Every finding on record at Amedisys Home Health, Inc. of Virginia

An unannounced Home Health Medicare Complaint Survey (ID# 94207) was conducted at the above noted agency January 17 to January 18, 2023 by one (1) Medical Facilities Inspector from the Office of Licensure and Certification, Virginia Department of Health. Deficiencies were identified related to the complaint. In conjunction with the survey, the clinical records of seven (7) discharged patients, the agency's complaint log, an admission packet, employee job description, agency's policy and procedures were all reviewed. Multiple staff interviews were also conducted. The agency was found not to be in compliance with the Federal requirements of 42 CFR 484, the Medicare Conditions of Participation of Home Health Agencies.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on clinical record review, staff interviews and agency discharge policy and procedure, it was determined the agency failed to provide a Notice of Medicare Non-Coverage (NOMNC) to Medicare patients in advance of terminating care for two (2) of two (2) closed/discharge clinical records reviewed in the survey sample for which a NOMNC was applicable. (Clinical Records #1 and #7). The findings: Seven closed/discharge clinical records were reviewed in the agency on 01/17/2023 via electronic medical record in read only mode with the following findings: 1. The clinical record of patient #1, a Medicare beneficiary with a documented start of care date of 02/26/2022 contained documentation patient was discharged from the agency on 08/24/2022 with goals met. The clinical record failed to contain evidence the agency provided the patient an advanced, written notice of discharge/Medicare Notice of Non-Coverage (NOMNC) prior to discharge from the agency. 2. The clinical record for patient #7, a Medicare beneficiary, with a documented start of care date of 07/28/2022 contained documentation patient was discharged from the agency on 08/17/2022 with goals met. The clinical record failed to contain evidence the agency provided the patient an advanced, written notice of discharge/Medicare Notice of Non-Coverage (NOMNC) prior to discharge from the agency. Staff interviews: On 01/17/2023 at 12:30 PM, the Medical Facilities Inspector asked staff #3 (Skilled Nurse who performed the non-visit discharge on 08/24/2023 for patient #1) if a skilled nurse visit was attempted, and if the patient was notified in advance of the discharge. Staff #3 stated, " yes, I knocked on the door 08/22/2022 but there was no answer. I did the non-visit discharge but not the notification of discharge to the patient...maybe the LPN (Licensed Practical Nurse) did a subsequent visit and discussed discharge with the patient". On 01/17/2023 at 1:50 PM, the Medical Facilities Inspector asked if patient #1 was discharged appropriately. The Administrator stated, "the patient may had been a discharge, but the nurse should have seen her first". On 01/18/2022, the Administrator reviewed patients #1 and #7 if any discharge planning was done and concluded the agency failed to document any discharge planning. Agency's Patient Information Booklet: On 01/17/2023, the agency's Patient Information Booklet was reviewed and read in part as follows: "E. Patient Transfer and Discharge Policies. Discharge planning begins when you are admitted to the agency based on your individual plan of care. You will be provided advance notice of your discharge or transfer in accordance with applicable regulation, except in the case of an emergency". The lack of providing patients a written notice in advance of terminating on-going care was reviewed with the Administrator on 01/18/2023.

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 agency's complaint log, select document review and staff interviews it was determined the agency failed to document a complaint with a documented investigation, and the resolution of the complaint reviewed for 2022-2023 (Client record #1). The findings: The agency's complaint log was reviewed in the agency on 01/17/2023. The complaint log did not contain the complaint of the complainant (patient #1). On 01/17/2023 at 12 PM, the Medical Facilities Inspector asked the Office Manager and Clinical Manager if they knew of this complaint that involved a discharge without notification from the agency. Both staff members confirmed that an LPN (Licensed Practical Nurse) did mention to them that patient #1 had contacted the LPN about the informal discharge and was upset. The Office Manager provided this Medical Facilities Inspector with the LPN's phone number. On 01/17/2023 at 2 PM, the Medical Facilities Inspector called the LPN (staff #5) and asked if the complaint was known to her. The LPN stated, "yes the patient (patient #1) called me on 08/25/2022 and told me the nurse (staff member #3) did not show up on Monday of 08/22/2023 or called her. I told the patient to call the office and make a complaint because it was late in the evening". On 01/17/2023 at 2:15 PM, the Medical Facilities Inspector asked the Administrator who may have taken patient #1's complaint within the office after the LPN spoke with the patient. The Administrator stated, " we have had a turnover with staff during that time. We have a different scheduler and case manager during this past August, so if the patient did call them...then those people are no longer here". Select Agency Policy Review: A copy of the agency's complaint policy was provided on 01/17/2023 at 3:00 p.m. to the Medical Facilities Inspector. The policy was titled, "Patient/Caregiver Grievance/Complaint" a select portion read as follows: "The agency is to initiate a complaint investigation within 10 business days of the agency's receipt of the complaint and document all components of the investigation. Documentation of the complaint is completed by the employee to whom the complaint is received and forwarded to the agency that include the following: a) Date of complaint b) Person filing report c) Person involved in complaint d) Person lodging complaint e) Nature of complaint f) Actions taken by agency's Director of Operations/designee g) Response of person involved in complaint.". The above noted findings regarding the incomplete process for handling the complaint and their resolution for a patient was reviewed with the Administrator on 01/18/2023.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on a review of clinical records and staff interview, it was determined the agency staff failed to follow the plan of care for one (1) of seven (7) patients in the survey sample (Clinical record #1). The findings: Seven closed/discharge clinical records were reviewed in the agency on 01/17/2023 via electronic medical record in read only mode with the following findings: The clinical record for patient #1 with a start of care date of 02/26/2022 was reviewed for the recertification period of 06/26/2022 to 08/24/2022. The skilled nurse was ordered for one (1) time per week for one (1) week effective 06/26/2022, then two (2) times per week for eight (8) weeks (total of 9 weeks for skilled nurse visits). During the clinical record review, it was noted, the nurse failed to make a visit for week 9. The record failed to contain documentation to support a missed visit and no evidence was provided that the physician was notified of the missed visit. Staff interviews: On 01/17/2023 at 12:30 PM, the Medical Facilities Inspector asked staff #3 (Skilled Nurse who performed the non-visit discharge on 08/24/2023 for patient #1) if a skilled nurse visit was attempted. Staff #3 stated, " yes, I knocked on the door 08/22/2022 but there was no answer. On 01/17/2023 at 2 PM, the Administrator confirmed there was no missed visit documentation by the skilled nurse, but a non-visit discharge was documented for patient #1.

An unannounced Home Health Medicare Complaint Survey (ID# 70890) was conducted at the above noted agency June 22, 2022 by one (1) Medical Facilities Inspector from the Office of Licensure and Certification, Virginia Department of Health The complaint was substantiated with related deficiencies cited. In conjunction with the survey, clinical records of two (2) patients with a pleural drainage catheter, the agency's complaint log and an admission packet were all reviewed. Multiple staff interviews were also conducted. The facility was found not to be in compliance with the Federal requirements of 42 CFR 484, the Medicare Conditions of Participation of Home Health Agencies.

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, document review and staff interview it was determined the agency failed to ensure patient needs were adequately met for two (2) of two (2) clinical records of patients with a pleural drainage catheter and were in the survey sample. (Clinical records #1 and #2) Findings: Two (2) clinical records of patients with a pleural drainage catheter were reviewed in the agency on 06/22/2022 with the following findings: 1. Clinical record #1 was reviewed for the certification period of 05/10/2022 to 07/08/2022. Patient's #1's plan of care contained physician orders for the skilled nurse to perform and teach patient/caregiver self management of the Pleurx pleural drainage system on the right chest to include a drain catheter, Pleurx drainage procedure, inspect catheter every day, change dressing every week, clean area with alcohol, cover with split gauze, secure with Tegaderm, May change dressing PRN (as needed) if soiled or dislodged. Skilled Nursing to teach patient/caregiver signs and symptoms to report to minimize the risk of complications. The clinical record contained documentation of the following: 05/10/2022 Supplies delivered 6 Asept drainage kit 1000ml vacuum bottle 05/20/2022 SN unable to drain Pleurx drain. Drain system not compatible. SN informed MD. MD states not much has drained from Pleurx. Supplies ordered. Continue with current POC (plan of care) Patient left in no distress. Supplies delivered 1. Aspira Pleural Drainage 1000ml bag kit bx/5 (BARD 4992301) 05/24/2022 Patient reports last time drain done on 05/21/2022 and 50 ml returned. Chest tube right lateral intact. Patient called MD during visit to report the Aspira drains that came during visit are not the right supply. The Aspira kit has no adapters for Pleurx tube. The patient has no bottles or bags on hand to drain at all today. Supervisor made aware. SN able to change chest tube dressing via sterile technique. Patient to see MD on 05/26/2022. Patient requested and was discharged from agency on 05/24/2022. 2. Clinical record #2 was reviewed for the certification period of 06/11/2022 to 08/09/2022. Patient's #2's plan of care contained physician orders for the skilled nurse to perform and teach patient/caregiver self management of the Aspira pleural drainage system on the right sided [sic] chest to include drain catheter every other day the Aspira drainage procedure, inspect catheter every day, change dressing every other day, clean area with alcohol, cover with gauze, cover with Tegaderm, May change dressing PRN (as needed) if soiled or dislodged. Skilled Nurse to teach patient/caregiver signs and symptoms to report to minimize the risk of complications. 06/15/2022 Patient has Aspira drain. Pleurx drains were ordered which are not compatible with Aspira. Aspira drains ordered today. SN will return on Friday and perform drain providing Aspira drains when they have been delivered. 06/17/2022 Patient has Aspira drain. SN performed pleural drain. Obtained 320ml of reddish fluid. Patient had no pain during or immediately after procedure. Document Review The agency's admission packet was reviewed in the agency on 06/22/2022 and contained a form titled "Home Health Patient Acknowledgements and Consent" select portion reads as follows: Provision of supplies and outpatient for those patient's with traditional Medicare, it is the policy of Amedisys to provide or arrange for all medically necessary physician ordered routine and non-routine medical supplies or outpatient services therapies furnished to the patient while under the care of Amedisys and to the extent arranged for by Amedisys there will be no additional charge to the patient. Staff Interview In an interview conducted in the agency on 06/22/2022 the Director of Operations/Administrator stated the hospital had sent a couple of drainage kits home with the patients when they were discharged and the agency had a prior patient with a Pleurx catheter that had an adapter so different brands were compatible and the staff had gotten use to that but the above noted patients didn't have an adapter so drainage kits ordered by the agency were not compatible. The failure to provide appropriate supplies was acknowledged by the Director of Operations/Administrator during the clinical record reviews and during the exit conference conducted in the agency on 06/22/2022.

An unannounced Medicare/Medicaid Home Health recertification survey was conducted at the above noted agency on January 31, 2021-February 2, 2022 by two (2) Medical Facilities Inspectors from the Virginia Department of Health Office of Licensure and Certification. In conjunction with this survey, the agency's emergency preparedness plan was reviewed. The agency was found to be in compliance with 42 CFR 484.102 the Conditions of Participation: Emergency Preparedness for Home Health Agencies.

An unannounced Medicare/Medicaid Home Health recertification survey was conducted at the above noted agency on January 31, 2021-February 2, 2022 by two (2) Medical Facilities Inspectors from the Virginia Department of Health Office of Licensure and Certification. The agency reported 961 unduplicated admissions during the last 12 months. In conjunction with the survey, the clinical records of (17) patients, (10) personnel files, an agency admission packet, the complaint log, the CLIA (Certified Laboratory Improvement Amendments) waiver, vaccination rule and seven (7) home visits and multiple staff interviews were conducted. The agency operates two branch locations and a visit was made to each site on January 31, 2022. The branch address' are: 200 Executive Center Parkway-Suite 100 1602 West Virginia Ave. Fredericksburg, VA 22401 Crewe, VA 23930 The agency was found not to be in compliance with 42 CFR 484, the Medicare Conditions of Participation for Home Health Agencies. Standard level deficiencies were identified and cited in this report.

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 clinical record review, observation(s) during home visits and staff interview, it was determined the agency failed to ensure each medical record contained accurate and complete medication reviews for three (3) of seventeen (17) clinical records reviewed in the survey sample (clinical records #2, 4, and 17). The findings were: The electronic clinical records were reviewed both onsite and offsite in read only mode from January 31 through February 2, 2022. Clinical record #2 was reviewed for the certification period of 12/22/2021 through 2/19/2022. Skilled nursing notes on 1/04/2022 and 1/12/2022 indicated the patient was taking Tylenol for pain. Physical Therapy notes on 1/04/2022 and 1/12/2022 indicated the patient was taking Tylenol for pain. Occupational Therapy notes for 1/11/2022 indicated the patient was taking Tylenol for pain and 1/19/2022 indicated the patient was taking Ibuprofen for pain. Tylenol and Ibuprofen were not listed on the patients medication profile or plan of care. Clinical record #4 was reviewed for the certification period of 1/19/2022 through 3/19/2022. The skilled nursing note on 1/19/2022 indicated the patient's caregiver was educated on the use of Narcan. Narcan was not listed on the patient's medication profile or plan of care. Clinical record #17 was reviewed for the certification period of 1/25/2022 through 3/25/2022. The Physical Therapy notes on 1/25/2022 and 1/31/2022 indicated the patient was taking Tylenol for pain. The Occupation Therapy note on 1/26/2022 indicated the patient was taking Tylenol for pain. A home visit was conducted with the Occupational Therapist on 2/01/2022 at 2 PM. During the home visit it was determined that in addition to the Tylenol, the patient had Tramadol ordered for pain which was being taken two times per day. Tylenol and Tramadol were not on the patient's medication profile or the plan of care. An interview was conducted with the administrator at 12 PM on 2/02/2022 to review the findings. The administrator acknowledged all medications including over-the-counter should be on the medication profile.

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 review, select policy review and interviews, it was determined the agency failed to ensure that each patient received home health services according to a written plan of care. Specifically, the agency failed to ensure each patient's plan of care was individualized and contained patient specific measurable outcomes and goals related to pain for six (6) of six (6) clinical records reviewed in the survey sample who experienced pain (clinical records #2, 4, 7, 8, 16 and 17). The findings were: The electronic clinical records were reviewed both onsite and offsite in read only mode from January 31 through February 2, 2022. 1. Clinical record #2 was reviewed for the certification period of 12/22/2021 through 2/19/2022. The plan of care goal related to pain stated, "patient/caregiver will be able to verbalize/demonstrate understanding of pain control measures by discharge". No patient specific measurable outcomes or goals were identified/documented related to pain on the plan of care to include but not limited to the patient's desired or acceptable level of pain. 2. Clinical record #4 was reviewed for the certification period of 1/19/2022 through 3/19/2022. The plan of care goal related to pain stated, "patient/caregiver will be able to verbalize/demonstrate understanding of pain control measures by 60 days". No patient specific measurable outcomes or goals were identified/documented related to pain on the plan of care to include but not limited to the patient's desired or acceptable level of pain. 3. Clinical record #7 was reviewed for the certification period of 11/29/2021 through 1/27/2022. A review of the care plan revealed no goals for pain, however a review of the clinical records revealed the patient had spinal pain with a score of 5 to 7. No patient specific measurable outcomes or goals were identified/documented related to pain on the plan of care to include but not limited to the patient's desired or acceptable level of pain. 4. Clinical record #8 was reviewed for the certification period of 8/29/2021 through 10/27/2021. The plan of care stated, "pain management-skilled nurse to observe, assess and provide education on pain management techniques. No patient specific measurable outcomes or goals were identified/documented related to pain on the plan of care to include but not limited to the patient's desired or acceptable level of pain. 5. Clinical record #16 was reviewed for the certification period of 12/31/2021 through 2/28/2022. The plan of care goal related to pain stated, "patient will verbalize understanding of pain management by discharge". No patient specific measurable outcomes or goals were identified/documented related to pain on the plan of care to include but not limited to the patient's desired or acceptable level of pain. 6. Clinical record #17 was reviewed for the certification period of 1/25/2022 through 3/25/2022. The plan of care goal related to pain stated, "patient will verbalize understanding of pain management techniques by discharge". No patient specific measurable outcomes or goals were identified/documented related to pain on the plan of care to include but not limited to the patient's desired or acceptable level of pain. A review of the policy on pain management and care planning was conducted in the agency on 2/02/2022. The pain policy # MSC:001 titled, Pain Assessment and Management states in part: Pain assessment should include ongoing goals and outcomes of pain control and management. The care plan policy # AA-014 states in part: Patients are informed about and encouraged to participate in the following: expected outcomes of care including patient-identified goals, and anticipated risks and benefits. The policy further states: The individualized plan must include the following: patient specific interventions and education, measurable outcomes and goals identified by the HHA (home health agency) and the patient. An interview was conducted with staff #1 and #3 at 12 PM on 2/02/2022. The staff members acknowledged the deficient practice and the need for staff education related to care plans.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner 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; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interview, it was determined the agency failed to send the patient's discharge summary to the primary care physician or primary care practitioner within 5 business days from the date of the final visit. The agency also failed to send the patient's transfer summary within 2 business days of becoming aware of an unplanned transfer to the appropriate facility for three (3) of five (5) closed clinical records reviewed in the survey sample. (Clinical record #'s 8, 9 and 10). The findings: Five (5) closed, electronic clinical records were reviewed both onsite and offsite in read only mode from January 31 through February 2, 2022. 1. The clinical record for patient #8 was reviewed for the certification period of 8/29/2021 to 10/27/2021. The record revealed that the patient was discharged from the agency on 9/16/2021. No discharge summary was sent to the primary physician. On 2/1/2022 at 10:45 AM the Office Business Manager confirmed the failed discharge summary to the primary physician and stated, we have a workflow that needs to be faxed out and it wasn't done but we will be training them on how to do this now. 2. The clinical record for patient #9 was reviewed for the certification period of 7/30/2021 to 9/27/2021. The record revealed that the patient was discharged from the agency on 8/26/2021. No discharge summary was sent to the primary physician. 3. The clinical record for patient #10 was reviewed for the certification period of 10/26/2021 to 12/24/2021. The record revealed that the patient was transferred from the agency on 11/9/2021. No transfer summary was sent to the primary physician. On 2/1/2022 at 11:20 AM the Office Business Manager confirmed the failed transfer summary to the primary physician and stated, no they weren't faxed but we will today. The lack of providing a discharge summary within 5 business days of the patient's discharge and a transfer within 2 business days was acknowledged prior to and during the exit conference with the area Vice President and the Administrator on 2/2/2022 at 12:00 PM.