relevant training or resources provided to improve performance, clarify the employee’s understanding of the workplace rules and job expectations, failed to be signed by the leader/witness/employee, failed to include monitoring of the progress and follow up with the individual, and notice to the employee of the follow-up timeframe. Exit interview with 2 Area Vice Presidents (AVP) of Clinical, AVP of Operations, 4 Directors of Operations, Manager of Clinical Regulatory, Clinical Regulatory Specialist, Director of Volunteer Services, Regional Manager of Bereavement Services, Director of Clinical Resource Services, Business Office Manager, and Regional Business Office Manager on 7/14/25, at approximately 2:00pm confirmed findings.”

“Based on review of clinical records (CR) and staff interviews, the hospice failed to ensure the Plan of Care (POC) included the drugs and treatment necessary to meet the needs of the patient for three (3) of twenty-seven (27) CR reviewed (CR 8, 9, & 18). Findings included: Review of CR8, benefit period 5/29/25-8/26/25, on 7/11/25 at approximately 12:00pm revealed Plan of Care (POC) included intervention “hospice nurse to assess effectiveness of cardiopulmonary symptom relief measures including oxygen treatment...” “ Hospice nurse to instruct regarding oxygen management include administration...” Oxygen concentrator listed in DME/supplies. Oxygen not included on medication list.Review of CF9, benefit period 5/29/25-8/26/25, on 7/11/25 at approximately 12:00pm revealed Plan of Care (POC) included intervention “hospice nurse to assess effectiveness of cardiopulmonary symptom relief measures including oxygen treatment...” Oxygen not included on medication list.Review of CF18, benefit period 4/29/25-7/27/25, on 7/14/25 at approximately 12:45pm revealed Plan of Care (POC) included intervention “hospice nurse to assess effectiveness of cardiopulmonary symptom relief measures including oxygen treatment...” oxygen included in DME/supplies. Oxygen not included on medication list. Exit interview with 2 Area Vice Presidents (AVP) of Clinical, AVP of Operations, 4 Directors of Operations, Manager of Clinical Regulatory, Clinical Regulatory Specialist, Director of Volunteer Services, Regional Manager of Bereavement Services, Director of Clinical Resource Services, Business Office Manager, and Regional Business Office Manager on 7/14/25, at approximately 2:00pm confirmed findings.”

“Based on review of clinical records (CR) and staff interviews, the hospice failed to ensure the Plan of Care (POC) included the medical supplies and appliances necessary to meet the needs of the patient for three (3) of twenty-seven (27) CR reviewed (CR 9-11). Findings included: Review of CF9, benefit period 5/29/25-8/26/25, on 7/11/25 at approximately 12:00pm revealed Plan of Care (POC) included intervention “hospice nurse to assess effectiveness of cardiopulmonary symptom relief measures including oxygen treatment...” Oxygen not included in durable medical equipment (DME)/supplies. Narrative note documented by nurse upon admission included shower chair, wheelchair, and diabetic supplies, none of which were included on POC in DME/supplies. POC documented “none” for DME/supplies.Review of CF10, benefit period 4/11/25-8/26/25, on 7/9/25 at approximately 2:15pm revealed narrative note documented 4/14/25 by social worker included patient need for four wheeled walker and wheelchair. Neither of these items included on POC in DME/supplies.Review of CF11, benefit period 6/30/25-9/27/25, on 7/14/25 at approximately 10:00am revealed POC included intervention “hospice nurse to assess effectiveness of cardiopulmonary symptom relief measures including oxygen treatment...” Oxygen not included on medication list.” “Hospice nurse to instruct regarding oxygen management...” Oxygen 4 liters daily and as need on medication list. Oxygen concentrator and supplies/tubing not included on POC in DME/supplies. Exit interview with 2 Area Vice Presidents (AVP) of Clinical, AVP of Operations, 4 Directors of Operations, Manager of Clinical Regulatory, Clinical Regulatory Specialist, Director of Volunteer Services, Regional Manager of Bereavement Services, Director of Clinical Resource Services, Business Office Manager, and Regional Business Office Manager on 7/14/25, at approximately 2:00pm confirmed findings.”

“Based on review of clinical records (CR) and staff interviews, the hospice failed to ensure the nurse ordered appropriate medications and supplies for one (1) of twenty-seven (27) CR reviewed (CR 8). Findings included:Review of complaint on 7/7/25 at approximately 11:00am revealed: called to agency on 6/27/25 reports patient has temperature and agonal breathing and nothing to treat symptoms. Review of CR8 on 7/11/25 at approximately 12:00pm revealed nurse conducted an assessment to bring the patient on to hospice services on 6/26/25. This documentation revealed that evidence of patient being able to take oral medication at this visit. On 6/27/25, the documentation reflected a nursing visit conducted at 8:05pm which reflects patient decline including inability to swallow or clear secretions. There is no evidence in the documentation from this visit that a comfort kit was ordered or a suction machine. Exit interview with 2 Area Vice Presidents (AVP) of Clinical, AVP of Operations, 4 Directors of Operations, Manager of Clinical Regulatory, Clinical Regulatory Specialist, Director of Volunteer Services, Regional Manager of Bereavement Services, Director of Clinical Resource Services, Business Office Manager, and Regional Business Office Manager on 7/14/25, at approximately 2:00pm confirmed findings.”

“Based on review of clinical records (CR) and staff interviews, the hospice failed to ensure hospice aide provides services provide per the plan of care for two (2) of twenty-seven (7) CR reviewed (CR 12 & 13). Findings included: Review of CF12, benefit period 6/17/25-9/14/25, on 7/14/25 at approximately 10:30am revealed hospice aid frequency to be twice a week effective 6/22/25. One hospice aide visit conducted week of 7/6/25.Review of CF13, benefit period 6/20/25-9/17/25, on 7/14/25 at approximately 11:00am revealed hospice aid frequency to be twice a week effective 6/22/25. One hospice aide visit conducted week of 6/22/25. Exit interview with 2 Area Vice Presidents (AVP) of Clinical, AVP of Operations, 4 Directors of Operations, Manager of Clinical Regulatory, Clinical Regulatory Specialist, Director of Volunteer Services, Regional Manager of Bereavement Services, Director of Clinical Resource Services, Business Office Manager, and Regional Business Office Manager on 7/14/25, at approximately 2:00pm confirmed findings.”

“Based on review of clinical records (CR), hospice policies, hospice complaint tracking, and staff interviews, the hospice failed to follow internal policy for investigation and resolution of grievances and complaints for one (1) of four (4) CR reviewed (CR1). Findings included:Review of Hospice policy on 4/7/25 at approximately 11:30am revealed:Policy: RI-006A... Patient Grievances and Complaints... Purpose: To ensure appropriate action will be taken to address all patient/caregiver complaint... Policy: A grievance is a formal or informal written or verbal complaint that is made to any hospice employee, including volunteers and individuals furnishing hospice services under arrangement, by a patient or the patient’s representative regarding the patient’s care, abuse, neglect, or misappropriation of property...The Agency (hospice director0 will initiate an investigation immediately upon receipt of the complaint. The complaint investigation shall be completed within 5 working days of the agency’s receipt of the complaint. All components of the investigation should be documented via the PointCare device or directly into HVHB console...Operational Guidelines: ...2. in the event of a complaint: HCHB system: The staff member receiving the complaint documents the complaint via the Point Care device directly into the HCHB console. a. The report is given to the DOO or designee., 3. The DOO or designee: a. Investigates and determines the nature of the complaint. b. HCHB system: Documents findings and resolution via the PointCare device or directly into the HCHB console., c. Communicates the resolution to the patient and/or caregiver that initiated the complaint process verbally and follow up via the Service Recovery letter... 4. In the event the complaint is not resolved at the agency level, the patient or interested party contacts the Regional Office. The Area Vice President or designee: a. HCHB system: Documents the complaint via the PointCare device or directly into the HCHB console., b. investigates the complaint., c. HCHB system: Documents finings and resolution via the PointCare device or directly into the HCHB console., d. Submits the Customer Complaint Report and all supporting documentation regarding the complaint to the Agency. Complaint intake record reviewed 4/7/25 at approximately 11:00am revealed complaint intake by agency director of operations on 1/3/24 documented the unsatisfactory survey returned by the complainant, as per the allegations reported. Action taken documented on 2/4/25 a service recovery letter was sent to complainant.During Interview on 4/7/25 at approximately 11:20am, Director of Operations reported start of employment with agency was 1/27/25 and the noted survey was in the que of returned surveys and the preceptor instructed to follow up like a complaint. Director of Operations reports sending a service recovery letter and confirms no contact was made with complainant and that the complaint was not logged into the Homecare Homebase (HCHB system or PointCare.Exit interview with the Area Vice President (AVP) of Operations, 2 AVP’s of Clinical, 2 Directors of Operations, and Director of Bereavement Services on 4/7/25, at approximately 3:00pm confirmed findings.”

“Based on review of clinical records (CR), hospice policies, and staff interviews, the hospice failed to ensure coordination of care between hospice staff and facility staff for two (2) of three (3) CR reviewed (CR1 & 3). Findings included:Review of Hospice policy on 4/7/25 at approximately 11:40am revealed:”... Professional Management...POLICY: ...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 by appropriately qualified persons, and in accordance with the patient’s plan of care... OPERATIONAL GUIDLINES: ...2. When hospice services are provided to a patient who is a resident of a licensed nursing facility, licensed intermediate care home or licensed personal care home the services will be provided under arrangement., b. the hospice will designate an IDT that will be responsible for i. Providing overall coordination of hospice care of the patient with the designated facility representative(s)., ii. Communicating with the designated facility representative(s) and other health care providers participating in the provision of care for the terminal and related and other conditions to ensure quality of care for the patient/family., iii. Ensure that the hospice IDT communicates with the facility medica director, the patient’s attending physician, and any other physicians participating in the provision of care to the patient as needed to coordinate the hospice care of the patient with the medical care provided by the other physicians., iv. Providing the facility with: the most recent hospice POC, the Hospice election of benefits, any advance directives, physician certifications and recertifications, names and contact information for hospice personnel involved in the patient’s care, instructions on how to access the hospices 24 hour on call system, hospice medication information, physician orders...” Review of CR1 conducted on 4/7/24, at approximately 12:20pm revealed an election of benefits dated 5/24/23. Dates reviewed were 5/24/23-9/16/24. CR revealed patient resided in a personal care facility. The CR included documentation dated 7/19/23, that the medication, Risperdal 2mg by mouth every morning, was changed to 1mg by mouth every morning. Skilled nursing note dated 7/19/23, documentation confirmed no medication reconciliation was conducted. No documentation in clinical note of coordination with the facility staff of the change in medication or symptoms to be aware of or education on the change. On 7/21/23, documentation that the medication, Risperdal 1mg by mouth every morning and Risperdal 1mg by mouth every night, was discontinued. Skilled nursing visit note dated 7/21/23, confirmed no medication reconciliation was conducted. No documentation in clinical note of coordination with the facility staff of the change in medication or education. Review of CR3 conducted on 4/7/24, at approximately 2:00pm revealed an election of benefits dated 1/12/24. Dates reviewed were 1/12/24-10/8/24. CR revealed patient resided in a nursing facility. The CR included documentation that upon election of benefits/start of services, patient was taking the medication, Atorvastatin 40mg by mouth daily. Th CR contained an order to discontinue this medication 4/22/24 noting the reason to be due to ineffectiveness. Skilled nursing note documentation confirmed no medication reconciliation and no coordination of care with the facility regarding medication change. Exit interview with the Area Vice President (AVP) of Operations, 2 AVP’s of Clinical, 2 Directors of Operations, and Director of Bereavement Services on 4/7/25, at approximately 3:00pm confirmed findings.”

“Based on review of clinical records (CR), hospice policies, and staff interviews, the hospice failed to follow internal policy for investigation and resolution of grievances and complaints for four (4) of four (4) CR reviewed (CR1-4). Findings included: Review of Hospice policy on 9/5/24 at approximately 10:30am revealed: Policy: RI-006A... Patient Grievances and Complaints... Operational Guidelines: ...2. in the event of a complaint: HCHB system: The staff member receiving the complaint documents the complaint via the Point Care device directly into the HCHB console., a. The report is given to the DOO or designee., 3. The DOO or designee: a. Investigates and determines the nature of the complaint. In the event that the complaint regards allegations of abuse or neglect by an employee, the DOO will remove the employee of any bedside care or contact with patients until the complaint has been fully investigated., b. HCHB system: Documents findings and resolution via the PointCare device or directly into the HCHB console., c. Communicates the resolution to the patient and/or caregiver that initiated the complaint process verbally and follow up via the Service Recovery letter... 3. In the event the complaint is not resolved at the agency level, the patient or interested party contacts the Regional Office. The Area Vice President or designee: a. HCHB system: Documents the complaint via the PointCare device or directly into the HCHB console., b. investigates the complaint., c. HCHB system: Documents finings and resolution via the PointCare device or directly into the HCHB console., d. Submits the Customer Complaint Report and all supporting documentation regarding the complaint to the Agency. Review of CR conducted on 9/5/24, from approximately 1:50pm to 3:30pm and 9/9/24 from approximately 11:45am -12:45pm revealed: CR1, election of benefit date 3/4/24, dates reviewed 3/4/24-3/7/24. Complaint intake documented by agency director of operations on 3/11/24 to include reported concerns of failure of DME to be picked up from home, medications received in pill form versus expected liquid form, different nurse providing visit than admission, and oxygen humidification bottle not filled. Agency follow-up documentation included that complainant “did not want to speak to anyone at from the care center at Mon Valley. Wished for higher up to call her back...” Email written from Area Vice President of Clinical to agency director dated 3/11/24 includes summary of noted concerns, and additional concerns to include: defibrillator shut off, nurse not offering to put air mattress on patient bed, not receiving aide visits daily, morphine dose different than complainant thought it would be, aide not having supplies, catheter not removed post death before sending patient to funeral home, follow up on death certificate. No agency documentation, per policy, of additional concerns relayed to Area Vice President of Clinical. No documentation, per agency policy in electronic medical record system, of findings and resolution or communication of the resolution to the patient and/or caregiver. CR2, election of benefit date 12/31/23, dates reviewed 12/31/23-1/1/24. Complaint intake documented 1/1/24 to include reported concerns of failure of medications to be provided to manage patient pain for 2 days. No documentation, per agency policy in electronic medical record system, of findings and resolution or communication of the resolution to the patient and/or caregiver. CR3, election of benefit date 5/29/24, dates reviewed 5/29/24-6/6/24. Complaint intake documented 6/1/24 to include reported concerns of failure of nurse to provide information and support to family, and alleged nurse was rude. No documentation, per agency policy in electronic medical record system, of findings and resolution or communication of the resolution to the patient and/or caregiver. CR4, election of benefit date 2/9/24, dates reviewed 2/9/24-2/23/24. Complaint intake documented 2/10/24 to include reported concerns of failure of medications to be provided to manage patient pain. No documentation, per agency policy in electronic medical record system, of findings and resolution or communication of the resolution to the patient and/or caregiver. Exit interview with the Area Vice President (VP) of Operations, VP of Clinical, Area VP of Clinical, Director of Operations, VP Regulatory Affairs, VP Clinical Practice and Quality, and Director of Bereavement Services on 9/9/24, at approximately 3:00pm confirmed findings.”

“Based on review of clinical records (CR), hospice policies, complaint log/reports, on call coordination notes, and staff interviews, the hospice failed to ensure that the patient had the appropriate medications available to manage the patient’s symptoms for two (2) of four (4) CR reviewed. (CR 2 & 4). Findings included: Review of Hospice policy on 9/5/24 at approximately 10:50am revealed: Policy: MM-001 PA... Medication Management Policy-Pennsylvania... Operational Guidelines: A. Provision of Medications: 1. Provision of medication to meet emergent needs of the patient will be made available twenty-four (24) hours, seven (7) days a week., 2. A pharmacist is available to all clinical staff twenty-four (24) hours, seven (7) days a week for consultation...” Review of CR conducted on 9/5/24, from approximately 1:50pm to 3:30pm and 9/9/24 from approximately 11:45am -12:45pm revealed: CR2, benefit election date 12/31/23, dates reviewed 12/31/23-1/1/24. Complaint Report documented complaint intake dated 1/1/24 at 6:52pm reporting concern that “patient has been home for 2 days now and still does not have pain medication. Patient is currently in pain and ...has nothing to give [patient] to help...” On call coordination notes include this call intake documented 2/10/24 at 6:47pm. At 6:59pm documentation reflects on call nurse “is at patient home and aware of medication need. AOC (administrator on call) has been made aware of need for pain medication at this time...” Narrative note dated 1/1/24 written by licensed nurse reads, “...No comfort kit medication administered as not yet delivered...”per available documentation patient/caregiver did not have the appropriate medications available to manage the patient’s symptoms from election of benefits on 12/31/24 through patient death on 1/1/24. CR4, benefit election date 2/9/24, dates reviewed 2/9/24-2/23//24. Admission note dated 2/9/24 included “ continue all medications, add Ekit [emergency kit] meds...” Complaint Report documented complaint intake dated 2/10/24 at 9:54am reporting concern that “PT [patient] was discharged from hospital on hospice yesterday [2/9/24]. Medications were supposed to be delivered last night or early this morning. No medications and patient is in distress. Trying to climb out of bed, restless, O2 [oxygen] dropping ...” on call coordination notes include this call intake documented 2/10/24 at 8:06am. At 8:10am documentation reflects on call nurse “stated [he/she] put orders in last night and requested MD scripts...” 8:30am documentation “Call placed to back-up nurse...states will follow-up with pharmacy and family.” Narrative note from nurse visit dated 2/11/24 states “Ekit meds present and narcotics counted.” per available documentation patient/caregiver did not have the appropriate medications available to manage the patient’s symptoms from election of benefits on 2/9/24 until 2/11/24. Exit interview with the Area Vice President (VP) of Operations, VP of Clinical, Area VP of Clinical, Director of Operations, VP Regulatory Affairs, VP Clinical Practice and Quality, and Director of Bereavement Services on 9/9/24, at approximately 3:00pm confirmed findings.”

“Based on review of clinical records (CR), and staff interviews, the hospice failed to provide services only as ordered by a physician for two (2) of four (4) CR reviewed (CR1 & 2). Findings included: Review of CR conducted on 9/5/24, from approximately 1:50pm to 3:30pm and 9/9/24 from approximately 11:45am -12:45pm revealed: CR1, benefit election date 3/4/24, dates reviewed 3/4/24-3/7/24. Plan of care (POC) and medication list included Oxygen to be administered at 3 liters via nasal cannula daily. Narrative note written by registered nurse dated 3/4/24 reads “...nasal flaring noted, oxygen in home from Medcare, O2 [oxygen] reading was 78%, placed on 5 L [liters], came up to 89%...” Narrative note written by registered nurse dated 3/5/24 reads, “...Patient currently on four liters nasal cannula and saturations were at eighty nine percent.” Narrative note written by registered nurse dated 3/7/24 reads “...oxygen saturation was eighty percent on five liters and went to ninety two percent when adjusted to six liters...” No order to administer oxygen at any other saturation than 3 liters nasal cannula. Narrative note written by registered nurse dated 3/6/24 reads, “...16 FR (French) (foley catheter) 10ml balloon placed today...” Additional narrative note dated 3/6/34 written by registered nurse reads, “...Patient now has a catheter draining a clear straw color urine...” No evidence of order obtained or written for insertion of foley catheter. CR2, benefit election date 12/31/23, dates reviewed 12/31/23-1/1/24. Plan of care (POC) and medication list included Oxygen to be administered at 3 liters via nasal cannula daily and PRN (as needed). Narrative note written by licensed nurse dated 1/1/24 reads, “...Terminal anxiety. Puling at bedsheets. Oxygen continuously 5 L...” No evidence of order to increase oxygen administration from 3L to 5L. Exit interview with the Area Vice President (VP) of Operations, VP of Clinical, Area VP of Clinical, Director of Operations, VP Regulatory Affairs, VP Clinical Practice and Quality, and Director of Bereavement Services on 9/9/24, at approximately 3:00pm confirmed findings.”