Amedisys Hospice of San Antonio

“Upon patient record review, 2 of 19 (Patients #4 and 8) did not contain a current/comprehensive Medication Profile: Patient #4: The Medication Profile included, “Remedy Calazime Protect for a wound. Apply to open area on left buttocks as per directions daily, and with each incontinence episode.” By 12/01/23 the nurse documented a “healed wound, dry skin with poor turgor.” The Nursing Supervisor reported that the Remedy was now being used as a barrier only. The Medication Profile had not been updated/modified. Patient #8: The Initial RN Assessment noted use of Oxygen 2 lpm continuous. This was not included on the Medication Profile.”

“Upon patient record review, 2 of 19 (Patients #4, 8, 9, 13) 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 medications: Patient #4: The POC dated 11/30/23 included, “Remedy Calazime Protect for wound. Apply to open area on left buttocks as per directions daily, and with each incontinence episode.” By 12/01/23 the nurse documented a “healed wound, dry skin with poor turgor.” The Nursing Supervisor reported that the Remedy was now being used as a barrier only. This wound intervention remained un-modified on the Plan of Care. Patient #8: The Initial RN Assessment reflected a PICC line for this GIP patient, and documented that it was not observed as it had an occlusive dressing. There was nothing on the Hospice POC regarding the presence of this PICC line, nor that it was being managed by the hospital clinical staff. The Initial RN Assessment noted use of Oxygen 2 lpm continuous. This was not included on the Hospice POC. Patient #9: A verbal order was obtained on 11/14/23 for, “Oxygen 2 lpm via nasal canula”. This is an incomplete order as it does not include whether continuous or p.r.n. administration. The Medication Profile reflects p.r.n. use. In addition, the POC dated 10/23-12/21/23 included, “SN to perform/instruct in management of Gastrostomy/Jejunostomy including: Care of site, equipment, preparation and administration of feeding 4x per day bolus. Flush with 50 cc water QID. Check tube placement and check for residual every feeding”. This is not a complete order as it does not detail ‘what’ the site/dressing change is, nor how often. Patient #13: The Physician initial CTI dated 10/24/23 noted, “Patient has an 1800 cc fluid restriction.” This was not included on the POC.”

“Upon patient record review, 3 of 19 (Patients #1, 3, 6) 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 equipment and supply needs: Patient #1: During Surveyor-attended home visit on 12/12/23 the patient had a hospital bed. This was not included on the most current POC. Patient #3: During Surveyor-attended home visit on 12/12/23 the patient had a Wheel Chair. This was not included on the most current POC. Patient #6: The11/03/23 CTI Narrative noted that the patient used a rollator. This was not included on the most current POC.”

“Upon patient record review, 3 of 19 (Patient #’s 4, 5, 7) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient #4: The POC dated 11/30/23 reflected both Chaplain and SW had been declined. However, the POC continued to have the following content: 1) Chaplain to conduct Spiritual assessment and establish a POC; and 2) SW to evaluate social, emotional, and financial factors and establish POC. In addition, The IDG POC dated 11/30/23 indicated “Volunteer Declined”. However, there remained multiple Volunteer interventions on such POC. Patient #5: A SW evaluation was conducted on 11/02/23, noting a planned visit frequency of 1x per month x3 month; with a resultant verbal order obtained on 11/02/23 for SW 1x per month x3, including multiple planned interventions. The current IDG POC dated 11/30/23 did not include the scope/planned interventions for the Social Worker. A verbal order was obtained on 11/08/23 for Chaplain 2x per month x3, and listed multiple planned interventions. The current 11/30/23 IDG POC did not include these scope and frequency for the Chaplain. Patient #7: The IDG POC dated 11/09-01/07/24 indicated “Volunteer Declined”. However, there remained multiple Volunteer interventions on the most current IDG POC dated 12/05/23”

“Upon patient record review, 1 of 19 (Patient #5) did not contain evidence that the IDG had shared information on a on-going basis with non-hospice healthcare providers, furnishing services unrelated to the terminal illness and related conditions. Patient #5: A verbal order was obtained on 11/14/23 for, “Podiatrist referral ordered for Plan of Care.” The Nurse Supervisor located evidence that a referral request had been faxed to a Podiatry provider. However, there was no documentation within the record that the Hospice had followed up with the provider or patient on this area of concern, to ascertain if the services were received. A phone call was made to the Podiatry office during survey which revealed that the patient had never received these services due to inadequate insurance coverage.”

“Upon observation, there was not evidence that the Hospice had investigated all adverse events, incidents, accidents, variances or unusual occurrences that involved patient care, and developed a Plan of Correction to prevent the same or similar event from occurring again. During clinical record review, it was noted that the Hospice Aide providing care to Patient #14 on 12/01/23, documented the following, “Patient was transferring from shower chair to WC and both knees buckled. I pulled the SNF ER cord. SNF staff responded, assisted the patient up, and examined him. No injuries were noted at this time.” Surveyor requested and reviewed the Hospice’s QI Event Report from 11/20 to 12/10/23. There was no evidence of this adverse event having been reported to/processed by the Hospice management staff.”

“Upon observation, there was not evidence that the Hospice followed acceptable standards of practice to prevent the transmission of infection. During Surveyor-attended home visit on 12/12/23, the Aide was in the process of transferring the patient to the bed, when the following occurred. After the Aide assisted the patient up from the wheel chair (WC), she set the Foley drainage bag on the floor under the wheel chair. The patient was pivoted, sat down, and was then was situated in the bed. The Aide then pushed the Foley bag across the floor with her foot, in order to move the WC out of the way from the bed. The Aide then moved the bed away from the wall, and proceeded to pull the patient up in the bed. Once up in bed she rolled the patient to her side (as the Surveyor had earlier asked if the patient had been noted to have any skin breakdown). The Aide then re-positioned the patient in the bed. The Foley bag remained on the floor. As Surveyor began to leave the room, she observed the privately-paid caregiver picking up the Foley bag from the floor.”

“Upon personnel record review, 1 of 16 (Personnel #7) did not contain evidence that an Aide Skills Competency assessment had been conducted, by the Aide with a patient, which contained all CMS-required subject matter, as follows. Personnel #7: The Aide documented/signed/dated a self-assessment of the following skills. However she was not individually signed off for each of these subject matter by a qualified RN. An RN had signed/dated her name on the last page only of the document. The Aide had signed/dated her competence for the following subject matter: 1. Reading and recording temperature, pulse, and respiration 2. Basic infection control procedures 3. Basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor 4. The need for respect for the patient, his or her privacy, and his or her property 5. Adequate nutrition and fluid intake Ÿ 6. Appropriate and safe techniques in personal hygiene and grooming that included ŸŸ 7. Bed bath 8. Sponge, tub, and shower bath 9. Shampoo, sink, tub, and bed 10. Nail and skin care 11. Oral hygiene 12. Toileting and elimination 13. Safe transfer techniques and ambulation 14. Normal range of motion and positioning The following skills had no Aide nor RN signature/date directly associated with them: Ÿ1.Communications skills including the ability to read, write, and verbally report clinical information to patients, caregivers, and other Hospice staff. 2. Observation, reporting, and documentation of patient status and the care or service furnished 3. Maintenance of a clean, safe, and healthy environment 4. Recognizing emergencies and knowledge of emergency procedures and their application 5.The physical, emotional, and developmental needs of and ways to work with the populations served by the Hospice”

“Upon patient record review, 2 of 19 (Patients #1 and 2) did not contain evidence that the Hospice had provided the following required information to the SNF: • The most recent Hospice Plan of Care specific to each patient • Hospice Election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for Hospice personnel involved in Hospice care of each patient • Instructions on how to access the Hospice’s 24-hour on-call system • Hospice medication information specific to each patient • Hospice Physician and Attending Physician (if any) orders specific to each patient Patient #1: During Surveyor-attended home visit on 12/12/23, the following items were not located in the SNF documents, as having been provided by the Hospice: • The Hospice Benefit Election form • Physician certification and recertification of the terminal illness. The most recent in the file was dated 08/2023. Patient #2: During Surveyor-attended home visit on 12/12/23, the following items were not located in the SNF documents, as having been provided by the Hospice: • The Hospice Benefit Election form • Physician certification and recertification of the terminal illness. The most recent in the file was dated 06/2023. • The most recent Hospice Plan of Care. The most recent in the file was dated 07/2023. • Current Hospice Medication information. The most current Hospice Medication Profile in the file was dated 07/2023. • The names and contact information for the Hospice personnel involved in the care of this patient.”

“Based on observation, interview, and record review the agency failed to ensure the ongoing sharing of information between all disciplines providing care and services in all settings for two of four patients (#9 and #1) reviewed for home visits in that: 1. There was no coordination to ensure the medication list from the agency and nursing facility were updated for Patient #9. 2. There was no coordination to ensure the medication list from the agency and nursing facility were updated for Patient #1. This failure could affect all patients that receive medications and could result in ineffective medication management and services. The findings were: A. Record review of Patient #9’s POC for certification date 12/1/2023 to 01/29/2024 revealed a SOC dated 02/09/2022, diagnoses included Senile Degeneration of Brain and Dementia (a range of conditions that affect the brain’s ability to think, remember, and function normally). During a home visit (at a nursing facility) with RN A on 12/06/2023 at 08:20 a.m., Patient #9 was observed in the memory care unit to be pleasant and calm but was unable to answer questions. Patient #9s current medication profile and medication list (from the nursing home she resided) were reconciled. Review of both lists with LVN E (LVN from the nursing home) revealed Mucinex (medicine used to relief coughs) 600 mg tablet, extended-release oral (every 12 hours PRN for congestion) and Sertraline (used to treat depression)50 mg tablet oral daily was not listed on nursing facilitys medication list. During an interview on 12/06/2023 at 08:50 a.m., LVN E revealed the hospice agency provided her an updated medication list monthly and the list was reviewed with the visiting nurse. Further interview with LVN A revealed Sertraline was discontinued on 05/31/2023 (from the nursing facilitys medication list) she did not know where the glitch was from or why there was a discrepancy with the Mucinex and Sertraline. During an interview on 12/06/2023 at 08:52 a.m., RN A revealed the Mucinex and Sertraline were discontinued and was not sure why it was on the agencys list. Record review of Patient #9s Client Medication Report from the agency revealed Mucinex 600 mg was discontinued on 05/01/2022. Further record review of Patient #9s clinical record revealed no documentation to coordinate the changes in medications regimen from both agencies. B. Record review of Patient #1s POC for certification dates 11/26/2023 to 01/14/2024 revealed a SOC date of 08/23/2022, diagnosis included Alzheimers Disease. During a home visit (at a nursing facility) with RN A on 12/06/2023 at 09:05 a.m., Patient #1 was observed in her wheelchair, she was calm and pleasant. Patient #1s nursing facility and agencys medication list were reconciled with LVN B. Further review revealed the following medications were not listed on the nursing facilitys medication list: -Dextromethorphan-Guaifenesin (used for cough) 10 mg-100 mg/5 ml oral syrup oral (10 ml) every 4-6 hours PRN (as needed), -Docusate Sodium (used for constipation) 100 mg capsule by mouth 100 mg two times daily as needed, -Remeron (appetite stimulant) 15 mg tablet oral one tablet at bedtime, -Robitussin Cough-Sore Throat 325 mg-10mg/10ml oral liquid (every 8 hours as needed). During an interview on 12/06/2023 at 09:24 a.m., LVN B revealed PRN medications were automatically discontinued if it was not used within 14 days. Further interview revealed Remeron 15 mg was discontinued on 02/21/2023. Also, LVN B did not know why there was a discrepancy during reconciliation. During an interview on 12/06/2023 at 09:43 a.m., RN A revealed she went over the medications last week with LVN B and was not sure why there was a discrepancy in the agency and nursing homes medication lists. Record review of Patient #1s Client Medication Report (from the agency) revealed Dextromethorphan-Guaifenesin was ordered on 06/23/2023 and discontinued on 06/24/2023, Robitussin was ordered on 04/26/2023 and discontinued on 04/26/2023, Docusate Sodium was ordered on 08/23/2023 and discontinued on 06/24/2023. Further record review of Patient #1s clinical record revealed no documentation to coordinate the changes in medications regimen from both agencies. During an interview on 12/07/2023 at 03:34 p.m., the Administrator revealed the nurses making the visits were responsible for ensuring the medication list were accurate and up to date. Further interview revealed an inaccurate medication list could result in inconsistent or inaccurate medication administration. During an interview on 12/08/2023 at 11:00 a.m., the Administrator revealed the nurses are communicating and going through the medications together but whats not happening is the MARs are not printed for them to see. The Administrator further revealed its a verbal medication reconciliation. Record review of the agencys policy and procedure titled “;Professional Management (10/16/2023)”, read in part, “;...290-9-43.16 (4)(b) The written communication shall specify an individual from the hospice and an individual from the facility where the patient resides who shall be responsible for communication between service providers regarding each patients treatment and condition and for addressing any care issues. Such communication shall be ongoing throughout the period of hospice service provision and shall be documented in the patients hospice medical record...” Record review of the agencys policy and procedure titled “;Medication Management (04/28/2022)”, read in part, “;...C. Medication Profile: ...5. A current medication profile will remain in the patients home folder and will be updated as modifications are made...””