Amedisys Hospice Care

“Based on review of agency policy, clinical records (CR), and staff (EMP) interview, the agency failed to ensure the interdisciplinary group maintained responsibility for directing, coordinating, and supervising the care and services provided for one (1) of three (3) patients (CR1). Findings included:Review of agency policy on May 14, 2025, at 12:30 p.m., showed, “Policy: AA-006 ... Topic: Interdisciplinary Team (IDT) ... The composition of the IDT includes at a minimum a physician, a registered nurse, a social worker, and a spiritual counselor, ... Members of the IDT must coordinate and supervise care with all service providers involved in the care of the patient ... Operational guidelines: The IDT maintains a system of communication and integration in order to: 1. Ensure that the IDT retains responsibility for directing, coordinating, and supervising the care and services provided. 4. Provide for and ensuring the ongoing sharing of information between all disciplines providing care and services in all setting. ... The IDT review is part of the overall agency evaluation process and assists the agency in meeting patient care objectives by: 1. Providing a means for effective interchange, reporting and coordination of patient care.”Review of CR1 on May 14, 2025, at 9 a.m. showed patient was admitted to hospice on 8/28/2024 for an initial benefit period ending 11/25/2024. The patient elected the hospice benefit on 8/28/2024 after an extended hospitalization for urinary problems that included an infection and stent placement to help drain urine from the bladder. The physician’s ordered plan dated 8/28/2024 included an order to place a foley urinary catheter (to drain urine from bladder into a bag), “Skilled nurse to perform insertion of 16F [size] catheter [urinary].” Review of CR1’s admission visit note from 8/28/2024 showed the RN (registered nurse) documented, “Patient is agreeable to have a foley [urinary] catheter placed after the weekend.” After the weekend and during a skilled nurse visit on 9/3/2024, the RN documented, “Unsuccessful [sic] attempted to place a foley catheter. Genital scarring [sic] from prior surgical procedures and genital disfigurement evident. Unable to successfully place foley catheter. Call placed to [patient’s urologist] to inquire on having the catheter placed in [his/her] office. Family calling urology office. No other needs at this time. Will call the office with further needs.” During the next skilled nurse visit the following week on 9/11/2024 the licensed practical nurse documented, “PT has 14 FR- 5 CC foley catheter inserted 9/6/2024 by a nurse neighbor after verbal call consent from [patient’s urologist]. Foley catheter patent straw colored urine.” Further review of CR1 showed the IDT was not aware of the registered nurse’s inability to place CR1’s urinary catheter, or the need for a urinary consult until 9/18/2024 or 15 days after the patient agreed to have it placed. Per the 9/18/2024 “Hospice IDG Comprehensive Assessment and Plan of Care Update Report” the medical director documented, “Current Meeting Summary IDG [interdisciplinary group] Team Members HOSPICE PHYSICIAN ... Details ... HAS NEW FOLEY.” Interviews with EMP1 (administrator) and EMP2 (regional vice president) on May 14, 2025, at 1 p.m. confirmed above findings.”

“Based on review of agency policy, a clinical record (CR), and staff (EMP) interview, the registered nurse failed to update the comprehensive assessment to ensure the needs of the patient were met for one (1) of three (3) records (CR1). Findings included:Review of CR1 on May 14, 2025, at 9 a.m. showed patient was admitted to hospice on 8/28/2024 for an initial benefit period ending 11/25/2024. The patient elected the hospice benefit on 8/28/2024 after an extended hospitalization for urinary problems that included an infection and stent placement to help drain urine from the bladder. The physician’s ordered plan dated 8/28/2024 included an order to place a foley urinary catheter (to drain urine from bladder into a bag), “Skilled nurse to perform insertion of 16F [size] catheter [urinary].” Review of CR1’s admission visit note from 8/28/2024 showed the RN1 (registered nurse) documented, “Patient is agreeable to have a foley [urinary] catheter placed after the weekend.” After the weekend and during a skilled nurse visit on 9/3/2024, RN1 documented, “Unsuccessful [sic] attempted to place a foley catheter. Genital scarring [sic] from prior surgical procedures and genital disfigurement evident. Unable to successfully place foley catheter. Call placed to [patient’s urologist] to inquire on having the catheter placed in [his/her] office. Family calling urology office. No other needs at this time. Will call the office with further needs.” During the next skilled nurse visit the following week on 9/11/2024, the licensed practical nurse documented, “PT has 14 FR- 5 CC foley catheter inserted 9/6/2024 by a nurse neighbor after verbal call consent from [patient’s urologist]. Foley catheter patent straw colored urine.” Further review of CR1 showed the IDT was not aware of the registered nurse’s inability to place CR1’s urinary catheter, or the need for a urinary consult until 9/18/2024 or 15 days after the patient agreed to have it placed. Per the 9/18/2024 “Hospice IDG Comprehensive Assessment and Plan of Care Update Report” the medical director documented, “Current Meeting Summary IDG [interdisciplinary group] Team Members HOSPICE PHYSICIAN ... Details ... HAS NEW FOLEY.” There was nothing in the clinical to show the RN updated the patient’s comprehensive assessment related to unsuccessful urinary catheter placement or that the IDT / urologist was notified concerning CR1’s needs.Review of RN1’s job description on May 14, 2025, at 12:30 p.m. showed, “Job Title: HSP Case Manager ... Job Summary: Responsible for providing coordinating, and directing the provision of hospice care according to the interdisciplinary team (IDT) plan of care through the competent application of the nursing process, ... Essential Functions: 1. Performs initial nursing assessment on new admissions and completed initial plan of care. Coordinates the total Plan of Care and maintains continuity of patient care by collaborating with appropriate staff. Revise plan of care as needed. Completes updated Plan of Care ... and communicates changes to attending physician, hospice staff.”Interviews with EMP1 (administrator) and EMP2 (regional vice president) on May 14, 2025, at 1 p.m. confirmed above findings.”

“Based on review of agency policy, documentation, and staff (EMP) interview, the agency failed to coduct annual exercises to test its emergency plan for 2022, and 2023. Findings: Review of agency policy on June 28, 2024, at 9 a.m. showed, “EMERGENCY MANAGEMENT PLANNING ... Emergency management is a dynamic process. Planning, though critical, is not the only component. Training, conducting drills, testing equipment and coordinating activities within the community are other important functions. ... POLICY: ... The agency will participate in practice drills.” Review of agency’s emergency preparedness binder on June 28, 2024, at 9:50 a.m. showed an incomplete fire drill (no evaluation and not community based) dated 7/31/2023. The agency had no other documentation to show it had completed required annual exercises for the years 2022 and 2023. Interview with EMP1 (administrator) on June 28, 2024, at 11 a.m. confirmed above findings.”

“Based on review of agency policy, clinical records (CR), quality assessment and performance improvement (QAPI) data, and staff (EMP) interview, the agency failed to measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the hospice to assess processes of care, hospice services and operations for two (2) of four (4) records with infections (CR15, & CR16). Review of agency policy on June 28, 2024, at 11:05 a.m. showed, “PI-001 Quality Assessment Performance Improvement (QAPI) ... PI Data includes and is not limited to systemic reviews of: ... 6. Adverse patient events ... 9. Infection Surveillance and Prevention practices and surveillance data.” Review of CR15 on June 25, 2024, at 10:30 a.m. showed a hospice plan of care with a recertification period from 2/21/2024 to 5/20/2024. A physician order from 4/28/2024 showed, Levaquin [medication/antibiotic] ... X 5 days ... Reason: UTI [urinary tract infection].” Review of CR16 on June 25, 2024, at 12:30 p.m. showed a hospice plan of care with a recertification period from 3/19/2024 to 6/16/2024. A physician order from 5/12/2024 showed, “Amoxicillin [medication/antibiotic] ... X 7 days for ear infection.” Review of QAPI documentation and agency’s method for tracking infections “QI Event Report” on June 28, 2024, at 10:45 a.m. did not show CR15’s or CR16’s infections listed. The “QI Event Report” period was from 6/28/2023 to 6/28/2024. Interview with EMP1 (administrator) on June 28, 2024, at 11 a.m. confirmed above findings, and that the above infections were not captured within QAPI for tracking purposes.”

“Based on observation, review of agency policy and procedure, and staff (EMP) interview, the agency failed to ensure one (1) of one (1) registered nurse followed agency policy and procedure for infection control (EMP6). Findings: Review of agency policy and procedure on June 24, 2024, at 11:15 a.m. showed, “Bag Technique ... Purpose: To provide guidance for the adherence of the principles of infection prevention in relationship to practitioner equipment and supply bag usage ... Procedure: ... 3. The field staff member cleanses hands prior to accessing materials from the supply bag. ... 4. Equipment and supplies to be used, such as blood pressure cuff and thermometer, are removed and placed on a clean field. Keep he supply bag closed when not in use. 5. Wash hands again if you need to re-enter the bag for additional supplies during patient care. ... 8. Hands are cleansed prior to returning clean equipment to the bag.” Observation during home visit on June 27, 2024, at 9:15 a.m., at a skilled nursing facility, revealed EMP6 enter facility wearing his/her stethoscope around his/her neck (not stored in supply bag). Once in patient’s room, EMP6 removed equipment from supply bag (blood pressure cuff, thermometer, etc.) without placing equipment on a clean field or closing the bag (open for entire visit). EMP6 then used equipment on patient. When EMP6 completed his/her assessment of the patient, he/she reached into supply bag to obtain a disinfectant wipe but did not sanitize his/her hands prior to entering the bag. Once the visit was finished, EMP6 used the previously retrieved disinfectant wipe on his/her equipment and placed each item back into bag one at a time without sanitizing his/her hands first. Interview with EMP6 on June 27, 2024, at 9:35 a.m. confirmed above findings.”

“Based on review of clinical records (CR), contracts, and staff (EMP) interviews, the agency failed to ensure the patient’s clinical record located at the skilled nursing facility (SNF) contained the patient’s initial certification of terminal illness, and election of the hospice benefit for one (1) of one (1) SNF record reviewed during a home visit (CR7). Findings: Review of contract between agency and SNF, “NURSING FACILITY SERVICES AGREEMENT” on June 28, 2024, at 11 a.m. showed, “3. Responsibilities of Hospice. ... (e) Provision of Information. ... At a minimum, Hospice shall provide the following information to Facility for each Hospice Patient residing at the facility: ... (ii) Elections form. The hospice election form and any advance directives; (iii) Certifications. Physician certifications and recertification of terminal illness.” Review of CR7 on June 27, 2024, at 9:00 a.m. showed a plan of care with an initial certification from 5/31/2024 to 8/28/2024. Further review of CR7’s clinical record maintained by the SNF during a home visit on June 27, 2024, at 9:45 a.m. showed that it did not contain the hospice election of benefit or the initial certification of terminal illness. EMP1 reviewed CR7’s clinical record maintained by the SNF during an interview on June 28, 2024, at approximately 11 a.m., and confirmed above findings.”