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
491626 A. BUILDING __________
B. WING ______________ 		06/03/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
AMEDISYS HOSPICE OF CHARLOTTESVILLE 1415 ROLKIN COURT SUITE 203, CHARLOTTESVILLE, VA, 22911
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)
L0687      
27661 Based on staff interview and clinical record review it was determined the agency failed to provide medical supplies in a timely manner related to the palliation and management of the terminal illness and related conditions in one (1) of five (5) clinical records reviewed in the survey sample (clinical record #1). The findings were: A review of the clinical record for the patient named in the complaint, identified in the survey sample as clinical record #1 was reviewed for the certification period of 5/10/2022 through 8/07/2022. The plan of care/physician orders for wound care were "nurse to perform/teach patient/caregiver pressure ulcer care to right and left inner posterior thighs: cleanse with wound cleanser, apply silver alginate to wounds, apply skin barrier to periwound prn to prevent maceration and protect periwound. Cover with optifoam. Change dressing every other day and prn (as needed) for soiling and loosening. Skilled nursing notes and physician orders revealed the following information: 5/10/2022 (date of admission) skilled nursing note, the nurse did not change the dressing as no orders had been obtained for wound care. The patient was being followed by the wound care clinic. The nurse reached out to the physician to obtain wound care orders. 5/11/2022 a verbal order was entered for wound care to include the order above as listed in the plan of care. 5/11/2022 skilled nursing note, wound care not provided as caregiver completed care prior to the nursing visit. 5/13/2022 skilled nursing note, wound care not provided as caregiver completed care prior to the nursing visit. 5/14/2022 skilled nursing note, wound care not provided, client completed care prior to the nursing visit. 5/15/2022 skilled nursing note, wound care not provided, not ordered this visit 5/17/2022 skilled nursing note, wound care not provided, refused care 5/19/2022 skilled nursing note, wound care provided by skilled nurse as ordered. A phone interview on 5/31/2022 at 1 PM with the nurse, staff member #3 that cared for the patient revealed the patient did not initially have orders for wound care and as soon as the orders were obtained the supplies were ordered. Staff #3 stated it usually takes a day or two to get the supplies. The nurse reported the patient had an adequate amount of supplies from previous care provided by other agencies however, the patient did not allow the nurse to use the supplies. The patient changed the dressing's most of the time using the supplies already in the home. There is no evidence the nurse spoke with the physician related to the issue with supplies. Per the interview with the nurse, the patient had the supplies needed, they were just provided by a previous agency caring for the patient. There was no indication in the electronic record that the nurse and/or hospice agency offered to replenish the supplies used by the patient. An interview was conducted with the Director of Operations, staff #2 at 1:20 PM on 5/31/2022. Staff #2 checked in the computer and advised the order for supplies for the patient were entered in the electronic record on 5/12/2022. Supplies were not ordered until 5/17/2022 and were not delivered to the patient until 5/18/2022. There was no documentation as to why there was a delay in ordering the supplies. The Director of Operations, staff #2 was not aware there was a problem with obtaining the wound care supplies until checking into the electronic documentation for the complaint investigation. The patient requested to be discharged from the agency after receiving the supplies 5/18/2022 and the last visit documented by nursing was on 5/19/2022. The agency had no other patients receiving wound care.