Amedisys Hospice of South Carolina

“Upon patient record review, 1 of 27 (Patient #9) did not contain evidence that a Registered Nurse was designated to ensure the continuous assessment of the patient and family’s needs, and to coordinate activities with other members of the interdisciplinary group (IDG): Patient #9: The Physician SOC CTI noted, “Chronic wound LLE recently re-opened due to sheer and friction. Wound care ongoing.” The RN 10/17/25 SOC assessment prompt for, “Is wound care ordered for this patient?, was answered as no”. At the body diagram section the RN entered, “LLE pressure ulcer Stage III. Wound care not provided, as caregiver had already completed.” It was not clear as to what wound care the caregiver had provided. Further along the RN documented, “LLE wound not assessed on admission. Daughter showed admitting RN a picture of wound; which had had a dressing placed prior to hospital discharge that same day. RN Case Manager to follow-up/assess for Physician wound care orders”. There was no documentation located reflecting that the RN assessed or followed up on proper wound care to be provided. The next SNV dated 10/18/25 documented, “Wound care not ordered at this visit. Wound not assessed. Left leg wound dressing was recently changed.” The next SNV dated 10/19/25 documented, “Wound not assessed. Caregiver has completed wound care.” Not documented as to what that wound care consisted of. The next SNV dated 10/21/25 documented, “Wound was assessed. RN provided wound care”. This patient was admitted 10/17/25. The Hospice nurse did not ensure continuous patient assessment, by not viewing a wound of concern until 10/21/25.”

“Upon patient record review, 3 of 27 (Patients #3, 12, and 17) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including the following: A detailed statement of both the frequency and scope of all services necessary to meet the specific patient and family need: Patient #3: The IDG POC dated 11/26/25, did not include a scope of planned SW interventions. Patient #12: The IDG POC dated 11/26/25 contained a SW entry of, “Patient making progress toward goals. SW will continue to support as desired.” This POC did not include a ‘scope’ of individualized SW interventions to meet previously identified patient needs. Patient #17: The IDG POC dated 12/04/25 did not include the ‘scope’ of planned Volunteer services.”

“Upon patient record review, 3 of 27 (Patients #4, 9, and 16) did not contain a Plan of Care which included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments: Patient #4: A verbal order was obtained on both 12/02/25 and 12/08/25 for, “Cleanse right heel area with wound cleanser, pat dry, apply Betadine twice daily, and PRN, without an indication for such PRN dressing change. A verbal order was obtained on 12/08/25 for, “Triad Paste to sacrum B.I.D.” This order is not clear as to ‘who’ is to provide such B.I.D. treatment. An additional verbal order was obtained on 12/08/25 for, “Sacrum and right heel wounds: Cleanse with dermal wound cleanser, apply medi-honey to wound bed, cover with dry dressing. Daily and as needed; without an indication for such ‘as needed’ dressing change. The interim Administrator confirmed that this written wound procedure was worded incorrectly, as the listed interventions are only applicable to the patient’s sacrum wound and not applicable to the patient’s right heel wound. Patient #9: A verbal order was obtained on 12/09/25 for, “Clean calf wound with wound cleanser, pat dry, apply petroleum dressing, then dry gauze. Caregiver may provide wound care in absence of RN”. There is no physician-ordered ‘frequency’ for the provision of this wound care. Patient #16: The 90-day SOC POC included, “SN to instruct on care/management of Nephrostomy. Cleanse with normal saline, apply gauze, stabilization device, transparent dressing. May change drainage bag PRN; without an indication for such PRN bag change. May flush with 10cc normal saline two times daily and PRN.; without an indication for such PRN flush. Change dressing Q week and PRN; without an indication for such PRN dressing change”.”

“Upon patient record review, 3 of 27 (Patients #2, 5, and 6) did not contain a Plan of Care which included all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs: Patient #2: During survey home visit on 12/08/25, it was noted that the patient had the following DME: 1) Hospital Bed; and 2) Bedside Table. These DME items were not included on either the IDG POC dated 11/26/25, nor the 60-day POC beginning 10/20/25. Patient #5: The Medical Director’s CTI for certification period beginning 11/17/25 documented, “Patient has fallen out of bed the past two months, now has ‘fall mats’ in place.” Fall mats were not included on the Hospice POC. Patient #6: During survey home visit on 12/09/25, it was noted that the patient had the following DME: 1) Hospital Bed; 2) Bedside Table; 3) Air pressure mattress; and 4) Wheelchair. These DME items were not included on the POC.”

“Upon patient record review, 3 of 27 (Patients #2, 6, and 20) did not contain evidence that the revised Plan of Care included information from the patient’s updated comprehensive assessment: Patient #2: The 60-day POC beginning 10/15/25 listed a Chaplain visit frequency of, “1 x per month x2 effective 11/01/25.” However, the IDG POC dated 11/26/25 included: 1) Patient refusing Chaplain services. Will develop POC and provide services if requested; and 2) Chaplain to conduct a Spiritual Care assessment and develop POC. This 11/26/25 IDG POC not current/updated. The Chaplain was making visits which included the date of 11/07/25. Patient #6: The 11/06/25 90-day SOC POC ordered, “Chaplain 1x per month. An 11/08/25 phone call documented, “Patient/family refuse Chaplain care/services.” However, the 11/28/25 IDG meeting notes, Spiritual Counselor section, continued to include, “Patient encouraged through ministry.” The POC was not current/updated. Patient #20: A verbal order was obtained on 11/10/25 for, “Cleanse wound #2 on back with soap/water, pat dry, apply Barrier Cream, cover with Opti-foam. Change every 4 days and PRN soiling. This wound care treatment was not forwarded to all subsequent IDG Plans of Care. The wound did not heal until 12/05/25.”

“Upon patient record review 1 of 27 (Patient #9) did not contain evidence that the IDG had ensured that all care and services were provided in accordance with the Physician-ordered Plan of Care: Patient #9: The SOC Physician CTI noted, “Chronic wound LLE. Wound care ongoing.” The 10/17/25 RN SOC visit documented, “RN Case Manager to follow-up/assess for Physician wound care orders”. There was no subsequent documentation reflecting that the RN had contacted a Physician for such wound orders. The SNV dated 10/21/25 documented, “RN cleansed with wound wash, applied Xeroform to wound bed, then ABD, then gauze wrap.” However, there was no Physician order obtained for this provided wound care until 12/09/25.”

“Upon patient record review, 1 of 27 (Patient #9) did not contain evidence that Hospice Aide assignments and duties were: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a Hospice Aide must be prepared by a Registered Nurse who is responsible for the supervision of a Hospice Aide Patient #9: The Aide POC’s assigned the task of weigh patient every visit. The patient is bedbound, with use of Hoyer Lift for any transfers. On the Aide home visit reports dated 10/20, 10/22, 10/24, 10/27/25, and multiple other visits, the Aide had documented “Not completed” for this assigned task. The task of weigh patient every visit was no longer applicable for this patient, and the RN had not maintained a current individualized Aide POC.”

“Upon patient record review 2 of 27 (Patients #6 and 9) did not contain evidence that the Hospice Aide had provided care/services that were: • Ordered by the Interdisciplinary Group • Included in the Plan of Care Patient #6: The Aide POC(s) effective 11/06/25 and 12/09/25, both assigned the Aide to obtain a T, P, R, and BP every visit. The Aide did not obtain/document the provision of these tasks on either the 12/08 or 12/09/25 visits. Patient #9: The Aide POC dated 12/09/25 assigned the task of weigh patient every visit. The patient is bedbound, with use of Hoyer Lift for any transfers. On the Aide home visit reports dated 10/20, 10/22, 10/24, and 10/27/25, and multiple other visits, the Aide documented “Not completed” for this assigned task.”

“Upon patient record review, 1 of 27 (Patient #18) did not contain evidence that all entries were legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice: Patient #18: The Aide POC effective 11/24/25 assigned, “Aide to report pain”, with a provided reporting parameter of >4. The Aide visit notes section, prompting the “Aide to report pain” on visit notes dated 11/25, 12/03, and 12/08/25, resulted in the Aide documenting a response of “Yes”. These Aide home visit notes did not document evidence of the Aide having assessed for patient pain level, as there was no pain level documented. This is unclear documentation.”

“Upon patient record review, 1 of 27 (Patient #23) did not contain evidence that the Hospice had created a Discharge Summary which included all CMS-required information: Patient #23: Discharged 06/02/25. There was no documented evidence of the Hospice having created/established a DC Summary document to include the following CMS-required information: • A summary of the patient’s stay, including treatments, symptoms and pain management • The patient’s current plan of care • The patient’s latest physician orders • Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility”