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

An Abbreviated/Partial Extended Survey investigating complaints # 2614642 and 2627976 were conducted at Tugaloo Home Health Agency on September 29, 2025, and concluded on October 1, 2025. At the time of the investigation, the agency was not in compliance with Chapter 42 CFR Part 418, Rules and Requirements for Home Health and Hospice Agencies. The census was 1154. Based on record reviews and interview(s), the agency was found to be in compliance with complaint #2614642. The agency was not found to be in compliance with complaint 2627976. The following deficiencies were cited: On September 29, 2025, an Immediate Jeopardy (IJ) was identified related to CFR 484.60 Care planning, coordination, quality of care and CFR 484.75 Skilled professional services. The agency Administrator was informed of the immediate jeopardy on September 30, 2025, at 4:00 p.m. The noncompliance related to immediate jeopardy was identified to have existed on September 15, 2024. Tugaloo Home Health Agency was found not to be in compliance with CFR 484.60 Care planning, coordination, quality of care and CFR 484.75 Skilled professional services. On 10/1/25/25, the Hospice Removal Plan was found acceptable by verifying the implementation of the following corrective actions: G700 The agency failed to ensure that skilled professional services were furnished in accordance with the physician's plan of care for the patient in question Actions to correct deficiency 1. Identification of all staff that failed to identify individual patient needs a. PTA BB will receive written performance improvement plan b. PT AA will receive written performance improvement c. Clinical Manager will receive written performance improvement. Responsible person: Administrator Completion date 10/1/2025 2. Physician of patient number 3 will be notified of the failure to appropriately follow plan of care regarding oxygen administration. Responsible person: Administrator Completion date 10/1/2025 3. Effective 10/1/25, all clinical staff for the provider number will attend an in-service training covering the proper execution and documentation of physician's orders as well as execution of the physician ordered the plan of care. Staff attendance via sign-in sheets and roster tracking for virtual attendees will be taken and all staff, including PRN, will complete the training in its entirety prior to performing further patient visits. The training will emphasize the importance of following the care plan as ordered and reporting any barriers to the clinical manager, director of operations and physician of record. The agenda for this training will include: · Policy AA-014 (Plan of Care/Care Planning Process) with emphasis on items that must be included in the plan of care including, but not limited to, Oxygen, both PRN and continuous · MA-002 (Drug Regimen Review Home Health) with emphasis on a complete medicine reconciliation policy on each visit · Policy TX-001 (Physician orders and medical supervision of the plan of care) with emphasis on the care plan specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment · Policy TX-002(Coordination of Care) with emphasis on notifying the physician of any change · State Survey Review PowerPoint will be presented. 4. Following the training, the Administrator/Director of Operations for the provider number will audit 100% of all patients identified by the physical assessment report in Homecare Homebase as having supplemental oxygen for a complete plan of care. A compliance goal of 100% is targeted. G570 1. Effective 10/1/25, all clinical staff for the provider number will attend an in-service training covering the proper execution and documentation of physician's orders as well as execution of the physician ordered the plan of care. Staff attendance via sign-in sheets and roster tracking for virtual attendees will be taken and all staff, including PRN, will complete the training in its entirety prior to performing further patient visits. The training will emphasize the importance of following the care plan as ordered and reporting any barriers to the clinical manager, director of operations and physician of record. The agenda for this training will include: · Policy AA-014 (Plan of Care/Care Planning Process) with emphasis on items that must be included on the plan of care including, but not limited to, Oxygen both PRN and continuous · MA-002 (Drug Regimen Review Home Health) with emphasis on a complete medicine reconciliation policy on each visit · Policy TX-001 (Physician orders and medical supervision of the plan of care) with emphasis on the care plan specify the care and services necessary to meet the patient- specific needs as identified in the comprehensive assessment · Policy TX-002(Coordination of Care) with emphasis on notifying the physician of any change Responsible person: Administrator Completion date 10/1/2025 2. Quality assurance performance improvement meeting to take place on 10/3/2025 to discuss and review findings of the complaint survey conducted on 09/29/2025. Corrective actions taken to include disciplinary action, education and audits conducted. Audit findings will be reported to the QAPI committee to include plans for remediation and disciplinary actions. All actions for correction to be reported to the QAPI committee no less than weekly until compliance threshold changes and then monitored and reported quarterly. Responsible person: Administrator Completion date 10/3/2025

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 policy titled "Plan of Care (POC) /Care Planning Process," review of clinical records and staff interviews, it was determined that the agency failed to follow the plan of care by not providing continuous oxygen at 3 liters per minute via nasal cannula and oxygen therapy interventions for one patient (P) (P#3) of five sampled patients. Findings include: Review of policy titled "AA-014 Plan of Care (POC) /Care Planning Process," with last review date 1/31/25 revealed the following: Purpose: A plan of care will be developed through a care planning process, which is designed to provide care, treatment, and services that are appropriate to the patient's individual needs. 7. The Clinical Manager is responsible for facilitating coordination among all disciplines. Review of document titled "Home Health Certification and Plan of Care" dated 9/13/24 revealed orders for oxygen 2 Liters per minute continuous via nasal cannula for P#3 and interventions that the Physical Therapist (PT) and the Physical Therapist Assistant (PTA) were to educate patient/caregiver on oxygen management. During an interview with the Executive Director of Operations on 9/30/25 at 12:30 p.m., the Executive Director of Operations acknowledged that the care plan for P#3 contained an order for oxygen. She stated that she was unaware P#3 was not receiving oxygen as ordered on the plan of care. She confirmed the Physical Therapist was assessing pulse oximetry (a measurement of the amount of oxygen that is in the blood, normal generally between 95% and 100%) on room air for P#3. The EDO confirmed that the agency failed to provide oxygen therapy and interventions as ordered on the plan of care. During an interview on 9/30/25 at 12:45 p.m. with the Physical Therapist (PT) PT AA states that he completed the recertification assessment for the period of 9/13/24 to 11/11/24 and was aware that oxygen 3 liters per minute continuous via nasal cannula had been ordered but failed to ensure that it was provided. During an interview with the Clinical Manager (CM) on 9/30/25 at 12:35 p.m. confirms that oxygen 3 Liters per nasal canula was ordered and listed on the plan of care for P#3. She was unaware that the oxygen was not available to P#3. She stated oxygen saturation levels were taken on room air. During an interview on 9/30/25 at 1:00 p.m. with Physical Therapist Assistant (PTA), PTA BB stated that there was no oxygen provided for P#3. She states that she looked for the oxygen but failed to report that the oxygen had not been provided to P#3. The PTA BB stated P#3 would have oxygen saturation levels below 90 while active and the levels would recover to the 90's after she rested.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on policy titled "Coordination of Care," record review and family and staff interviews, it was determined the agency failed to ensure communication to the physician involved in the plan of care. Specifically, the agency failed to notify the physician that P#3 was not receiving oxygen therapy and oxygen therapy interventions as ordered on the plan of care for one patient (P) (P#3) of five sampled patients. Findings include: Review of policy titled "TX-002 Coordination of Care," last reviewed 7/10/25 revealed the following: Purpose: The patients’ care and services will be coordinated among staff and branches. To ensure consistent documentation, communication, retrieval of significant administrative and patient/family information. Procedure: 6. The overseeing physician is notified promptly of any changes in patient's condition or needs that suggest that outcomes are not being achieved and /or the pan of care should be altered. 7. Agency staff involved in the patient's plan of care provides patient related updates in a timely manner to the physician and includes as appropriate: Patient's current condition Changes in patient's condition Patient response to treatment, if negative will be reported to the physician immediately During an interview with the Clinical Manager (CM) on 9/30/25 at 12:35 p.m. confirms that oxygen 3 Liters per nasal canula was ordered and listed on the plan of care for P#3. She was unaware that the oxygen was not available to P#3. She stated oxygen saturation levels (a measurement of oxygen found in the blood) were taken on room air. CM denies notifying the physician that P#3 did not receive oxygen as ordered. The agency failed to notify the physician that P#3 was not receiving oxygen therapy and oxygen therapy interventions as ordered.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and staff interviews, the agency failed to ensure that oxygen was initiated for one patient (P) (P#3) of five sampled patients (P) (P#3). Findings include: Review of visit note report dated 10/23/24, Physical Therapist Assistant (PTA) BB obtained pulse oximetry (a measurement of the amount of oxygen that is in the blood, normal generally between 95% and 100%) on room air for P#3 with results of 65% saturation. P#3 had ambulated to the bathroom. PTA BB waited 10 minutes of rest time, and the recovery time returned to above 90% on room air. During an interview on 9/30/25 at 12:45 p.m. with Physical Therapist (PT) PT AA confirmed that the care plan did contain orders for oxygen 3 liters per minute continuous via nasal cannula for P#3, but he failed to coordinate care with other disciplines to ensure that P#3 received the oxygen. He stated that he assessed P#3’s pulse oximetry on room air and did not provide interventions for oxygen therapy. During an interview on 9/30/25 at 1:00 p.m. with Physical Therapist Assistant (PTA), PTA BB stated that there was no oxygen provided for P#3. She states that she looked for the oxygen but failed to report that the oxygen had not been provided to P#3. The PTA BB stated P#3 would have oxygen saturation levels below 90 while active and the levels would recover to the 90's after she rested. The agency failed to coordinate care delivery to meet patient’s needs.

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 policy titled “AA-014 Plan of Care (POC) Care Planning Process,” record review, and family and staff interviews, it was determined the home health agency failed to provide services as ordered by the physician as indicated in the plan of care for one patient (P) (P#3) of five sampled patients. Findings include: Review of the policy titled “AA-014 Plan of Care (POC)/Care Planning Process,” revised January 2025 revealed the following: PURPOSE: To provide physician/allowed practitioner ordered care, treatment, and services through an organized process and plan Review of document titled "Home Health Certification and Plan of Care" dated 9/13/24 revealed orders for oxygen 2 Liters per minute via nasal cannula for P#3 and interventions that the Physical Therapist (PT) of Physical Therapist Assistant (PTA) were to educate patient/caregiver on Oxygen management. Review of PTA BB visit note report dated 10/23/24, PTA BB obtained oxygen saturation level on room air for P#3 with results of 65% saturation. (Normal oxygen saturation rates are typically between 95% and 100%.) PTA BB provided 10 minutes of rest time after exercises, and after recovery period of 10 minutes oxygen saturation returned to above 90% on room air. During an interview on 9/30/25 at 12:45 p.m. with the Physical Therapist (PT) PT AA states that he completed the recertification assessment for the period of 9/13/24 to 11/11/24 and was aware that Oxygen 3 liters per minute via nasal cannula had been ordered but failed to ensure that it was provided. During an interview on 9/30/25 at 1:00 p.m. with Physical Therapist Assistant (PTA) BB, PTA BB stated that there was no oxygen provided for P#3. She states that she looked for the oxygen but failed to report that the oxygen had not been provided to P#3. The PTA BB stated P#3 would have oxygen saturation levels below 90 while active and the levels would recover to the 90's after she rested. During an interview with the Clinical Manager (CM) on 9/30/25 at 12:35 p.m. confirms that oxygen 3 Liters per nasal canula was ordered and listed on the plan of care for P#3. She was unaware that the Oxygen was not available to P#3. She stated oxygen saturation levels were taken on room air.

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 the policy titled “AA-014 Plan of Care (POC)/Care Planning Process,” record review and staff interviews, the agency failed to provide services ordered by the physician as indicated on the plan of care. Specifically, the agency did not follow the plan of care of one patient (P) P#3 to provide Oxygen 3 liters per minute via nasal cannula. Findings include: Review of the policy titled “AA-014 Plan of Care (POC)/Care Planning Process,” revised January 2025 revealed the following: PURPOSE: · To provide physician/allowed practitioner ordered care, treatment, and services through an organized process and plan Review of document titled "Home Health Certification and Plan of Care" dated 9/13/24 revealed orders for oxygen 3 Liters per minute continuously via nasal cannula for P#3 and interventions that the Physical Therapist (PT) of Physical Therapist Assistant (PTA) were to educate patient/caregiver on oxygen management. The plan of care also lacked oxygen saturation parameters to notify the physician of potential complications. Review of PTA BB visit note report dated 10/23/24, PTA BB obtained oxygen saturation level on room air for P#3 with results of 65% saturation. (Normal oxygen saturation rates are typically between 95% and 100%.) PTA BB provided 10 minutes of rest time after exercises, and after a recovery time of 10 minutes oxygen saturation returned to above 90% on room air. The agency staff failed to follow physician's orders to oxygen administration as outlined in the plan of care. During an interview on 9/30/25 at 12:45 p.m. with Physical Therapist (PT), AA states that he completed the recertification assessment for the period of 9/13/24 to 11/11/24 and was aware that oxygen 3 liters per minute via nasal cannula had been ordered but failed to ensure that it was provided. During an interview on 9/30/25 at 1:00 p.m. with Physical Therapist Assistant (PTA), PTA BB stated that there was no oxygen provided for P#3. She states that she looked for the oxygen but failed to report that the oxygen had not been provided to P#3. The PTA BB stated P#3 would have oxygen saturation levels below 90 while active and the levels would recover to the 90's after she rested. During an interview with the Clinical Manager (CM) on 9/30/25 at 12:35 p.m., CM confirms that oxygen 3 Liters per nasal canula was ordered and listed on the plan of care for P#3. She was unaware that the oxygen was not available to P#3. She stated oxygen saturation levels were taken on room air.

An Abbreviated/Partial Extended Survey investigating complaint #111199 was conducted at Tugaloo Home Health, An Amedisys Company on January 27, 2025, and concluded on January 28, 2025. The agency was found to be in compliance with complaint #111199. However, at the time of the survey, unrelated to the complaint, the agency was not in compliance with Chapter 42 CFR Part 418, Rules and Requirements for Home Health and Hospice Agencies. The census was 1151. The following deficiencies were cited:

Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: Based on review of policy “Complaint Documentation,” record reviews, and staff interview, it was determined the agency failed to process and resolve complaints for one patient (P) (P#5) of two patients sampled who submitted complaints to the agency. Findings include: A review of the policy titled “Complaint Documentation,” revised 7/2023 reveals the following: The Home Health Agency should be able to produce documentation for each complaint received that confirms an investigation was conducted and records the investigation findings as well as the ultimate resolution of the complaint. 7) The Administrator/DOO is responsible for reviewing every complaint, determining the necessary action, communicating the resolution with the person filing the complaint no later than 30 calendar days following receipt of the complaint. A review of P#5’s clinical record revealed the patient was admitted on 8/13/2024 with a diagnosis of pneumonia and co-morbidities of cellulitis (a bacterial infection that affects the skin and underlying tissues) of both legs. The patient was discharged on 10/15/2024 due to no further skilled needs. A review of complaint logs revealed a document titled, “Complaint Report”, dated 11/12/2024, which revealed complaints were received by P#5. The report failed to reveal documentation of a resolution to the complaint. The clinical record failed to reveal documentation of communication with the patient regarding the complaint. The Executive Director of Operations (EDOO) provided copies of several emails between upper-level agency management and revealed calls from P#5 were received on 11/9/2024 and twice on 11/11/2024. The Complaint Report and the clinical record failed to reveal documentation of the content of these calls or the resolution of the complaints. An interview on 1/28/2024 at approximately 10:45 a.m. was conducted with the EDOO, who confirmed that all documentation related to this complaint had been provided.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on review of the policy “Discharge of Patients,” record reviews, and staff interview, it was determined the agency failed to provide the patient with written notice of discharge and send all necessary medical information to the receiving healthcare practitioner upon discharge for one patient (P) (P#5) of four sampled discharged patients. Findings include: A review of the policy titled, “Discharge of Patients”, Policy AA-016, reviewed 10/10/2024 reveals the following: Procedure: 7. The physician/allowed practitioner will be notified of the patient’s discharge from the home health agency. Documentation of physician/allowed practitioner communications/notification will be evident in the patient’s medical record. 11. A completed discharge summary is sent to the primary care physician/allowed practitioner, receiving facility or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge. 16. C. Verbal notification to non-institutionalized patients not in jeopardy will be followed by written notice- Notice of Medicare Non-Coverage (for traditional Medicare and Medicare Advantage patients.) A copy of this written notice shall be placed in the patient’s chart. A review of P#5’s clinical record revealed the patient was admitted on 8/13/2024 and discharged on 10/15/2024 due to no further skilled needs. A clinical chart review failed to reveal a signed Medicare Notice of Non-Coverage, documentation of physician notification of the discharge, or evidence the discharge summary was sent to the physician. The Executive Director of Operations (EDOO) provided the surveyor with a document titled “Event-Stages History Report”, which revealed that P#5’s discharge summary was faxed to an unnamed physician on 11/13/2024, 27 days after discharge. An interview on 1/28/2024 at approximately 10:45 a.m. was conducted with the EDOO, who agreed the clinical record lacked documentation of the discharge process.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on a review of policies, record reviews, and staff interview, it was determined the hospice governing body failed to assume responsibility for the agency’s management and operation by failing to process and resolve complaints, failing to provide patients with written notice of discharge and send discharge summaries to the receiving healthcare practitioner upon discharge for one patient (P) (P#5). Findings include: A review of an unnumbered policy titled, “Complaint Documentation”, revised 7/2023 reveals the following: 7) The Administrator/DOO is responsible for reviewing every complaint, determining the necessary action, communicating the resolution with the person filing the complaint no later than 30 calendar days following receipt of the complaint. A review of the policy titled, “Discharge of Patients”, Policy AA-016, reviewed 10/10/2024 reveals the following: Procedure: 7. The physician/allowed practitioner will be notified of the patient’s discharge from the home health agency. Documentation of physician/allowed practitioner communications/notification will be evident in the patient’s medical record. 11. A completed discharge summary is sent to the primary care physician/allowed practitioner, receiving facility or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge. 16. C. Verbal notification to non-institutionalized patients not in jeopardy will be followed by written notice- Notice of Medicare Non-Coverage (for traditional Medicare and Medicare Advantage patients.) A copy of this written notice shall be placed in the patient’s chart. A review of complaint logs revealed a document titled, “Complaint Report”, dated 11/12/2024, which revealed complaints were received by P#5. The report failed to reveal documentation of a resolution to the complaint. A review of P#5’s clinical record revealed the patient was admitted on 8/13/2024 with a diagnosis of pneumonia and co-morbidities of cellulitis (a bacterial infection that affects the skin and underlying tissues) of both legs. The patient was discharged on 10/15/2024 due to no further skilled needs. The clinical record failed to reveal documentation of communication with the patient regarding the complaint. The Executive Director of Operations (EDOO) provided copies of several emails between upper-level agency management and revealed calls from P#5 were received on 11/9/2024 and twice on 11/11/2024. The Complaint Report and the clinical record failed to reveal documentation of the content of these calls or the resolution of the complaints. Further review of P#5’s clinical chart review failed to reveal a signed Medicare Notice of Non-Coverage, documentation of physician notification of the discharge, or evidence the discharge summary was sent to the physician. The Executive Director of Operations (EDOO) provided the surveyor with a document titled “Event-Stages History Report, which revealed discharge summary was faxed to an unnamed physician on 11/13/2024, 27 days after discharge. An interview on 1/28/2024 at approximately 10:45 a.m. was conducted with the EDOO, who confirmed that all documentation related to the discharge and the complaint had been provided, and agreed the clinical record lacked documentation of the discharge process.

A complaint 31974 survey was conducted at Tugaloo Home Health, Gainesville, Georgia, on 9/14/22, by Surveyors. The complaint was Substantiated with deficiencies. It was revealed that the agency was in compliance with Chapter 42 CFR Part 418, Rules and Requirements for Home Health and Hospice Agencies. The census was 228. Deficiencies were cited.

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 1 (one) of 3 (three) (#1) sampled patients. Finding includes: 1. Review of the plan of care for patient with a recertification period of 7/3/21 – 9/8/21 revealed the patient has a primary diagnosis of Alzheimer, with Dementia and Hypertension. During the Certification period the Home Health Aide (HHA) was to visit patient once per week for 1 week, twice per week for 2 weeks, then once per week for the remainder of the certification period. Physician orders were that the patient was to have a shower with hair care, shave, nail care, and barrier cream applied. Patient was also to have routine vital signs taken and documented. The HHA failed to follow physician orders according to patients Plan of Care (POC). 2. During an interview with Administrator on 9/14/22 at approximately 1:30 pm administrator reported HHA did not go out to visit patient on 8/9/21, 8/16/21 and 8/19/21. HHA failed to follow physician orders laid out in patient’s Plan of Care (POC).

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 record reviews and staff interviews, it was determined that the agency failed to notify physician about the aide’s missed visits, for 1 (one) of 3 (3) sampled patients (P#1). The Findings include: Review of the plan of care for Patient (P#1) was admitted on 7/31/21, with a diagnosis of Alzheimer’s disease, dementia, and hypertension, revealed that the aide missed visits on 8/9/21, 8/16/21, and 8/19/21, but completed visits documentation and signed P#1’s signature. On 9/14/22 at 1:00 p.m., an interview was conducted with P#1’s daughter, who stated that the aide failed to come on 8/16/21, and 8/19/21. Patient #1’s daughter called agency on 8/20/21 to report the aide’s missed visits, and to request for help in bathing and grooming her father. P#1’s daughter said the agency’s staff were nice to them and sent someone to perform the grooming the next day. On 9/14/22 at 1:30 p.m., an interview was conducted with the previous Administrator, who stated that she did the investigation and confirmed that the aide signed patient’s signature on 8/16/21 and 8/19/21; she said the aide confessed the falsification of documentation, which resulted in the aide’s termination. The Administrator also confirmed that the agency did not notify physician, because the aide lied that she did the visits.

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 clinical record review and interviews, it was determined the agency failed to ensure that the Home Health Aide (HHA) provided services to meet the patient’s needs 1 (one) of 3 (three) (#1) sampled patients. Findings include: 1. 1. Review of the plan of care for patient with a recertification period of 7/3/21 – 9/8/21 with a primary diagnosis of Alzheimers, with Dementia and Hypertension. required the HHA to visit the patient once per week for 1 week, twice per week for 2 weeks, then once per week for the remainder of the certification period. According to the records The HHA had missed visits on 8/9/21, 8/16/21, and 8/19/21. The Patients’ needs were not met according to the plan of care, facility failed to address patient needs by neglecting to provide HHA services that were missed. No missed visits were documented. Family was not notified of any plan to make up the visits and had to care for the patient themselves. 2. During a phone interview with daughter on 9/14/22 at 2:10pm. Daughter Confirmed HHA did not make a visit on 8/9/21, 8/16/21 or 8/19/21. Daughter stated had contacted the facility to request help in bathing her father. 3. During an interview with previous Administrator on 9/14/22 at approximately 1:30 pm the administrator reported aide did have missed visits on 8/9/21, 8/16/21 and 8/19/21. Administrator admitted she did not follow up with family regarding need for bathing and grooming of the patient.

Administrator must: CFR(s): 484.105(b)(1) Standard: Administrator. The administrator must: This STANDARD is not met as evidenced by: Based on record reviews and staff interviews, it was determined that the Administrator failed to conduct in-service training or have a plan to prevent the situation of not meeting patients’ needs, for 1 (one) of 3 (three) sampled patients (P#1). The Findings include: Review of the plan of care for Patient (P#1) was admitted on 7/31/21, with a diagnosis of Alzheimer’s disease, dementia, and hypertension, revealed that the aide missed visits on 8/9/21, 8/16/21, and 8/19/21, but completed the visits documentation and signed P#1’s signature. On 9/14/22 at 2:15 p.m., an interview was conducted with P#1’s daughter, who stated that the aide failed to come on 8/16/21, and 8/19/21. On 9/14/22 at 1:30 p.m., an interview was conducted with the previous Administrator, who stated that she received a phone call from P#1’s daughter on 8/20/21, reporting the aide’s missed visits, and requesting for help in bathing and grooming her father. The Administrator said that she did the investigation and confirmed that she did not conduct in-service training for the staff, to prevent the re-occurrence of the situation.