Amedisys Hospice of York

“Based on a review of agency policy/procedure, clinical record review, and an interview with the agency Director of Operations, it was determined that the agency failed to forward to the patient’s attending physician a copy of the hospice discharge summary for one (1) of three (3) live discharge clinical records (MR) reviewed (MR # 1). Findings:Review of Amedisys, Inc. Hospice discharge policy on 1/7/26 at approximately 2:20 PM revealed: “j. If a patient is discharged alive, the hospice will forward the attending physician. i. a copy of the hospice discharge summary; ii. The patient’s clinical record if requested.”; 418.104 Conditions of participation: Clinical records: A clinical record containing past and current findings is maintained for each hospice patient. e. Standard: Discharge or transfer of care: (3) The hospice discharge summary as required in paragraph (e) (1) and e (2) of this section must include: (iv) Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility.”Review of MR # 1 on 1/7/26 between 2:45 PM-3:15 PM revealed:SOC: 1/14/25; Date of discharge: 7/12/25Review of RN Hospice discharge from agency visit note dated 7/12/25 revealed: Indicate support services needed/referrals required: No service/referral needs identified” There was no documentation of discharge instructions given to family or that attending physician was notified or received a copy of the discharge summary. An interview conducted with Agency’s Director of Operations on 1/15/26 at 1:00 PM confirmed the above findings.”

“Based on a review of agency policy/procedure, clinical record review, and an interview with the agency Director of Operations, it was determined that the agency failed to ensure the discharge summary included all required elements including but not limited to: a plan to address conflicting Functional Assessment Staging Tool (FAST) scores prior to discharge for one (1) of three (3) live discharge clinical records (MR) reviewed (MR # 1). Findings:Review of Hospice admission packet on 1/7/26 at approximately 2:30 PM revealed: “D. Transfer and discharge: transfer, referral, or discharge from this agency may result from several types of situations including the following: The level of care you need may change, ..there may be a failure to fulfill your responsibilities as a patient; If any of the above situations apply, you will be given timely advance notice of a transfer to another agency or discharge from our agency, except in case of emergency. When a discharge occurs, you will receive instructions for ongoing care or treatment. We will assist in coordinating your continued care. You will not be involuntarily discharged without a written order from your attending physician or our medical director stating that you do not meet hospice criteria, or through other legal processes, and timely notification of your next of kin and/or your authorized representative…”. Review of Amedisys, Inc. Hospice discharge policy on 1/7/26 at approximately 2:20 PM revealed: “h. The hospice must document the problem(s) and efforts to resolve the problem(s) and include such documentation in the patient’s medical record. j. If a patient is discharged alive, the hospice will forward the attending physician. i. a copy of the hospice discharge summary; ii. The patient’s clinical record if requested. Federal regulations: “418.26 Discharge from hospice care: “(a) reasons for discharge. A hospice may discharge a patient if: (2) The hospice determines that the patient is no longer terminally ill; (b) discharge order: Prior to discharging a patient for any reason listed in paragraph (a) of this section, the hospice must obtain a written physician’s discharge order from the hospice medical director. If a patient has an attending physician involved in his or her care, this physician should be consulted before discharge and his or her review and decision included in the discharge note…”; 418.104 Conditions of participation: Clinical records: A clinical record containing past and current findings is maintained for each hospice patient. e. Standard: Discharge or transfer of care: (3) The hospice discharge summary as required in paragraph (e) (1) and e (2) of this section must include: (i) A summary of the patient’s stay including treatments, symptoms and pain management; (ii) The patient’s current plan of care; (iii) The patient’s latest physician orders and (iv) Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility.”. Review of MR # 1 on 1/7/26 between 2:45 PM-3:15 PM revealed:SOC: 1/14/25; Date of discharge: 7/12/25Review of RN hospice recertification assessment dated 6/27/25 revealed: FAST 6E; mid upper arm circumference: thirty-one centimeters (31 cm); PPS: forty percent (40%).Client coordination note dated 7/8/25 entered by agency clinical manager revealed: “Per IDG and face to face, patient not eligible for recertification. Phone call to daughter. She was explaining all the declines she feels has occurred since patient came on services. However, her examples do not align with what multiple nurses and aides are documenting. Explained the Evidence of Coverage (EOCE) will be emailed and hand delivered in next twenty-four (24) hours and let her know the appeal process is explained on the form. Notified of coverage ending on today’s date and last date of service will be 7/12/25.Verbal order received from hospice medical director on 7/8/25 at 12:31 PM. Order description: discharge patient on 7/12/25 due to extended prognosis. Order was taken by hospice director of operations on 7/8/25. Order was approved and processed by hospice director of operations on 7/14/25 and was electronically signed by medical director on 7/20/25.Review of RN hospice subsequent visit note dated 7/10/25 revealed: “MUAC: thirty-one centimeters (31 cm); PPS: forty percent (40%)”; no changes noted in functional status.Review of RN Hospice discharge from agency visit note dated 7/12/25 revealed: PPS: forty percent (40%); Discharge/inpatient admission: Indicate who discharge was initiated by: agency; reason: extended prognosis; Narrative no longer terminally ill; Narrative: “RN discharge visit. Daughter voices unhappiness with decision to discharge patient. Active listening provided. There was no documentation of discharge instructions given to family or that attending physician was notified. Review of MR # 1 Nurse Practitioner Hospice face to face encounter visit note on 1/13/26 at 2:17 PM revealed: visit date: 7/7/25; Narrative: She does not appear to have lost weight in the past few months. Arm circumference was twenty-eight and five tenths (28.5); Assessment: FAST 7C; PPS: thirty percent (30 %); patient and family are on board with current plan of care and hospice philosophy.”Review of MR # 1 discharge/transfer summary report dated 7/12/25 revealed: Discharge information: “Discharge to home or self-care/reason: Hospice discharge-agency decision. There was no documentation of discharge instructions given to family or that attending physician was notified. An interview conducted with Agency’s Director of Operations on 1/15/26 at 1:00 PM confirmed the above findings.”