Amedisys Hospice Care

“Upon patient record review, 1 of 19 (Patient #11) did not contain evidence that a Registered Nurse had been designated to ensure the continuous ongoing assessment of the patient and family’s needs, and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family: Patient #11: The RN 08/13/25 SOC documentation included, “Recent laceration to right forehead, with x7 resulting stitches. Now open to the air, with the application of topical ATB by caregiver.” The next subsequent SN visits dated 08/14 and 08/20/25 did not document a nurses assessment of this area of concern.”

“Upon patient record review, 3 of 19 (Patients #2, 7, and 9) did not contain evidence that the Hospice had developed an individualized written Plan of Care for each patient. The Plan of Care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The Plan of Care must include all services necessary for the palliation and management of the terminal illness and related conditions: Patient #2: SOC 02/20/25. The record contains a completed DPOA-Medical form. This Advance Directive information is not included on either the POC dated 08/19-10/17/25, nor the IDG POC dated 09/03/25. Patient #7: The 08/19/25 SOC CTI reflected that the patient was a DNR; with a copy of a Virginia State DNR form dated 08/19/25 within the clinical record. However, the 09/03/25 IDG POC only contained the Advance Directive of Living Will, and not the DNR status of this patient. Patient #9: The record contained both a completed Living Will and a DPOA-Medical form. However, these Advance Directive(s) information is not included on either the POC beginning 08/14/25, nor the IDG POC dated 09/02/25.”

“Upon patient record review, 1 of 19 (Patient #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 the following: A detailed statement of both the scope and frequency of the services necessary to meet the specific patient and family needs: Patient #13: A verbal order was obtained on 08/28/25 for, “Volunteer requested. Effective 09/01/25 Volunteer 1x per month x1.” Both the 90-day 08/20/25 SOC POC, and the 09/02/25 IDG POC included the following, “Volunteer services available as needed: (delete those services not applicable). 1) Companion; 2) House chores; 3) Emotional/Spiritual support; 4) Telephone contact; 5) Music Therapy; 6) Food preparation; 7) Caregiver respite; 8) Shopping errands; 9) Oral History/Memory Project; and 10)Veteran activities. This potential scope of Volunteer services had not been individualized. Additionally, the 09/02/25 IDG POC did not include a planned/ordered Volunteer frequency.”

“Upon patient record review, 1 of 19 (Patient #3) did not have evidence that the hospice assumes responsibility for professional management of the resident’s hospice services in accordance with the hospice plan of care. The hospice is responsible for providing all hospice services including: • Ongoing assessment, care planning, monitoring, coordination and provision of care by the Hospice IDG • Assessment, coordination and provision of any needed general inpatient or continuous care • Consultation about the patient’s care with facility staff • Coordination by the hospice RN for the implementation of the plan of care for the patient • Provision of hospice aide services, if these services are determined necessary by the IDG to supplement the nurse aide services provided by the facility • Provision, in a timely manner, of all supplies, medications, and DME needed for the palliation and management of the terminal illness and related conditions • Financial management responsibility for all medical supplies, appliances, medications and biologicals related to the terminal illness and related conditions • Determination of the appropriate level of care to be given to the patient (routine homecare, inpatient, or continuous care) • Arranging any necessary transfers from the facility, in consultation with the facility personnel Patient #3: The IDG POC dated 09/03/25 included, “Oxygen 4 lpm for shortness of breath.” The SN’s SNF visit note of 09/05/25 documents that, “Patient is using 5.5 lpm of Oxygen upon SN arrival.” The subsequent 09/06, 09/07, and 09/08/25 SNV’s also document the patient actively using Oxygen at 5 lpm. There was no documentation at any four of these SN visits of care coordination with the SNF staff, to clarify the variance of the Oxygen dosage. During surveyor record review on 09/10/25, the Hospice contacted the SNF, and was told that the SNF had received a Physician order to increase Oxygen to 5-7 lpm on 09/04/2025.”

“Upon personnel record review, 1 of 13 (Personnel #8) did not contain evidence of Criminal Background Checks having been obtained in accordance with Virginia State requirements as follows: A. Section 32.1-162.9:1 of the Code of Virginia requires Hospice providers, as defined in § 32.1-162.1 of the Code of Virginia, to obtain a criminal record report on applicants for compensated employment from the Virginia Department of State Police. Section 32.1-162.9:1 also requires that all applicants for compensated employment in a Hospice program provide a sworn statement regarding their criminal history. B. The criminal record report shall be obtained within 30 days of compensated employment. It is the Hospice program’s responsibility to ensure that its compensated employees have not been convicted of any of the barrier crimes listed in § 32.1-162.9:1 of the Code of Virginia. C. The Hospice program shall not accept a criminal record report dated more than 90 days prior to the date of compensated employment. D. Only the original criminal record report shall be accepted. Personnel #8: DOH was 08/27/24. The Hospice was not able to locate documented evidence of his having had a Virginia State CBC conducted.”