Every finding on record at Amedisys Georgia, L.L.C.

An Abbreviated/Partial Extended Survey investigating complaint 3022894 was conducted at Amedisys Home Health on May 27, 2026, and concluded on May 27, 2026. At the time of the survey, the agency was not in compliance with Chapter 42 CFR Part 418, Rules and Requirements for Home Health and Hospice Agencies. The census was 218. Based on record reviews and interviews, the agency was found not to be in compliance with complaint 3022894. The following deficiency was cited.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interview, it was determined that the agency failed to revise the last two plan of cares from the initial comprehensive assessment for one Patient (P) P1 of three sampled patients. Specifically, the agency failed to update the services, treatment, and care ordered by a physician required to meet the needs of P1 in the plan of care recertifications dated 03/14/2026 to 05/12/2026 and 05/13/2026 to 07/11/2026. The findings included: Review of the plan of care for P1 (certification period of 1/13/2026 to 3/13/2026) revealed P1 was admitted on 01/13/2026 with other specified disorders of bladder (indwelling Urinary catheter-suprapubic (drains urine from the bladder through a small incision in the lower abdomen) and Obstructive and Reflux Uropathy (blockage in the urinary system). Orders of Discipline and Treatments: Indwelling urinary catheter insertion; RN/LPN/LVN (Registered Nurse, Licensed Practical Nurse, Licensed Vocational Nurse) to perform insertion of 18FR suprapubic indwelling catheter, instill 10cc of sterile water into balloon, secure tubing with appropriate securement device, change every month and PRN (as needed) for leakage, blockage, dislodgment, or malfunction. Review of physician order dated 01/21/2026, for P1 revealed may use either #16FR/10cc or #18 FR/10cc for suprapubic catheter changes. Review of the plan of care (POC) for P1 (certification period of 1/13/2026 to 3/13/2026) revealed P1 was admitted on 1/13/2026 with other specified disorders of bladder (indwelling Urinary catheter-suprapubic and Obstructive and Reflux Uropathy (blockage in the urinary system). Orders of Discipline and Treatments: Indwelling urinary catheter insertion; RN/LPN/LVN to perform insertion of 18FR suprapubic indwelling catheter, instill 10cc of sterile water into balloon, secure tubing with appropriate securement device, change every month and PRN for leakage, blockage, dislodgment, or malfunction. Briefly Describe Patient who is being admitted to Home Care services: Recent prolonged hospital/rehab stay for CVA. Had ruptured Bladder and now has permanent opening for suprapubic catheter. Review of the plan of care for P1 (certification period of 3/14/2026 to 5/12/2026) revealed P1 was admitted on 01/13/2026 with other specified disorders of bladder with Obstructive and Reflux Uropathy (blockage in the urinary system). The agency failed to address in the plan of care the diagnoses and Orders of Discipline and Treatments related to the indwelling Urinary suprapubic catheter. Review of the plan of care for P1 (certification period of 5/13/2026 to 7/11/2026) revealed P1 was admitted on 01/13/2026 with other specified disorders of bladder with Obstructive and Reflux Uropathy (blockage in the urinary system). The agency failed to address in the plan of care the diagnoses and Orders of Discipline and Treatments related to the indwelling Urinary suprapubic catheter. During an interview with Director of Operations (DOO) on 05/27/2024 at 12:25 PM. The DOO confirmed the agency failed to include treatments and services for P1 for the continued care of P1 Suprapubic catheter in the plans of care for certification period 3/14/2026 to 5/12/2026 and 5/13/2026 to 7/11/2026. The DOO further reported during the agency review of the complaint filed by the care giver (CG) of P1, it was discovered a contracted Registered Nurse (RN) had failed to revise the diagnoses and orders of discipline and treatments for P1 in the plan of care from the initial comprehensive assessment, specifically for the suprapubic catheter care, accurately and according to the physicians’ orders from the initial recertification period of 1/13/2026 to 3/13/2026 through the following recertification periods 3/14/2026 to 5/12/2026 and 5/13/2026 to 7/11/2026. The agency failed to provide in the plan of care for P1 the supplies, treatment, and services needed for the care of the patient's suprapubic catheter, which caused harm to P1 and required hospitalization.

An extended survey was conducted at Amedisys Home Health in Savannah Georgia from 6/ 27- 6/29/22. The extended survey revealed that the facility was in substantial compliance with Conditions of Participation at 42 CFR Part 484.22, Emergency Preparedness for Home Health Agencies.

At the time of the survey, Amedisys Home Health in Savannah, GA, was not in substantial compliance with 42 CFR Part 484, Requirements for Home Health Agencies as a result of extended recertification survey conducted from June 27- 29, 2022. On June 29, 2022, a determination was made that a situation in which the agency's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm or impairment to patients. The agency's Area Vice President and Branch Director of operations were informed of the immediate jeopardy on June 29, 2022, at 1:30 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on February 28, 2022. The State Survey Agency received an acceptable Removal Plan on June 30, 2022. The agency census was 545 at the time of the onsite visit. The following deficiencies were cited:

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on review of document titled, “Complaint Report” dated 3/1/21, and review of the complaint log from 3/7/19 to present, the agency failed to follow-up on a complaint received on 3/1/21 by family member (FM) of Patient (P) #10 for 1 of 3 patients with complaint. Findings include: Review of the clinical record for Patient (P) #10 with a certification period of 1/10/21 to 3/10/21 revealed P#10 was admitted to home health services on 9/18/19, with diagnosis of quadriplegia, encounter for fitting and adjustment of urinary device, neuromuscular dysfunction of bladder, unsp injury at unsp level of cervical spinal cord. Review of document titled, “Clinical Skills New Hire Checklist (Home Care): Skilled Nursing” for LPN GG, dated 10/9/20, for Urinary Catheter Insertion Male checked complete. The evaluation method was by Field Observation (FO). Review of the document titled, “Visit Note Report” dated 2/24/21, revealed LPN wrote, “Foley Catheter changed this visit. Patient tolerated well. Placement and flow stable.” Review of document titled, “Complaint Report” dated 3/1/21, family member (FM) of P#10 filed a complaint that they were not happy with the last nurse visit (2/24/21). She reported the nurse changed the patient Foley catheter and the catheter bag was “full of blood” when the nurse left the home. She stated P#10 had to be sent to the ER where she was told the catheter “Was not done right.” She reported the ER replaced the Foley catheter and P#10 went home the same night. Further review of the “Complaint Report” dated 3/1/21, revealed the resolution column; was blank. The Prevention column documented; “change in staff assignment.” The Follow-up Comments revealed; DOO offered to reassign a new nurse to this patient with LPN GG not to see this patient anymore. daughter says okay that’s fine. On 6/28/22, at 2:00 p.m., DOO was asked for In-services related to Foley Catheter training/ education conducted after the complaint and she stated all she had for LPN GG was the “Clinical Skills New Hire Checklist (Home Care): Skilled Nursing.” DOO did not provide any in-service/education documents requested.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on the review of clinical records and staff interviews, it was determined that the Condition of Participation for Comprehensive Assessment of Patients was not in compliance as a result of the agency's failure to perform patient assessment visits as required for 1 of 18 sampled patients (G-514), agency’s failure to meet patient’s needs (G534), for one of 18 sampled patients and agency's failure to ensure medication profiles were reviewed and updated at each clinical visit to reflect the patients' current medication regime in the home for 3 of 7 home visits (G-536). The cumulative effect of these systemic problems resulted in the agency's inability to ensure the provision of quality health care. These failures jeopardized patients' health and safety. (Refer to G-514, G-534, and G-536). Refer to G-514, G-534, and G-536.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, it was determined the agency failed to conduct an ongoing assessment to determine the immediate needs of the patient for 1 of 18 (#1) sampled patients (P). Findings were: 1.Review of a communication note dated 3/4/22 for patient #1 with a certification period of 2/24/22 to 4/24/22 and a diagnosis of Amyotrophic lateral sclerosis (ALS) and Respiratory failure revealed the on-call registered nurse received a call from the patient’s caregiver/spouse on 2/26 and 2/27/22 with concerns related to the patient having difficulty breathing. The spouse reported the patient’s trilogy ventilator alarm was constantly beeping and the patient appeared to be in respiratory distress as evidenced by the patient having difficulty breathing. The spouse called the on-call registered nurse on 2/26/22 to report these concerns however, the on-call failed to make a home visit to assess the patient’s condition and determine the immediate needs of the patient. The spouse again called the on-call nurse on 2/27/22 and again reported that the patient trilogy ventilator was still alarming, and the patient was still presenting with respiratory distress and difficulty breathing. The on-call nurse did not make a home visit on 2/27/22 to assess the patient’s immediate needs and monitor for complications and provide safety measures. According to the clinical record, the patient did have 3 as needed (PRN) visits ordered for the skilled nurse to complete a home visit as needed however, these PRN visits were not utilized by the nurse. The SN failed to visit the patient and assess the patient for potential complications and provide safety measures to the patient. During an interview on 6/29/22 at 1:00p.m., the Director of Operations, did confirm the SN failed to visit the patient and assess the patient on 2/26 and 2/27/22 for potential complications and provide safety measures to the patient as needed.

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews, it was determined that the agency failed to meet patient's medical and nursing needs for one of 18 (P#1) sampled patients. Review of the plan of care for patient #1 with a certification period of 2/24/22 to 4/24/22 revealed a pertinent diagnosis Amyotrophic Lateral Sclerosis, Acute respiratory failure with hypoxia and hypercapnia, encounter for attention to tracheostomy, personal history of cardiac arrest and patient is on ventilator Trilogy. The skilled nurse (SN) was required to instruct on disease process, and its complications, signs and symptoms of respiratory failure and tracheostomy care and its complications. . The SN was required to visit the patient three times as needed (PRN) for respiratory /tracheostomy complications. Based on review of SN statement dated 3/4/22 it was determined that the agency failed to complete home visits to assess the patient as required for complications related to tracheostomy. The agency SN received a call from caregiver on 2/26/22 and 2/27/22 regarding the Trilogy (Respiratory Ventilator) machine alarm going off and patient in respiratory distress stating problems with breathing However, the SN failed to complete home visits to address caregiver concerns and to assess the patient for complications to address the patient’s needs. The agency failed to provided PRN visits to the patient to meet patient’s needs and concerns. Additionally, the record lacked any coordination efforts to transfer the patient to a facility which would be better equipped to handle the patient’s immediate medical needs in the event the home health agency was not able to provided to necessary care and services needed to maintain patient safety. The agency failed to communicate with the physician and team to effectively coordinate the patient's care for identifying the patient's needs and services. During an interview on 6/29/22 at 3:30 p.m., the Director of Operations and Area Vice President (AVP) acknowledged the SN failed to complete home visits to address patient and caregiver ‘s concerns and to assess the patient for trach and breathing complications.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, clinical record review, and staff interviews, it was determined that the agency failed to ensure that patient medication profiles and plan of care were updated to reflect current medications at the time of the comprehensive assessment for four (4) of eighteen (18) sampled patients (,#5, #6, #7 and #11). The Findings include: During a home visit observation conducted on 6/28/22 at approximately 9:17 a.m., with Registered Nurse (RN) DD, for (P#7), it was revealed that (P#7) was admitted on 4/20/22, with a diagnosis of left bottom pressure ulcer and congestive heart failure. The surveyor compared P#7's current medication list at home to the home health agency's medication profile. Discrepancies were found. 1. The home health agency medication profile and plan of care revealed Lispro insulin 100 units/milliliters, inject 20 units subcutaneous pen three times daily; P#7’s home medication revealed Humalog 100 unit/ml Kwik pen inject 18 units into the skin four times daily as needed per sliding scale. 2. The home health agency medication profile and plan of care revealed Metformin extended release 750milligrams (MG), take one tablet oral twice daily; P#7’s Metformin ER750 mg discontinued on 6/6/22. On 6/28/22 at 10:40 a.m., an interview was conducted with Registered Nurse (RN) DD, who confirmed that he did not check the medications, and did not update the medication profile and plan of care. 1. A home visit was conducted at 8:30 a.m. on 6/28//22, at the residence of Patient (P#5) with Occupational Therapist (OT) EE. P#5 was admitted to the home health agency on 5/17/22, with the diagnosis of Venous insufficiency (chronic) peripheral). The clinical record was reviewed for certification period 5/17/22 to 7/15/22. During the home visit, the surveyor compared P#5 current medication list in the agency’s Electronic medical record (EMR) to the medications present in P#5 home. P#5 had the following medication listed in the home but not in the EMR: Phillips milk of magnesium 30-60 milligram 1 capful as needed an antidiarrheal supplementImmodium A-D x2 tabs initially as needed the 1 tab after, an antidiarrheal supplementTramadol 50 mg x1 tab every 6 hours as needed for pain, a medication used for pain The following medication was listed incorrectly in the EMR: Tramadol 50 mg x1 tab every 6 hours as needed for pain, a medication used for painO2-Oxygen 1.5 liter continuous, used to treat shortness of breath and COPD was listed on the EMR as O2-Oxygen 2.0 liter continuous While reviewing medications in the home with (OT) EE, (OT) EE verbalized understanding of the requirement to reconcile all medications in the home with medications listed in the agency EMR during every comprehensive visit. 2. A home visit was conducted at 10:00 a.m. on 6/28//22, at the residence of Patient (P#6) with Physical Therapist (PT) FF. P#6 was admitted to the home health agency on 6/8/22, with the diagnosis of Type 2 Diabetes with Diabetes peripheral angio path without gangrene. The clinical record was reviewed for certification period 6/8/22 to 8/6/22. During the home visit, the surveyor compared P#6 current medication list in the agency’s Electronic medical record (EMR) to the medications present in P#6 home. P#6 had the following medication listed in the home but not in the EMR: Nature Bounty D3 125 mcg 1x1 tab daily a dietary supplementNature made Vitamin C 1000 mcg x1 tab daily, a dietary supplementCitracal 1 tab daily, a calcium supplementCentrum Silver Adults 50+ x1 tab daily, a dietary supplement Tramadol 50 mg x1 tab every 6 hours as needed for pain, a medication used for painFelodipine ER 10 mg tab x1 tab daily The following medication was listed incorrectly in the EMR: Atorvastatin 20 mg x1 tab daily, used to treat cholesterol was listed on EMR as Atorvastatin 10 mg tab While reviewing medications in the home with (PT) FF, (PT) FF verbalized understanding of the requirement to reconcile all medications in the home with medications listed in the agency EMR during every comprehensive visit. During a home visit observation on 6/29/22 at approximately 9:30 a.m. for patient #11 with a certification period of 6/1/22 to 7/30/22, this surveyor compared the patient's current medication list in the patient’s home to the home health agency's medication profile. According to the patient, the patient is taking: Valsartan 320 mg tablet (high blood pressure) half tab daily by mouth, however the agency medication profile dated 6/27/22 patient is on Valsartan 320 mg one tablet daily by mouth. Oxycodone-Acetaminophen 5 mg-325 tablet every 4 hours as needed for pain. However, the agency medication profile listed this medication as discontinued. According to the agency medication profile dated 6/27/22 patient is taking Clopidogrel 75 mg (blood thinner) once daily, however, patient verbalized that patient is no longer takes this medicine as the doctor discontinued the blood thinner. According to the agency medication profile patient is taking Famotidine 40 mg one tablet daily. However, patient stated that patient does not take this medication. During an interview on 6/29/22 at 3:30 p.m., the Director of Operations provided no evidence the medication profile had been updated to reflect the patient's current medication regimen.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on review of clinical records, policy review, personnel file reviews, and staff interviews, it was determined the Condition of Participation for Comprehensive Assessment of Patients was not in compliance for 1 of 18 sampled patients as evidenced by the agency's failure to ensure the clinicians promptly alert physician to changes in condition (Refer to G-590) and failure to coordinate care for the patient to ensure immediate needs and services were provided safely for 1 of 18 sampled patients (Refer to G-600). The cumulative effects of these systemic problems resulted in the home health agency’s inability to provide optimal care and services as ordered on the plans of care which could result in serious patient injury/harm or death. (Refer to G-590 and G-600). Refer to G-590 and G-600

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, it was determined the agency failed to ensure the patients' clinical record contained complete, concise, and clear documentation of all services including evaluations, treatments, progress notes, and individualized plan of care, and all of the required elements to address the patients' needs for one (1) of eighteen (18) sampled patients. (P#14). The Findings include: 1. Review of the plan of care for Patient (P#14) with a certification of 4/23/22 to 6/21/22 diagnosed with end stage renal disease and dialysis three time per week, required the skilled nurse (SN) to assess and instruct patient /caregiver on precautions to monitor and document patient’s dialysis assess site for bleeding and infection. However, according to the plan of care the patient dialysis assess site was not monitored nor documented for bleeding nor infection. The agency failed to ensure that the plan of care contained clear, accurate, and concise orders as per the needs of the patient. During an interview on 6/28/22 at 3:00 p.m., Licensed Practical Nurse (LPN) CC confirmed that the agency failed to ensure the plan of care contained accurate and complete documentation regarding the assessment and needs of the patient.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on clinical record reviews and staff interviews, it was determined the agency staff failed to ensure that care and services were provided in conformance with plans of treatment as ordered by physicians for one of 18 sampled patients (P) (#1). Findings include: Review of the plan of care for patient #1with a certification period of 2/24/22 to 4/24/22 revealed a pertinent diagnosis Amyotrophic Lateral Sclerosis, Acute respiratory failure with hypoxia and hypercapnia, encounter for attention to tracheostomy, personal history of cardiac arrest and patient is on ventilator Trilogy. The skilled nurse (SN) was required to instruct on disease process, and its complications, signs and symptoms of respiratory failure and tracheostomy care and its complications. Tracheostomy cares follows skilled nurse to provide teaching on trach care including suctioning. Change the trach inner cannula weekly and change the dressing weekly, cleanse area gently with normal saline and gauze, pat dry. SN may change dressing as needed and on each visit. The SN was required to visit the patient three times a week for one week and three times as needed (PRN) for respiratory /tracheostomy complications. Review of the SN visit notes dated 2/24 (initial assessment) and 2/28/22 lack evidence that SN provided tracheostomy care as ordered on plan of care. Based on review of SN statement dated and signed on 3/4/22, the skilled nurse documented “I have not changed a cuff trach with a vent in place in a while, so I want to make sure we are doing it safely and educating you all on how to do it in the future”. Review of the SN statement dated 3/4/22, also revealed the SN was called on 2/2622 and 2/27/22 by the caregiver with respiratory concerns of the patient. However, the SN failed to visit the patient as needed to assess patient’s respiratory concerns. The SN did not make a PRN visit on 2/26 and 2/27/22 to assess the patient’s respiratory needs as ordered on the plan of care. The agency failed to ensure the SN followed the plan of care for tracheostomy care and provided PRN visits as needed by the patient and caregiver. The agency's skilled professional staff failed to provide services as ordered by the physician in the plans of care for patient #1 as evidence by SN not providing tracheostomy care on 2/24/22 and 2/28/22, SN was required to visit the patient three times a week for one week, however, patient was seen only one time the week of 2/24/22, and SN did not visit patient as needed (PRN) for Tracheostomy complications. During an interview on 6/29/22 at 3:30 p.m., the Director of Operations and Area Vice President (AVP) acknowledged the SN did not perform trach care on 2/24 and 2/28/22, did not follow the frequency for three times a week for one week and made home visits on 2/26/22 and 2/27/22 as per patient’s /caregiver’s needs.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, it was determined the agency failed to ensure that the physician was notified of changes in a patient’s condition that might have resulted in a need to alter treatment for 1 of 18 (#1) sampled patients (P). Findings were: 1.Review of a communication note dated 3/4/22 for patient #1 with a certification period of 2/24/22 to 4/24/22 and a diagnosis of Amyotrophic lateral sclerosis (ALS) and Respiratory failure revealed the on-call registered nurse received a call from the patient’s caregiver/spouse on 2/26 and 2/27/22 with concerns related to the patient having difficulty breathing. The spouse reported the patient’s trilogy ventilator alarm was constantly beeping and the patient appeared to be in respiratory distress as evidenced by the patient having difficulty breathing. Ventilators are equipped with safety alarms which will alarm if the ventilator exceeds or drops below certain limits. Patients should be assessed and evaluated to ensure safety if the machine starts to alarm. The spouse called the on-call registered nurse on 2/26/22 to report these concerns however, the on-call failed to make a home visit to assess the patient’s condition and determine the immediate needs of the patient. The spouse again called the on-call nurse on 2/27/22 and again reported that the patient trilogy ventilator was still alarming, and the patient was still presenting with respiratory distress and difficulty breathing. The on-call nurse did not make a home visit to assess the patient’s immediate needs and monitor for complications and provide safety measures 2/26 and 2/27/22. According to the clinical record, the patient did have 3 as needed (PRN) visits ordered for the skilled nurse to complete a home visit as needed however, these PRN visits were not utilized by the nurse. The clinical record lacked evidence that the physician was notified of the patient’s change in condition as evidenced by a constant alarming ventilator or the spousal concerns regarding the patient being in respiratory distress. The SN failed to intervene and immediately notify the physician of the patient’s alarming ventilator and failed to notify the physician of the spousal concerns regarding the patient being in respiratory distress which might have resulted in a need to alter the plan of care for this patient. During an interview on 6/29/22 at 1:00p.m., the Director of Operations, provided no evidence of physician notification of the alarming ventilator or the patient being in respiratory distress.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on clinical record reviews, observations, and staff interviews, it was determined that the agency failed to leave copy of home exercise program (HEP) at Patient (P) (P#5 and #6) home folder two (2) of eighteen (18) sampled patients. The Findings include: 1. A home visit was conducted at 10:00 a.m. on 6/28//22, at the residence of Patient (P#5) with Occupational Therapist (OT) FF. P#5 was admitted to the home health agency on 6/8/22, with the diagnosis of Type 2 Diabetes with Diabetes peripheral angio path without gangrene. The clinical record was reviewed for certification period 6/8/22 to 8/6/22. During the home visit, the surveyor noted the home exercise plan (HEP) was not in patient folder in the home. On 6/28/22 at 10:00 A.M., while reviewing the patient’s folder in the home with (OT) EE, (OT) EE verbalized understanding of requirement of education on HEP and HEP to be placed in the patient folder in the home. 2. A home visit was conducted at 8:30 a.m. on 6/28//22, at the residence of Patient (P#6) with Physical Therapist (PT) EE. P#6 was admitted to the home health agency on 5/17/22, with the diagnosis of Venous insufficiency (chronic) (peripheral). The clinical record was reviewed for certification period 5/17/22 to 7/15/22. During the home visit, the surveyor noted the home exercise plan (HEP) was not in the patient folder in the home On 6/28/22 at 8:30 A.M., while reviewing the patient’s folder in the home with (PT) FF, (PT) FF verbalized understanding of requirement of HEP education and HEP to be placed in patient folder in the home.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on home visit observations and staff interviews, it was determined the agency failed to ensure the agency staff followed accepted standards of practice to prevent the transmission of infectious and communicable diseases for 1 of 7 (#11) sampled home visit patients. Findings include: 1. During a home visit observation on 6/28/22 at 9 :35 a.m. for patient #11 with a recertification period of 6/1/22 to 7/30/22 with a pertinent diagnosis of osteomyelitis and type 2 diabetes mellitus with chronic kidney disease, this surveyor observed a skilled nurse (SN) perform wound care to lower extremities. A resumption of care order dated 6/11/22 required the SN to perform the wound care to 2ND toe amputation and right 4th toe partial amputation area as follows: Irrigate /cleanse with wound cleanser, normal saline, or soap and water. Apply Aquacel AG or generic equivalent, may apply skin barrier to peri wound as needed to prevent maceration and protect peri wound cover with foam. Secure with rolled gauze and tape. Change dressing twice weekly and as needed for soiled or loosened dressings. However, at the home visit, the LPN AA did not use aseptic technique when providing wound care. The LPNAA did not change the gloves after cleansing the wound. The LPNAA used the same gloved hands to retrieve supplies from the supply container trying to find the Aquacel while opening every packet in the supply container, thus contaminating the entire supply box. The LPNAA did not use clean hand/gloves and/or technique to avoid introducing contaminates into the entire supply container. The LPNAA failed to ensure the wound care procedure was performed with aseptic technique, putting the patient at risk for infection. During an interview on 6/29/22 at 3:30 p.m., the Direction of Operations acknowledged the LPN AA did not follow acceptable standards of care for infection prevention to prevent the transmission of infectious and communicable diseases.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on review of clinical records, policy review, and staff interviews, it was determined that the Condition of Participation for Skilled Professional Services was not in compliance for 4 of 18 sampled patients as evidenced by the agency's failure to ensure the clinicians provide services as ordered on the plans of care (Refer to G-710) and failure to provide care coordination amongst physician and team members for 2 of 18 patients (Refer to G-718). The cumulative effects of these systemic problems resulted in the home health agency’s inability to provide optimal care and services as ordered on the plans of care which could result in serious patient injury/harm or death. (Refer to G-710 and G-718) Refer to G-710 and G-718

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, it was determined the agency failed to provide services as ordered by the physician in the plan of care for 6 of 18 (#1, #5, #6, #7, #12 and #17) sampled patients (P). Findings include: 1. Review of the plan of care for patient #1 with a certification period of to 2/24/22 to 4/24/22 required the skilled nurse (SN) to visit the patient three times a week for one week, and once a week for one week starting 2/24/22. According to the clinical record, RNAA visited the patient on 2/24/22 did not visit the patient the until the week 2/28/22. The record did not contain SN missed visits note to notify the physician of the missed visit thus, resulting in 2 unauthorized missed visits. Additionally, the plan of care requires the SN to visit patient three times as needed for tracheostomy /respirator complications. Based on review of the statement dated 3//22 given by RN AA, the RNAA received a call on 2/26/22 (Saturday) and 2/27/22(Sunday) from the caregiver to assist patient with complications of ventilator and breathing difficulties. The clinical record lacked evidence that the RNAA made the visit to patient’s home on 2/6 and 2/27/22 as needed and requested by the patient and caregiver. Furthermore, the coordination note lacked documentation that the physician was notified of the missed visit resulting in two unauthorized PRN (as needed) missed visits. RNAA failed to follow the ordered visit frequency. During an interview on 6/29/22 at 3:30 p.m., the Director of Operations did not provide any documentation to show the physician was notified of the SN missed visits which resulted in unauthorized missed visits and the SN visited the patient as per patient /care giver’s needs. 1.Review of the plan of care for patient #1 with a certification period of 2/24/22 to 4/24/22 and a diagnosis of Amyotrophic lateral sclerosis (ALS) and Respiratory failure , required the skilled nurse (SN) to visit the patient 3 times a week for 1 week starting the week of 2/24/22. The clinical record revealed the SN only visited the patient 1 time the week of 2/24/22 instead of 3 times as ordered. The record lacked any documentation to indicate the physician was notified of the 2 missed visits resulting in 2 unauthorized missed visits. Additionally, the plan of care instructed the SN to perform tracheostomy care at each SN visit. The SN visited the patient on 2/24/22 however, the SN failed to perform tracheostomy care as ordered. During an interview on 6/29/22 at 1:00p.m., the Director of Operations, did confirm the SN failed to meet the patient visit frequency and failed to perform tracheostomy care as ordered. The Findings include: 1. Patient #7 was admitted to agency on 4/20/22, with a diagnosis of left bottom pressure ulcer and congestive heart failure. Physician order dated 6/23/22: skilled nurse to perform wound care to left buttock pressure ulcer cleanse with wound cleanser or soap and water, then apply Medihoney to wound bed cover wound with hydrocolloid dressing wound care to be performed by SN once a week and as needed if soiled or dislodgement. Licensed Practical Nurse (LPN) CC used Opti foam and Medi pore to cover the left bottom pressure ulcer wound, instead of Medihoney and cover with hydrocolloid dressing per physician’s order. On 6/28/22, at 2:30 p.m., an interview was conducted with (LPN) CC, who stated that she did not recollect that she did not follow physician’s order for P#7’s left bottom pressure ulcer wound care done on 6/21/22. 2. Patient #12 was admitted to agency on 10/23/21, with a diagnosis of heart failure. Physician order dated 10/26/21: skilled nurse to assess, monitor and record daily weight, if unable to weigh patient, may measure abdominal girth and notify physician if P#12 gained two pounds in one day or five pounds in one week. (LPN) CC did not weigh P#12. There was no record showing that (LPN) CC notified physician for not obtaining P#12’s weight. On 6/28/22, at 2:40 p.m., an interview was conducted with (LPN) CC, who stated that she did not weigh P#12’s because he was bed bound. (LPN) CC confirmed that she did not measure abdominal girth or notify the physician. The Findings include: Patient #17 was admitted to agency on 10/14/20, with a diagnosis of heart failure. Physician order dated 2/08/21: skilled nurse to assess, monitor and record daily weight, if unable to weigh patient, may measure abdominal girth and notify physician if P#17 gained two pounds in one day or five pounds in one week. (LPN) CC did not weigh P#17. There was no record showing that (LPN) CC notified physician for not obtaining P#17’s weight. On 6/28/22, at 2:30 p.m., an interview was conducted with (LPN) CC, who stated that she did not weigh P#12’s because he was bed bound. (LPN) CC confirmed that she did not measure abdominal girth or notify the physician. The Findings include: 1. A home visit was conducted at 10:00 a.m. on 6/28//22, at the residence of Patient (P#5) with Physical Therapist (PT) FF. P#5was admitted to the home health agency on 6/8/22, with the diagnosis of Type 2 Diabetes with Diabetes peripheral angio path without gangrene. The clinical record was reviewed for certification period 6/8/22 to 8/6/22. During the home visit, the surveyor noted the home exercise plan (HEP) was not in patient folder in the home. While reviewing the patient folder in the home with (OT) EE, (OT) EE verbalized understanding of requirement of HEP to be placed in patient folder in the home. The Findings include: 2. A home visit was conducted at 8:30 a.m. on 6/28//22, at the residence of Patient (P#6) with Physical Therapist (OT) EE. P#6 was admitted to the home health agency on 5/17/22, with the diagnosis of Venous insufficiency (chronic) (peripheral). The clinical record was reviewed for certification period 5/17/22 to 7/15/22. During the home visit, the surveyor noted the home exercise plan (HEP) was not in patient folder in the home While reviewing the patient folder in the home with (PT) FF, (PT) FF verbalized understanding of requirement of HEP to be placed in patient folder in the home.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, it was determined that the personnel furnishing services failed to maintain liaison to ensure their efforts were coordinated effectively and timely to support the objectives outlined in the plan of care for one of 18 (#1) sampled patients. Findings include: Review of the plan of care for patient #1 with a certification period of 2/24/22 to 4/24/22 revealed pertinent diagnoses of Amyotrophic Lateral Sclerosis, Acute respiratory failure with hypoxia and hypercapnia, encounter for attention to tracheostomy, personal history of cardiac arrest and patient is on ventilator Trilogy. The skilled nurse (SN) was required to instruct on disease process, and its complications, signs and symptoms of respiratory failure and tracheostomy care and its complications., The SN was required to visit the patient has needed for respiratory /tracheostomy complications. SN was also required to report changes in patient condition to the physician. Review of the RNAA statement signed and dated on 3/2/22 revealed that RNAA received a call from the caregiver on 2/26/22 at 1:38 a.m., stating that the trilogy alarm is keep going off, and caregiver stated to the RNAA that PT#1 “feels like he can’t breathe”. The statement document revealed that the RNAA advised the patient to call the respiratory company Aero care and if patient gets worse to call 911. The RNAA statement also revealed that RNAA received another call on 2/27/22 at 12 p.m. from the caregiver stating that Trilogy alarm is going off every 30 minutes and the caregiver called the respiratory therapist from Aero care, who advised the caregiver to silence the alarm because the RT will not be able to visit the patient. the care giver calls the 911, the paramedics arrived but was not able to assist with the Trilogy. The RNAA advised caregiver that RNAA will visit the patient on 2/28/22 between 10 and 11:00 a.m. The clinical record lacked communication or coordination efforts made with care team members and physician to discuss the concerns that the patient addressed during the phone call on 2/26/22 and on, 2/27/22. furthermore, review of the RNAA visit note 2/28/22 revealed that caregiver was upset regarding the trilogy alarm keep going on and off and respiratory therapist and the paramedics were not able to identify and assist with the trilogy alarm issues. RNAA visit note 2/28/22 revealed that RN left the patient’s residence without notifying the physician and the agency team members. Updated to the RN visit note date 2/28 revealed that RT arrived after RN’s departure and found patient hypoxic thus transferred patient to the hospital and found patient to be brain dead and patient expired o 3/11/22. The agency failed to maintain liaison to ensure their efforts were coordinated effectively and timely to support the objectives outlined in the plan of care for patient #1 as evidenced by clinical record lacked documentation that the skilled nurse alerted the physician and pertinent team members of patient needs and assessment and change in patient conditions on 2/28/22 and lack of documentation on the on-call report for the calls received on 2/26/22 and 2/27/22. The SN failed to communicate with the care team and the physician to effectively coordinate the patient's identified needs prior to patient was transferred to the hospital. Additionally, the record lacked any coordination efforts to transfer the patient to a facility which would be better equipped to handle the patient’s immediate medical needs in the event the home health agency was not able to provided to necessary care and services needed to maintain patient safety. The agency failed to communicate with the physician and team to effectively coordinate the patient's care for identifying the patient's needs and services. During an interview on 6/29/22 at 3:30 p.m., Director of operations and Area Vice President (AVP) provided no evidence of coordination with the physician and/or agency team members regarding patient's current status and patient specific needs.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on record review, staff interview and patient family interview, it was determined that the agency failed to ensure the home health aide (HHA) BB followed the orders of the plan of care for 1 of 7 sample Patients(P) (#2). Findings include: Review of the clinical record for Patient (P) #2 with a certification period of 6/9/22 to 8/7/22, revealed P#2 was admitted to home health services on 6/9/22, with diagnosis of hemiplegia following cerebral infarct affecting right dominant side. Review of the Plan of Care dated 6/9/22, it was documented frequency of (HHA) 1W4 (one time week/4wks). Under the orders of Discipline and Treatment revealed HHA service for assistance with personal care, hygiene and activities of daily living. Review of the Aide Care Plan Report dated 6/9/22, revealed under Care Plan Category/Services-Bathing-Bed Bath. Review of document titled, “Visit Note Report” dated 6/22/22, the HHA BB documented the Bed bath as complete. Review of document titled, “Visit Note Report” dated 6/28/22, the HHA BB documented the Bed bath as complete. During an interview on 6/28/22, at 11:00 a.m., during a home visit observation, family member (FM) of P#2 questioned HHA BB why patient was not getting a shower. HHA BB reported the Care Plan has order of bed bath and she has to follow that care plan. FM of P #2 stated the same HHA BB assisted him giving P#2 a shower last week, 6/22/22, and he was not sure what the difference was today. During observation on 6/28/22, the HHA provided a “sponge bath” with P#2 sitting on the toilet. HHA BB assisted P #2 from the wheelchair to the toilet. She bathed him and then asked the FM of P #2 if he could assist her with the patient while she cleaned his “bottom.” It was observed P #2 was very unsteady on his feet with need of assistance at all times of one to two person while out of the wheelchair. HHA BB did not follow the care plan of a bed bath for that visit observation. FM P #2 further stated, if P#2 does not get a shower, but instead a sponge bath on the toilet, P#2 will insist he get a shower once everyone leaves. He stated that is double work and he is willing to assist the HHA with giving P#2 a shower on her visits like before.

Duties of a HH aide CFR(s): 484.80(g)(3) The duties of a home health aide include: (i) The provision of hands-on personal care; (ii) The performance of simple procedures as an extension of therapy or nursing services; (iii) Assistance in ambulation or exercises; and (iv) Assistance in administering medications ordinarily self-administered. This ELEMENT is not met as evidenced by: Based on clinical record reviews, home visit observation and staff interviews, it was determined that home health aide failed to follow the plan of care for 1 of 7 (#2) sampled patients receiving home health aide services. Findings include: Review of the home health aide (HHA) care plan dated 6/16/22 for patient #2 with a certification period of 6/9/22 to 8/9/22 required the HHA to provide bed bath for the patient two times a week. However, during a home visit on 6/28/22 approximately at 11:15 a.m., the CNABB provided sponge bath on the commode in the bathroom. Furthermore, the patient’s caregiver verbalized that patient usually takes shower and the HHABB gave a shower to the patient on 6/21/22. CNABB also verbalized that during the last visit on 6/22/22, the HHABB assisted the caregiver with giving shower to the patient. HHA failed to follow the care plan in completing the assigned tasks as required. During an interview on 6/29/22 at 3:30 p.m., Director of Operations provided no evidence the HHA followed the established care plan as required on the above referenced dates.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, it was determined the agency failed to ensure that clinical records contained clear, complete, and accurate documentation and orders in the record for 1 of 18 (#2) sampled patients. Findings include: 1. Review of the plan of care for patient #2 with a certification period of 6/9/22 to 8/7/22 required the certified nurse assistant (CNA) to visit the patient twice per week for four weeks to include the tasks of identifying the patient, taking vital signs and providing bed bath during each visit. However, during a home visit on 6/28/22 approximately at 11:15 a.m., the HHABB provided sponge bath on the commode in the bathroom. Furthermore, the patient’s caregiver verbalized that patient usually takes shower and the HHABB gave a shower to the patient on 6/21/22. CNABB also verbalized that during the last visit on 6/22/22, the HHABB assisted the caregiver with giving shower to the patient. However, review of the HHA note dated 6/22/22 and 6/29/22, the CNABB documents bed bath given to the patient. HHA failed to document the accurate type of bath that was given to the patient as ordered in the plan of care and failed to ensure the record was clear and concise to reflect the care was provided as ordered by the physician. During an interview on 6/29/22 at 3:30 p.m., the Direction of Operations acknowledged the CNABB failed to document clear and accurate information regarding the patient's bath in the clinical record.