Every finding on record at Amedisys Louisiana, LLC

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey

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 observations, interviews, and record reviews, the agency failed to ensure an accurate medication reconciliation was completed for 4 (Patient #1, Patient #3, Patient #4, Patient #5) of 5 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5) sampled patient’s medications observed during medication reconciliation in the course of home visit observations. Findings: Review of the agency’s Drug Regimen Review policy and procedure, with a review date of 12/09/2024, revealed, in part, when a patient was admitted to the agency from an acute of post-acute facility, it was the responsibility of the admitting clinician to assure they review the discharge paper from the facility to assure all medications with correct dosages were captured. The clinician will also ask the patient periodically to allow them visualize all medications the patient is current taking. The visualized medications are compared to the current medication profile to ensure accuracy of the medication profile, and any discrepancies should be clarified with the patient’s physician/allowed practitioner (NP/PA). In an interview on 02/25/2025 at 9:39AM, S1Administrator/Director of Nursing (DON) indicated all clinicians were expected to do a medication reconciliation of all the patient’s medication(s) at each visit by viewing the medication bottles and reconciling the medications in the home to the patient’s Client Medication Reports. Patient #1 Review of Patient #1’s Home Health Certification and Plan of Care for the certification period of 01/08/2025 through 03/08/2025 revealed Patient #1 received skilled nursing services twice a week. Review of Patient #1’s Client Medication Report, confirmed by S1Administrator/DON as the most accurate medication reconciliation, revealed, in part, Levofloxacin (antibiotic used to treat infections) 8 percent powder apply 1 gram (gm) to wound topically daily with a start date of 10/23/2024. In an interview on 02/26/2025 at 9:30AM, Patient #1 indicated he had the powder in the home but it had been discontinued from his treatment for a while now. In an interview on 02/26/2025 at 9:31AM, S3Registered Nurse (RN) indicated Patient #1 was not currently on the Levofloxacin powder; however, since it was in the home she did not remove it from the current medication list, and should have. In an interview on 02/27/2025 at 3:16PM, S1Administrator/DON indicated after reviewing Patient #1’s record, the nurse had not discontinued the Levofloxacin powder as required. Patient #3 Review of Patient #3’s Home Health Certification and Plan of Care for the certification period of 01/19/2025 through 03/19/2025 revealed Patient #3 received skilled nursing services once a week and physical therapy services once a week for one week then twice a week for two weeks, then once a week for six weeks. Review of Patient #3’s record revealed Patient #3 was last seen by the registered nurse (RN) on 02/17/2025 and the physical therapist (PT) on 02/19/2025. Review of Patient #3’s Hospital Discharge Summary dated 01/18/2025 revealed Patient #3 was to start the following medications, in part, Folic Acid (medication used for vitamin supplement) 1 milligram (mg) by mouth once a day, and Thiamine (Vitamin B-1 supplement) 100mg one tablet by mouth once a day. Review of Patient #3’s Client Medication Report, confirmed by S1Administrator/DON as the most accurate medication reconciliation, revealed, in part, no documented evidence of either Folic Acid or Thiamine (Vitamin B-1) was included as a current medication Patient #3 was to receive. Observation on 02/26/2025 at 10:03AM revealed Patient #3 had a bottle of Folic Acid (nutritional supplement) 1 milligram (mg) tablets one tablet by mouth daily, and Vitamin B-1 (Thiamine) (vitamin supplement) 100mg one tablet by mouth daily with a filled date of 02/17/2025. In an interview on 02/27/2025 at 3:13PM, S1Administrator/DON indicated the agency had no documented evidence the nurse nor the PT had identified and included Folic Acid and Vitamin B-1 (Thiamine) on Patient #3’s medication report. Patient #4 Review of Patient #4’s Home Health Certification and Plan of Care for the certification period of 01/10/2025 through 03/10/2025 revealed Patient #4 had a skilled nurse once a week for five weeks, and occupational therapist (OT) once a week for two weeks, twice a week for one week, then weekly for four weeks. Review of Patient #4’s Client Medication Report, confirmed by S1Administrator/DON as the most accurate medication reconciliation, revealed, in part, Cyancobalamin (Vitamin B-12, a vitamin supplement) 1,000 micrograms (mcg) one tablet by mouth daily; and Oxycodone (medication used to treat pain) 5mg one tablet by mouth every 6 hours as needed for pain. Further review revealed no documented evidence of Hydrocodone-Acetaminophen (medication used to treat pain) had been identified as a current medication. Observation on 02/26/2025 at 12:35PM revealed no evidence of Oxycodone 5mg or Cyancobalamin 1,000 mcg in the home; however, a prescription for Hydrocodone-Acetaminophen 10/325 mg one tablet by mouth four times a day as needed for pain was presented in the home with a fill date of 02/05/2025. In an interview on 02/26/2025 at 12:35PM, Patient #4 indicated she had stopped the Cyancobalamin three months ago, and was taking the pain medication that was presented to the surveyor, Hydrocodone-Acetaminophen 10/325mg. In an interview on 02/27/2025 at 3:14PM, S1Administrator/DON indicated the clinicians did not catch the change in medication orders and should have documented the changes. Patient #5 Review of Patient #5’s Home Health Certification and Plan of Care for the certification period of 01/16/2025 through 03/16/2025 revealed, in part, Patient #5 was to receive skilled nursing services every week for three weeks, then once every other week for six weeks. Review of Patient #5’s Client Medication Report, confirmed by S1Administrator/DON as the most accurate medication reconciliation, revealed, in part, Clopidogrel (medication used to prevent blood clots from forming) 75mg one tablet daily was listed as a current medication; however, there was no documented evidence of Brilinta (medication used to prevent blood clots from forming) had been captured as a current medication. Observation on 02/26/2025 at 1:45PM revealed a prescription for Brilinta 60mg one tablet twice a day with a prescription fill date of 01/19/2025 was present in the home; however, there was no evidence of a prescription of Clopidogrel 75mg in the home. In an interview on 02/26/2025 at 1:46PM, Patient #5’s spouse indicated Patient #5 was no longer taking Clopidogrel 75mg, because his medication changed to Brilinta 60mg. In an interview on 02/27/2025 at 3:21PM, S1Administrator/DON indicated she did not have the updated hospital notes nor the physician progress notes from recent doctor visits. S1Administrator/DON indicated she could not offer an explanation for the reason as to why the the medication changes were not identified.

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 interviews and record reviews, the agency failed to ensure: 1. The skilled nurse monitored patient weights and/or abdominal circumferences for weight gain (Patient #1, Patient #10); and, 2. The skilled nurse monitored patient capillary blood glucose readings (Patient #9, Patient #10). This deficient practice was identified for 3 (Patient #1, Patient #9, Patient #10) of 13 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13) sampled patients reviewed for care and services provided per the plan of care. Findings: 1. Patient #1 Review of Patient #1’s Home Health Certification and Plan of Care for the certification period of 01/08/2025 through 03/08/2025 revealed, in part, Patient #1 was to receive skilled nursing services twice a week for nine weeks. Further review revealed the skilled nurse was to observe Patient #1’s ability to monitor and report daily weights. The skilled nurse was to record Patient #1’s reported weight, or weigh patient as needed. The skilled nurse was to report a weight gain of greater than 2 pounds in a day or greater than 5 pounds in a week. Further review revealed the skilled nurse may measure abdominal girth if unable to weigh. Review of Patient #1’s Skilled Nurse Visit Note Report for the following dates revealed no documented evidence of a weight being obtained or abdominal circumference being obtained and recorded, and/or that the nurse reviewed Patient #1’s weights, in part: 01/15/2025, 01/17/2025, 01/24/2025, 01/29/2025, 02/05/2025, 02/07/2025, and 02/12/2025. There was no documented evidence, and the agency presented no documented evidence, Patient #1’s weights and/or abdominal circumference was obtained and/or monitored as per the plan of care for the above mentioned dates. In an interview on 02/27/2025 at 3:16PM, S1Administrator/DON indicated the skilled nurses were not monitoring Patient #1’s weight during every visit, due to Patient #1’s right leg amputation which made it difficult for Patient #1 to stand for a weight. S1Administrator/DON confirmed the skilled nurses did not take an abdominal circumference in the place of Patient #1’s weight on the above mentioned dates as required. Patient #10 Review of Patient #10’s Home Health Certification and Plan of Care for the certification period of 01/08/2024 through 03/07/2024 revealed, in part, the skilled nurse was to provide care and services once a week for nine weeks. Further review revealed the skilled nurse was to observe Patient #1’s ability to monitor and report daily weights. The skilled nurse was to record Patient #1’s reported weight, or weigh Patient #10 as needed. The skilled nurse was to report a weight gain of greater than 2 pounds in a day or greater than 5 pounds in a week. Further review revealed the skilled nurse may measure abdominal girth if unable to weigh Review of Patient #10’s Skilled Nurse Visit Note Report for the following dates revealed no documented evidence of a weight being obtained or abdominal circumference being obtained and recorded, and/or that the nurse reviewed Patient #10’s weights, in part: 01/18/2024, 01/23/2024, 02/01/2024, 02/08/2024, 02/15/2024, 02/22/2024, 03/01/2024, and 03/05/2024. There was no documented evidence, and the agency presented no documented evidence, Patient #10’s weights and/or abdominal circumference was obtained and/or monitored as per the plan of care for the above mentioned dates. In an interview on 02/27/2025 at 3:35PM, S1Administrator/DON indicated the skilled nurses were not monitoring Patient #10’s weight during every visit. S1Administrator/DON confirmed the skilled nurses did not obtain an abdominal circumference in the place of Patient #10’s weight on the above mentioned dates as required. 2. Patient #9 Review of Patient #9’s Home Health Certification and Plan of Care for the certification period of 01/17/2025 through 03/17/2025 revealed, in part, the skilled nurse was to monitor Patient #9’s blood sugar (capillary blood glucose) log for blood sugar readings that were being checked by Patient #9 two times a day. Review of Patient #9’s Skilled Nurse Visit Note Report dated 01/17/2025 revealed no documented evidence of Patient #9’s capillary blood glucose (blood sugar) readings were obtained and/or no documented evidence the skilled nurse reviewed Patient #9’s capillary blood glucose readings. There was no documented evidence, and the agency presented no documented evidence, Patient #9’s capillary blood glucose was obtained and/or monitored as per the plan of care for the above mentioned dates. In an interview on 02/27/2025 at 3:10PM, S1Administrator/DON indicated the skilled nurse did not document Patient #9’s capillary blood glucose on 01/17/2025, nor did the skilled nurse document she reviewed Patient #9’s capillary blood glucose readings as required. Patient #10 Review of Patient #10’s Home Health Certification and Plan of Care for the certification period of 01/08/2024 through 03/07/2024 revealed, in part, the skilled nurse was to provide care and services once a week for nine weeks. Further review revealed the skilled nurse was assess and teach patient/caregiver ability to perform and record blood glucose testing as ordered and to report abnormal findings. The nurse was to notify the physician if a blood glucose reading was greater than 300 milligrams/deciliter (mg/dl) or less than 70 mg/dl. Review of Patient #10’s Skilled Nurse Visit Note Report dated 01/08/2024, 01/18/2024, 01/23/2024, 02/01/2024, 02/08/2024, 02/15/2024, 02/22/2024, 03/01/2024, and 03/05/2024 revealed no documented evidence Patient #10’s capillary blood glucose (blood sugar) reading were obtained and/or documentation that skilled nurse had reviewed Patient #10’s capillary blood glucose readings. There was no documented evidence, and the agency presented no documented evidence, Patient #10’s capillary blood glucose readings were obtained and/or monitored as per the plan of care for the above mentioned dates. In an interview on 02/27/2025 at 3:35PM, S1Administrator/DON indicated the skilled nurse did not document capillary blood glucose readings, and/or document reviewing blood glucose readings as required.

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 observation, interview, and record reviews, the agency failed to ensure the skilled nurse removed her gloves and performed hand hygiene after coming into contact with items in the environment and prior to performing wound care for 1 (Patient #1) of 1 (Patient #1) sampled patients observed for wound care during a home visit. Findings: Review of the agency’s Standard Precautions policy and procedure, with a reviewed date of 03/28/2024, revealed in part, staff were to change gloves and perform hand hygiene when moving from a contaminated to a clean site during patient care, and in between patient contacts to avoid cross-contamination. Review of Patient #1’s Home Health Certification and Plan of Care for the certification period of 01/08/2025 through 03/08/2025 revealed, in part, Patient #1 was to receive wound care twice a week for diabetic foot ulcers on the left lateral foot and the dorsal side of the left great toe. Observation of Patient #1’s wound care on 02/26/2025 at 9:26AM, revealed S3Registered Nurse (RN) pushed her hair behind her ears then grabbed a chair leg to pull the chair forward with gloved hands. S3RN then proceeded to clean Patient #1’s left lateral foot wound without performing hand hygiene or changing gloves. After cleaning the wound, S3RN removed her gloves then performed hand hygiene. S3RN then put on a new pair of gloves, moved the chair closer by grabbing its leg, and without changing gloves or performing hand hygiene again, applied a clean dressing to Patient #1’s left foot. In an interview on 02/26/2025 at 3:16PM, S1Administrator/Director of Nursing (DON) was informed of the above mentioned observation. S1Administrator/DON indicated S3RN should have performed hand hygiene and changed gloves anytime she made contact with the environment and prior to performing wound care.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on interviews and record reviews, the agency failed to ensure all identified infections were included in the agency’s surveillance of infections for 3 (Patient #1, Patient #10, Patient #13) of 9 (Patient #1, Patient #4, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #12, Patient #13) sampled patients identified as having infections. Findings: Review of the agency’s Infection Prevention Program Overview, with a reviewed date of 04/30/2024, revealed, in part, documentation of infections on the infection report must include at minimum the date the infection was detected, the patient’s name, primary diagnosis, signs/symptoms of infection, type of infection, and in the medical record, document if the pathogen was identified and treatment. Further review revealed the agency’s infection data was collected using infection reports and trending the agency’s infection report data through the Quality Assurance and Performance Improvement program. Agency leadership was to identify the types of infections most common to its care, services, and population. Patient #1 Review of Patient #1’s Client Medication Report revealed Patient #1 received Levofloxacin (antibiotic used to treat infections) 8 percent powder apply 1 gram topically to the wound daily starting on 10/23/2024. Patient #10 Review of Patient #10’s Client Medication Report revealed, in part, Ciprofloxacin (Cipro) 500 milligrams (mg) one tablet twice a day for urinary tract infection (bladder infection) with a start date of 02/12/2024. Review of Patient #10’s Client Coordination Note Report dated 02/15/2024 revealed, in part, Patient #10 had completed the course of Cipro (antibiotic used to treat infections). Patient #13 Review of Patient #13’s Visit Note Report dated 08/14/2024 revealed, in part, an order for Doxycycline Hyclate (antibiotic used to treat infections) 100 mg one tablet by mouth twice a day. Review of Patient #13’s Wound Care Clinic Visit Note dated 08/19/2024 revealed, in part, unstageable pressure ulcer to the left heel still with an odor on 08/12/2024 after Doxycycline was prescribed on 08/08/2024 due to positive wound cultures. Review of the agency’s Quality Improvement (QI) Event Report 2024 for infections revealed no documented evidence, and the agency presented no documented evidence, the above mentioned patient infections were captured on the QI Event Report for infections for 2024. In an interview on 02/28/2025 at 12:33PM, S1Administrator/Director of Nursing (DON) indicated the process for infection surveillance was anytime a new infection was suspected, or new antibiotics were identified in the home, the clinician was to enter an infection log into the patient's chart. S1Adminsitrator/DON further indicated the clinician would then monitor infection symptoms. The infection log would then trigger a QI Event Report which would go to her workflow to review for trends. S1Administrator/DON further indicated the above mentioned patient infection logs were not entered; therefore, would not have been included in the tracking and trending infection control QI event statics. In an interview on 02/28/2025 at 1:08pm, S2Corporate Nurse indicated the above mentioned patients would not have been included in the agency’s tracking and trending of infections and should have been.

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey

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 record review and interview the agency failed to ensure the physician was notified of upper extremity numbness and weakness for 1 of 13 sampled patients (Patient #9) reviewed for care and services in a total sample of 14. Findings: Review of Patient #9’s Home Health Certification and Plan of Care for Certification Period of 05/05/2022 to 07/03/2022 revealed Patient #9 was to receive skilled nursing care and physical therapy services. Review of Patient #9’s Client Coordination Note Report dated 05/21/2022 at 5:05pm revealed Patient #9’s daughter called the agency on-call nurse due to Patient #9 complaining her arm was numb. Further review revealed the nurse instructed Patient #9’s daughter to monitor, and if any changes or more symptoms develop to notify the office. Review of Patient #9’s Medical Record revealed no further follow-up to the call made on 05/21/2022 until 05/23/2022 and the agency provided no additional evidence of any further follow-up or physician notification made regarding the call on 05/21/2022. Review of Patient #9’s Client Coordination Note Report dated 05/23/2022 revealed S1Administrator/DON (Director of Nursing) spoke with Patient #9’s daughter, who stated her mother was weak. Review of Patient #9’s Visit Note Report by the PTA (Physical Therapy Assistant) dated 05/23/2022 revealed Patient #9 complained her right arm felt weaker today. Patient #9’s caregiver reported she had no control over her right upper extremity. Further review of the Care Coordination section revealed no care coordination with the physician or treatment team were made due to no changes since the last visit. In an interview on 06/16/2022 at 9:40am, S1Administrator/DON stated the on-call nurses were with the corporate call center and therefore she was not aware of the call regarding Patient #9’s arm numbness until Monday, 05/23/2022. S1Adminsitrator/DON further stated due to the numbness of the upper extremity having been a new finding Patient #9’s physician should have been notified.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure: 1. Staff requesting a medical exemption for the COVID-19 vaccination had a medical exemption completed by a licensed practitioner operating within their specified scope of practice for 1 of 1 employees (S3Registered Nurse (RN) reviewed for a COVID-19 medical vaccination exemption; 2. Staff requesting a medical exemption had documentation of which vaccine was contraindicated with a reason for the contraindication for 1 of 1 employees (S3RN) reviewed for a COVID-19 medical vaccination exemption; 3. A system was present to review all employee vaccination statuses and exemptions to ensure all staff had either completed the primary vaccination series of the COVID-19 or had an appropriate medical or religious exemption for 1 of 28 employees (S3RN) reviewed for COVID-19 vaccination per the agency’s Employee COVID-19 Vaccination Status List. Findings: Review of the agency’s COVID-19 Vaccination Policy revealed staff members who request a medical exemption must provide clinical documentation of their clinical contraindication to the COVID-19 vaccines, and it must be signed and dated by a licensed practitioner, who is acting within their respective scope of practice. The documentation must contain all information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindication. Review of Louisiana Statutes Title 37 Professions and Occupations; Chapter 36. Chiropractors revealed the "Practice of chiropractic" means holding one's self out to the public as a chiropractor and as being engaged in the business of, or the actual engagement in, the diagnosing of conditions associated with the functional integrity of the spine. The practice of chiropractic does not include the right to prescribe, dispense or administer medicine or drugs. Review of S3RN’s Medical Exemption request dated 01/11/2022 revealed the medical exemption was approved. Review of S3RN’s documentation for medical exemption revealed, in part: -A letter dated 02/10/2020 from a chiropractor with a diagnosis of MTHFR (Methylenetetrahydrofolate reductase) (condition in which the enzyme that breaks down the amino acid homocysteine does not work properly) allergy. Further review revealed the chiropractor advised she not have any further vaccine, however no documented evidence of which vaccines should not be administered. -A letter dated 02/13/2020 from a chiropractor which documented it was contraindicated and recommended that S3RN not receive any vaccinations due to her lack of detoxification ability and MTHDR gene. Review revealed no documented evidence of which vaccines should not be administered. In an interview on 06/16/2022 at 3:55pm, S1Administrator/DON (Director of Nursing) stated she could not comment if the medical exemption should be approved, as the agency’s staff religious and medical exemptions were reviewed and completed at the corporate level. In an interview on 06/16/2022 at 4:00pm, S2Senior Employee Relations Consultant stated he was unaware if a chiropractor could give a medical exemption. In an interview on 06/20/2022 at 9:36am, S2Senior Employee Relations Consultant stated all employees requesting a medical exemption were to fill out a medical exemption form which required the name and credentials of the clinician and the information on each vaccine contraindicated. S2Senior Employee Relations Consultant stated corporate had reviewed the medical exemption and the agency thought the letter was by a physician, but the letter was from a chiropractor. S2Senior Employee Relations Consultant further stated the chiropractor was not operating within their scope of practice, and the documentation also did not have each vaccine contraindicated listed with the contraindication documented for each vaccine. Review of the Agency’s Employee COVID-19 Vaccination Status List revealed 28 active employees. Further review revealed 20 employees had completed the primary vaccination series, 7 religious exemptions, and one medical exemption (S3RN). Review of S3RN’s medical exemption revealed the medical exemption was not approved within federal regulatory requirements, therefore, the agency had a 96.4% COVID-19 vaccination compliance. In an interview on 06/20/2022 at 9:36am, S2Senior Employee Relations Consultant confirmed due to S3RN not having the proper medical exemption the agency was not at 100% compliance with the COVID-19 vaccination requirements.