Initial Comments:
Based on the findings of an onsite unannounced complaint investigation completed May 14, 2025, Amedisys Hospice Care was found not to be in compliance with the following requirements of 42 CFR, Part 418, Subparts A, C, and D, Conditions of Participation: Care.
Plan of Correction:
418.56(e)(1) STANDARD
COORDINATION OF SERVICES
Name - Component - 00
§418.56(e) Standard: Coordination of services
The hospice must develop and maintain a system of communication and integration, in accordance with the hospice’s own policies and procedures, to-
§418.56(e)(1) Ensure that the interdisciplinary group maintains responsibility for directing, coordinating, and supervising the care and services provided.
Observations:
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. 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. 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. 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]." 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." 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. to successfully place foley catheter. placed to [patient's urologist] to inquire on having the catheter placed in [his/her] office. calling urology office. other needs at this time. 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]. catheter patent straw colored urine."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 which 15 days after the patient agreed to have it placed. 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." with EMP1 (administrator) and EMP2 (regional vice president) on May 14, 2025, at 1 p.m. confirmed above findings.
Plan of Correction:TAG L0554 §418.56(e)(1) Coordination of Services:
1.Upon notification of areas of deficiencies, the Administrator/Director of Operations with the assistance of the Area Vice President of Operations and the Area Vice President of Clinical implemented comprehensive and systemic changes to ensure that coordination of services is occurring, and the interdisciplinary group maintains responsibility for directing, coordinating, and supervising the care and services provided.
A.Education/Training –
- On 5/28/2025 Comprehensive re-education and remediation was provided for all staff on agency policies related to coordination of services.
TX-005 Professional Management
AA-006 Interdisciplinary Team (IDT)
AA-005 Hospice Plan of Care
TX-012 Core Services-Nursing Service
AA-003 Assessments
B.Identification/Implementation –
- Initiated on 5/27/2025 all active patients plan of care will be reviewed at the next IDG and continue every 2 weeks with each subsequent IDG to ensure the plan of care and reflected goals based on current patient assessment are provided to ensure palliation and management of the terminal illness and related condition are addressed and completed in accordance to the established plan of care per IDG team and hospice medical director with appropriate interventions, coordination of care, and an individualized patient-specific plan of care.
- With each IDG and order changes the patient plan of care will have appropriate revision to the plan of care as reflected in the clinical documentation in accordance with the patient's current condition/needs and agency's policies and procedures in coordination with the patient's physician, Interdisciplinary Team; nursing facility (as applicable) and patient/patient caregiver to the extent possible.
C.Auditing/Monitoring –
- Effective immediately 100% of current patients' plan of cares will be audited to ensure they are individualized to meet patients' current needs based on most recent nursing assessment and include coordination of services with identified healthcare facilities and healthcare providers.
- Auditing will continue monthly for a period of 2 months or until 90% compliance is met. If compliance is not met after 2 months, the audits will continue for the next 2 months, and staff remediation will be completed to ensure compliance.
- Audits will be added to QAPI plan.
- All findings will be reported at the quarterly QAPI committee meeting and the Governing Body as appropriate, but at a minimum annually.
- Completion date 7/27/2025
418.64(b)(1) STANDARD
NURSING SERVICES
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§418.64(b) Standard: Nursing services
§418.64(b)(1) The hospice must provide nursing care and services by or under the supervision of a registered nurse. Nursing services must ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and updated assessments.
Observations:
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.
Plan of Correction:TAG L0591 §418.64(b)(1) Nursing Services:
1.Upon notification of areas of deficiencies, the Administrator/Director of Operations with the assistance of the Area Vice President of Operations and the Area Vice President of Clinical implemented comprehensive and systemic changes to ensure that nursing care and services are being provided by or under the supervision of a registered nurse and the needs of the patients' are met as identified in the initial, comprehensive, and updated assessments.
A.Education/Training –
- On 5/28/2025 Comprehensive re-education and remediation was provided for all staff on agency policies related to coordination of services.
TX-005 Professional Management
TX-012 Core Services-Nursing Service
Hospice Registered Nurse Job Description
AA-006 Interdisciplinary Team (IDT)
AA-005 Hospice Plan of Care
AA-003 Assessments
B.Identification/Implementation –
- Initiated on 5/27/2025 all current patients' charts will be reviewed to ensure a case manager is assigned to oversee the patients' plan of care.
- Initiated on 5/27/2025 all active patients' plan of care will be reviewed at the next IDG to ensure collaboration with hospice staff as well as the attending physician chosen on Election of Benefits at start of care.
- With each IDG and order changes the patient plan of care will have appropriate revision to the plan of care as reflected in the clinical documentation in accordance with the patient's current condition/needs and agency's policies and procedures in coordination with the patient's physician, Interdisciplinary Team; nursing facility (as applicable) and patient/patient caregiver to the extent possible.
C.Auditing/Monitoring –
- Effective immediately 100% of current patients' charts will be audited to ensure a registered nurse case manager is assigned.
- Effective immediately 100% of patients' plan of care will be audited to ensure it includes all necessary patient services and procedures for the palliation and management of the terminal illness and related conditions necessary to meet the patients' needs.
- Auditing will continue monthly for a period of 2 months or until 90% compliance is met. If compliance is not met after 2 months, the audits will continue for the next 2 months, and staff remediation will be completed to ensure compliance.
- Audits will be added to QAPI plan.
- All findings will be reported at the quarterly QAPI committee meeting and the Governing Body as appropriate, but at a minimum annually.
- Completion date 7/27/2025
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