DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
341560 A. BUILDING __________
B. WING ______________ 		12/17/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
AMEDISYS HOSPICE 3320 US 1 HIGHWAY, SUITE B, FRANKLINTON, NC, 27525
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0513      
37615 Based on clinical record review, nurse practitioner interview, and staff interview, the agency failed to assist in transferring the patient to the patient and nurse practitioner's preferred level of care for 1 of 3 patients (#1). Findings include: Patient #1 was admitted on 9/12/19 with prostate cancer, chronic obstructive pulmonary disease (COPD) and diabetes. The Plan of Care (POC) for 9/12/19-12/10/19 included orders for skilled nursing (SN) to visit weekly for 13 weeks, and medical social worker (MSW) to visit 1 time for an evaluation, then weekly. The MSW (#2) evaluation on 9/16/19 confirms "Patient shared not having any family members or supports. Patient reported that his neighbor is a [sic] emergency contact individual." A note from the nurse practitioner visit on 10/11/19 was reviewed. The cover sheet to the hospice agency stated, "He [patient] has progressed with cancer ...Due to his social situation along with disease and transfusion dependent because of cancer, he was willing to have hospice with trf [transfer] to hospice house when necessary. Dr ___ and ____ [nurse practitioner] feels like he will need hospice home by the end of next week at the latest. Maybe sooner." The patient was also seen by the physician on 10/11/19. The note stated, "I anticipate that his health will continue to decline and he would need to be transferred to hospice home in the near future." A communication note by the MSW (#2) on 10/22/19 stated, "SW [social worker] communicated with ___ [RN at cancer center] in reference to patient agreed to transfer to ___ Hospice Home due to patient decline. SW informed RN anout [sic] protocols to transfer and being approved to be appropriate for hospice home with facility." MSW #2 made a joint visit RN #3 on 10/24/19. The visit note stated, "SW and Case manager attempted to encourage patient to participate in assistance [sic] living facility ...Patient was adamant about not wanting to participate in transitioning to assistant [sic] living facility. Patient reported only having interests for hospice home. Patient reported cancer doctor and nurse believes he is appropriate for hospice home ..." On 10/24/19 RN #3 conducted a visit. The visit note stated "PRN visit made to update pt on status of ALF [assisted living facility] placement. Pt refused to go to ALF of any kind. He wants to go to hospice home because he's heard thats [sic] where he needs to be from outside influences." A note on 10/29/19 by RN #3 stated, "Visited pt after receiving email from chaplain that pt passed out and fell ...Once again expressed growing concerns about pt safety being alone in home. Bed at ALF in _______ [city name] still available but pt does not want to go ...Providers from cancer center have visited pt and expressed concerns he is not in the hospice home run by __________ Hospice. Numerous members of _____ [hospice agency] staff have repeatedly told pt and cancer center why pt is not eligible for placement there." A note from the agency director of operations (#1) on 10/29/19 stated, "___NP from cancer center called to discuss a hospice home for patient. He feels hospice home is the best and safest option. Reviewed that patient had an ALF bed in _ [city name] but refused after meeting with him last week. He believed pt will pass in the next few weeks .... [NP] insisted that he hospice home was the only option ...Info was faxed to _______ [hospice home] for review." On 10/30/19, MSW #2 conducted a visit. The note stated, "SW assist case manager with home visit due to safety concerns. SW and CM [case manager] provided presences [sic] and support for patient. SW contacted several transportation companies to request for assisting patient to assistance [sic] living facility. SW explained to patient about options to transfer to assistance [sic] living facility of having adult protective serviced contacted due to safety concerns." The MSW note also stated, "Patient had old fecal matter embedded on back of head in his hair ...Patient appeared confused. Delusional." RN #3 note on 10/30/19 stated, "HHA phoned office to report she had found pt on floor covered in feces and confused. Spoke with SW and manager and decided pt needed to be transferred to ALF so he wouldn't be alone. This was the second fall in two days. Pt passed out and fell both times ...Pt was wearing O2 but still breathing with pursed lips and respirations were labored. Pt was very weak and took three people to get him up and back into recliner. Spoke with pt about going to ALF and pt agreed he wasn't well enough to stay alone ...Pt not thrilled about going but explained to him how dangerous his living situation was and APS would have to get involved." Pt transferred to ALF. On 10/30/19, in the evening, the ALF called for visit. RN #11 visited at approximately 7:00 p.m. The note revealed BP 230/200, "Pulse weak 54 bpm, oxygen saturation not registering on pulse ox. Oxygen increased to 4 lpm, resident reaching out into air. Conversation nonsensical." Transferred to ED. A coordination note on 10/31/19 by the agency director of operations (#1) stated, "_____Hospital MSW and Dr adamant that pt not return to facility. He was to go to the hospice home. Patient was discharged from this agency at that time. Interview with the director of operations #1 on 12/16/19 at 3:25 p.m. confirmed the only referral to the hospice home was on 10/29/19. An interview with medical social worker #2 on 12/16/19 at 3:50 p.m. confirmed that she did not make referral to hospice home. MSW stated, "The cancer center would have made that referral." An interview with RN #3 on 12/16/19 at 4:08 p.m. confirmed she never talked with the hospice home. "The office staff would have done that." Interview was conducted with Nurse Practitioner (NP) from the cancer center was conducted on 12/16/19 at 12:15 pm. The NP stated the patient "would have been best served in a 24-hour hospice facility ...My nurse tried to get ____ (hospice agency) to refer him (to hospice home) but got push back." The NP stated transfer to an inpatient unit was delayed. The NP also stated the hospice "Did not respect my clinical judgement" when he asked for inpatient hospice.
L0549      
37615 Based on clinical record review and staff interview, the plan of care failed to include all medications for 1 of 3 patient (#1). Findings include: Patient #1 was admitted on 9/12/19 with prostate cancer, chronic obstructive pulmonary disease, and diabetes. The Plan of Care (POC) for 9/12/19-12/10/19 included orders for skilled nursing (SN) to visit weekly for 13 weeks. The initial assessment conducted by the agency director on 9/12/19 revealed patient was on oxygen 2 liters nasal cannula. The POC did not include oxygen. An interview with the Director of Operations #12 on 12/17/19 at approximately 1:00 p.m. confirmed the Plan of Care did not contain oxygen.
L0555      
37615 Based on clinical record review and staff interview, the agency failed to follow the plan of care for physician notification related to oxygen saturations outside ordered parameters for 1 of 3 patients (#3). Findings include: Patient #3 was admitted on 3/28/19 with respiratory failure, shortness of breath, dependence on supplemental oxygen and chronic obstructive pulmonary disease (COPD). The Plan of Care (POC) for 3/28/19-6/25/19 included orders for skilled nursing (SN) to visit 2 times for 1 week, 3 times per week for 2 weeks, 2 times per week for 10 weeks, and 1 time per week for 1 week. The POC also stated, "Hospice nurse to obtain O2 sats [oxygen saturation] via pulse oximeter for baseline and prn. Report to MD for O2 sats <85 [less than 85%]." A visit was conducted by LPN #8 on 3/29/19. The visit note revealed the following respiratory findings: " Abnormal breath sounds " Abnormal breath patterns " Apnea " Requires oxygen " Periods of apnea " Diminished breath sounds in the lower lobes The visit note stated, "Pt very weak, O2 via NC [nasal cannula] with O2 sats 56%...Patient is increasingly having trouble breathing. Pt gets SOB [short of breath] with minimal exertion and uses accessory muscles during breathing ...Talked with ____ RN and request for respiratory [respiratory therapy] to come and evaluate equipment and do family teaching. SN also asked family to turn on air conditioner, room very hot and pt agreed. Decline is evident by weight at 65 lbs, increase SOB decreased sats 56 with O2 sat 4-5 litters [sic]." The LPN left prior to respiratory therapist arriving. The patient's family sought care from the emergency department. There was no evidence that the physician was notified of the assessment and the oxygen saturation outside of ordered parameters. An interview with LPN #8 was conducted on 12/17/19 at approximately 1:30 p.m. The LPN stated that "a piece of equipment was not working" and she had called to have respiratory therapy make a home visit. The interview confirmed the physician was not notified of the low oxygen saturation levels.
L0672      
37615 Based on clinical record review and staff interview, the agency failed to document the death assessment in 1 of 3 records reviewed (#3). Findings include: Patient #3 was admitted on 3/28/19 with respiratory failure, shortness of breath, dependence on supplemental oxygen and chronic obstructive pulmonary disease (COPD). The Plan of Care (POC) or 3/28/19-6/25/19 included orders for skilled nursing (SN) to visit 2 times for 1 week, 3 times per week for 2 weeks, 2 times per week for 10 weeks, and 1 time per week for 1 week. On 4/29/19 RN #6 made a home visit. Temperature was 97, pulse 58, respirations 22, blood pressure 86/62, and oxygen saturation 74%. The visit note stated, "Did death occur during this visit? No." On 4/29/19 the chaplain and MSW conducted Bereavement Visits. RN #6 was unavailable for an interview. An interview was conducted with the chaplain on 12/17/19 at 1:00 p.m. The chaplain confirmed the RN was in the home when the patient died. An interview with Director of Operations #12 confirmed the death "had not been entered into the system.