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 ______________ 		12/02/2020
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)
L0552      
34981 Based on policy review, clinical record review and staff interviews the IDG [interdisciplinary group] failed to revise/document the individualized plan as frequently as the patient's condition requires for 1 of 1 patient [#1] who was discharged due to change in terminal status. The findings included: The policy, "Discharge", with a revised date of 10/29/20 was provided by the agency director on 12/2/20 at approximately 2 pm. The policy stated, " ...Possible discharges of live patients will be reviewed and agreed upon by the IDT [interdisciplinary team] prior to beginning the discharge process ...The patient/family will be notified that discharge is being considered. Prior to any discharge, a written order for the discharge must be obtained from the medical director ..." Patient # 1 had a Start of Care [SOC] date of 6/24/20 with a terminal diagnosis of Coronary Heart Disease. A review of the Plan of Care [POC] for the certification period 9/22/20 to 11/20/20 revealed orders for skilled nursing 2 times a week for 1 week; 3 times a week for 8 weeks and 3 PRN's [as needed] for symptom management. A review of the IDG meeting details revealed Patient # 1 care was discussed 10/6/20, 10/20/20, 11/3/20 and 11/18/20. A review of the IDG minutes revealed no discussion between the team related to the upcoming discharge. A review of the medical director's IDG note on 11/17/20 revealed the following information, " ...a 48-year-old with terminal diagnosis of CAD [coronary artery disease]. This was changed recently from colon cancer ..." A review of the skilled nursing visit note dated 11/16/20 revealed the visit type was classified as "RN Hospice Recert Assessment". A review of the SN [skilled nurse] visit note revealed the following information, " ...patient is a 48-year-old female with a terminal diagnosis of Atherosclerosis Heart Disease ..." Further review of the clinical record revealed Patient # 1 was discharged on 11/20/20 for Extended Prognosis. A review of the POC revealed no update by the IDT in relation to an upcoming discharge or an extended prognosis. Further review of the clinical record did not contain any evidence the patient/caregiver was notified of the possibility of an upcoming discharge. An interview was conducted with the agency manager on 12/2/20 at approximately 330 pm. During the interview the agency manager confirmed there was no evidence of discussion by the IDT prior to the patient being discharged.
L0555      
34981 Based on clinical record review and staff interviews the agency failed to obtain a urinalysis with culture and sensitivity for 1 of 1 patients [#2]. The findings included: Patient # 2 had a Start of Care [SOC] date of 10/1/20 and a terminal diagnosis of Senile Degeneration of Brain. A review of Plan of Care for the certification period 10/1/20 to 12/29/20 revealed orders for skilled nursing 2 times a week for 1 week; 1 time a visit for 11 visits and 3 PRN's [as needed] for symptom management. A review of the clinical record revealed on 10/4/20 an order was obtained for a urinalysis to be obtained on 10/5/20. No nursing visit was made until 10/6/20. During the 10/6/20 visit RN # 2 documented, "Attempted to perform procedure. Writer was unsuccessful." The clinical record revealed 8 nursing visits were made between 10/6/20 and 11/5/20. On 10/15/20 RN # 3 documented the following information, "RN attempted to obtain in and out cath [sic] for UA specimen ..." Further review of the clinical record revealed the urinalysis was not obtained prior to Patient # 2's discharge. Did they patient have any symptoms. If so, add An interview was conducted with the agency's area vice president on 12/2/20 at approximately 4 pm. During the interview the VP confirmed the urinalysis was not obtained.