Every finding on record at Amedisys Missouri, LLC

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 05/15/2024. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A partial extended survey for Medicare recertification for the home health provider was completed on 05/15/2024. The provider had 242 current patients.

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 policy review, record review, observation, and interview, the home health provider failed to ensure staff maintained an accurate/updated medication profile in two of three home visit observations (Records/Patients #1 and #3). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #1: Review of the record showed the patient was admitted to home health services on 04/03/2024. The patient had a history of meningioma (a tumor that grows from the membranes that surround the brain and spinal cord) and craniotomy (brain surgery). Observation and interview during the patient’s home visit showed the following medication discrepancies with the provider’s medication profile: -The physical therapist (PT) provided care for the patient. The PT did not request to look at the patient’s medications. At the end of the visit, the surveyor requested to review the medications; -The medication profile showed an order for Prednisolone (used to treat inflammation in the eyes) eye drops. The patient stated that he/she had not used these for quite some time; -The patient had a bottle dated 04/22/2024, of brimol/timolol (used to treat glaucoma) 0.2%/0.5% one drop two times a day that he/she used. This was not included on the medication profile; -The medication profile showed an order for metformin (diabetic medication) 500 milligrams (mg) two tablets two times a day. The patient stated that he/she usually took one tablet twice a day; -The patient took Colace (stool softener) 100 mg one in the morning and night since home from the hospital. This was not included on the medication profile; -The patient took naproxen (anti-inflammatory) 220 mg occasionally. The patient stated that he/she never took more than two at a time. This was not included on the medication profile; and -The patient took Goli sleep medication two gel caps at night for about two weeks. This was not included on the medication profile. During an interview on 05/14/2024, beginning at 12:10 PM, the administrator stated that each discipline should have the patient get their medication out at every visit and compare them to the medication list. RECORD/PATIENT #3: Review of the clinical record showed the patient admitted to home health services on 01/17/2024 with a primary diagnosis which included falls, an open wound on the left foot, and diabetes (a condition of excess sugar in the blood). The patient lived at home alone. Observation and interview on 5/13/2024 at 2:30 PM, during the patient’s home visit, showed the following medication discrepancies with the provider’s medication profile: -The medication profile showed an order for Nitroglycerin (a medication which widens blood vessels) 0.4 milligram (mg) tab to be taken sublingually (SL) as needed for chest pain (The patient stated that he/she had not used the medication and was currently out of the medication for a couple weeks; -The medication profile showed an order for Lidocaine Topical Patch (a medication to relieve pain) 5% to be applied to the skin daily for back pain. The patient stated that he/she no longer used the patch; -The patient took Xphozah (a medication used to lower phosphorus in the body) 30 mg tablet twice daily. This was not included on the medication profile; -The patient took Centrum Silver (a multi- vitamin supplement) 1 tablet daily. The medication was not included on the medication profile; -The patient took Ared 2 (a multi- vitamin eye supplement) 1 tablet daily. The medication was not included on the medication profile; -The patient took Garlic (a dietary supplement) 1000 mg, 1 tablet daily. The medication was not included on the medication profile; and -The patient took Biotan (a dietary supplement) 5000 micrograms (mcg) 1 tablet daily. The medication was not included on the medication profile. During an interview on 05/13/2024 at 3:00 PM, RN-E stated each patient should have their medication checked and compared to the current medication list during each visit to ensure accuracy. During an interview on 05/14/2024 at 12:10 PM, the administrator stated that each discipline should have the patient get their medication out at every visit and compare them to the medication list.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure the plan of care (POC) was updated with a complete physician order in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Physician Orders and Medical Supervision of the Plan of Care," revised 06/22/2023, showed in part that all patient care orders from all physicians/allowed practitioners including verbal orders, must be recorded/integrated in the POC to assure coordination of services and interventions provided. RECORD/PATIENT #1: Review of the record showed the patient was admitted to home health services on 04/03/2024. The patient had history of meningioma (a tumor that grows from the membranes that surround the brain and spinal cord) and craniotomy (brain surgery). Review of a PTA (physical therapy assistant) visit note dated 04/25/2024, showed he/she notified the physician’s nurse of fluid weeping from the patient’s incision. Review of a patient information report dated 04/25/2024, showed the PTA notified the physician’s nurse of the patient’s report of fluid weeping from his/her head. The patient reported a wet pillow and wet hair from the fluid. The PTA could not see any open areas. The nurse was calling in an antibiotic for prevention and to educate the patient to use peroxide to clean the area two to three times a day and pat dry. The PTA relayed all instructions to the patient and spouse. They verbalized understanding. The physician's nurse requested a report on 04/29/2024. The spouse would pick up the antibiotic. Review of an RN (registered nurse) phone call note dated 04/25/2024, showed the RN called to check on the incision. The patient stated that the incision had been leaking. The PTA saw the patient that day and had spoke with the surgeon's office regarding the drainage and the patient was started on an antibiotic for the drainage. The RN educated the patient to call the home health provider’s office if he/she developed a foul odor to the drainage, fever, chills, or increased pain. The patient verbalized understanding. Review of physician order dated 04/29/2024, showed an order for cephalexin (antibiotic) 500 milligrams (mg) one capsule four times a day with a start dated of 04/25/2024. The order failed to include the order to educate the patient to clean the area with peroxide two to three times daily and pat dry. During an interview on 05/14/2024, beginning at 12:10 PM, clinical manager A stated that there should have been an order update to the POC.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure the nurse documented a full assessment after the patient reported fluid weeping from his/her incision in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Patient Assessment/Reassessment,” revised 11/06/2023, showed in part that additional assessments/updates will be conducted as frequently as the patient’s condition warrants. RECORD/PATIENT #1: Review of the record showed the patient was admitted to home health services on 04/03/2024. The patient had history of meningioma (a tumor that grows from the membranes that surround the brain and spinal cord) and craniotomy (brain surgery). Review of a PTA (physical therapy assistant) visit note dated 04/25/2024, showed he/she notified the physician’s nurse of fluid weeping from the patient’s incision. Review of a patient information report, dated 04/25/2024, showed the PTA notified the physician’s nurse of the patient’s report of fluid weeping from his/her head. The patient reported a wet pillow and wet hair from the fluid. The PTA could not see any open areas. The nurse was calling in an antibiotic for prevention and to educate the patient to use peroxide to clean the area two to three times a day and pat dry. The PTA relayed all instructions to the patient and spouse. They verbalized understanding. The physician's nurse requested a report on 04/29/2024. The spouse would pick up the antibiotic. Review of an RN (registered nurse) phone call note dated 04/25/2024, showed the RN called to check on the incision. The patient stated that the incision had been leaking. The PTA saw the patient that day and had spoke with the surgeon's office regarding the drainage and was started on an antibiotic for the drainage. The RN educated the patient to call the home health provider’s office if he/she developed a foul odor to the drainage, fever, chills, or increased pain. The patient verbalized understanding. The nurse failed to physically assess the weeping wound. Review of a PTA visit note, dated 04/29/2024, showed the PTA left a message for the physician’s nurse that the patient had started his/her antibiotic, but continued to have some weeping from his/her incision. Review of physician order, dated 04/29/2024, showed an order for cephalexin (antibiotic) 500 milligrams (mg) one capsule four times a day for incision infection with a start dated of 04/25/2024. The order did not include the order for the patient to clean the area with peroxide two to three times daily and pat dry. Review of an RN visit note, dated 04/30/2024, showed no abnormal findings in the integumentary (pertaining to the skin) assessment. The documentation failed to show any documentation regarding the patient’s incision and/or fluid weeping from the head. Review of an SN (skilled nurse) telehealth phone visit, dated 05/07/2024, showed the patient had not had changes since the last home visit. The documentation failed to show any documentation related to the patient’s weeping drainage from his/her head. Per interview conducted during observation, on 05/13/2024, beginning at 12:30 PM, the patient stated that he/she continued to have weeping from his/her head, and that the physician was aware. During an interview on 05/14/2024, beginning at 12:10 PM, clinical manager B stated that the weeping should have been specifically addressed. The area vice president of operations stated that if there were no open areas it would fall under general assessment findings. The weeping should have been specifically addressed. During an interview on 05/15/2024, at approximately 9:45 AM, clinical manager B talked with the nurse. The nurse stated that there was not any drainage when he/she looked at the incision. The administrator stated that there should have been more documentation.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on review of Missouri state statute Section 192.2490.12 RSMo, review of Missouri code of federal regulations 19 CSR 30-26.010 (1) (B), policy review, employee file review, and interview the home health provider failed to check the employee disqualification list (EDL; a list that shows individuals who have been determined to have abused or neglected, misappropriated funds or property, or falsified documentation that delivery of services were provided to a patient, client, resident or consumer) prior to hire in two of five employee files reviewed (Employees #1 and #4), and failed to ensure Alzheimer's and dementia training was provided during orientation for two of five employee files reviewed (Employees #4 and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of Missouri state statute Section 192.2490.12 RSMo: "No person, corporation, organization, or association who received the employee disqualification list under subdivisions (1) to (7) of subsection 11 of this section shall knowingly employ any person who is on the employee disqualification list." Review of 19 CSR 30-26.010 (1) (B) required: "Licensed home health agencies shall provide dementia-specific training about Alzheimer's disease and related dementias to their employees and those persons working as independent contractors who provide direct care to or may have daily contact with residents, patients, clients or consumers with Alzheimer's disease or related dementias. 1. The training for persons providing direct care shall address the following areas, at a minimum: (A) An overview of Alzheimer's disease and related dementias; (B) Communicating with persons with dementia; (C) Behavior management; (D) Promoting independence in activities of daily living; and (E) Understanding and dealing with family issues. 2. Employees or independent contractors who do not provide direct care for, but may have daily contact with, persons with Alzheimer's disease or related dementias shall receive dementia-specific training that includes, at a minimum: (A) An overview of Alzheimer's disease and related dementias; and (B) Communicating with persons with dementia. 3. Dementia-specific training about Alzheimer's disease and related dementias shall be incorporated into orientation for new employees with direct patient contact and independent contractors with direct patient contact. The training shall be presented by an instructor who is qualified by education, experience, and knowledge in the current standards of practice regarding individuals with Alzheimer's disease and other related dementias. The training shall be provided annually and updated as needed. " Review of the provider’s policy titled, “Background Checks,” revised 10/31/2023, showed in part that as part of the new hire application process, the human resources department will utilize an approved third-party vendor to perform a criminal background check on all employees. When hiring/employing or re-hiring a candidate, the results of the approved third-party vendor background check will stipulate that an offer of employment is “conditional” upon background check results being favorable to the individual. In Missouri the provider will make an inquiry to the department of health and senior services whether the person is listed on the employee disqualification list. Review of the provider’s policy titled, “Competency Plan – RN (registered nurse)/LPN (licensed practical nurse)” revised 10/05/2023, showed in part that in Missouri dementia-specific training about Alzheimer’s disease and related dementias shall be incorporated into orientation for new employees with direct patient contact and independent contractors with direct patient contact. The training shall be presented by an instructor who is qualified by education, experience, and knowledge in the current standards of practice regarding individuals with Alzheimer’s disease and other related dementias. EMPLOYEE #1: Review of the employee file showed: - Date of hire 05/12/2021; and - EDL check 05/12/2021 (not completed prior to hire). EMPLOYEE #4: Review of the employee file showed: - Date of hire 07/05/2023; - EDL check 07/05/2023 (not completed prior to hire); and - No evidence of Alzheimer's and dementia training during orientation. EMPLOYEE #5: Review of the employee file showed no evidence of Alzheimer's and dementia training during orientation. During an interview on 05/14/2024, at 11:15 AM, the administrator stated that the office manager completed the EDL checks on hire. The administrator and office manager acknowledged the EDL checks had not been completed prior to hire. During an interview on 05/14/2024, at 11:30 AM, the administrator stated that the training had not been assigned during orientation. They were aware it needed to be done during orientation.

Two complaint investigations (99001 and 94404) were completed on 07/19/2023 at the home health provider. The home health provider had 237 current patients. The complaints are substantiated. One or more of the allegations reported are verified and standard deficiencies were cited that are related to the allegations being investigated.

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 policy review, record review, observation, and interview, the provider failed to ensure wound measurements were documented at least weekly in, but not limited to, one of four records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients receiving wound care by the provider. Findings included: Review of the provider’s policy titled, “The Provisions of Wound and Skin Care”, dated 03/08/2023, showed, in accordance with best practice in standard of care, wounds will be measured a minimum of one time a week, preferably on the first visit of the week, by the same nurse, and utilizing the same tool. RECORD/PATIENT #2: Review of the clinical record showed that the patient was admitted to home health on 04/01/2021, with a diagnosis of cellulitis (a common and potentially serious bacterial skin infection) of left lower limb and stasis ulcer (a wound on the leg or ankle caused by abnormal or damaged veins). The patient was discharged on 04/29/2021. Review of the plan of care, dated 04/01/2021, showed skilled nursing (SN) was directed to assess the lower extremity venous stasis ulcer(s) and intervene to minimize complications and report significant changes in status to the physician for early intervention. Review of the wound record report, dated 04/01/2021, showed the left lower extremity venous ulcer measured 16 centimeters (cm) in length, by 15 cm in width, by 0.5 cm in depth, with surface area of 240 cm. Review of all visits/records after 04/01/2021 failed to show any further measurements of the left lower extremity venous stasis ulcer. During an interview on 07/18/2023 at 10:13 AM, clinical manager A stated that wound assessments were not done after 04/01/2021. The provider’s policy was to measure wounds weekly.

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 home health provider failed to promptly alert the physician to 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, in two of four records reviewed (Records/Patients #1 and #3). This deficient practice has the potential to affect the coordination of care and services for all patients on service with the provider. Findings included: RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health on 03/16/2023, the patient underwent a CABG (coronary artery bypass graft surgery [surgical procedure to treat coronary artery disease]) on 02/27/2023. Review of a skilled nurse note, dated 03/30/2023, showed the licensed practical nurse (LPN) documented that the patient had abnormal respiratory assessment findings which included diminished and distant breath sounds (failed to include location) (absent or decreased sounds can mean air or fluid in or around the lungs) and cough (no description of the cough). The documentation failed to include physician notification of the abnormal diminished and distant breath sounds and cough. During an interview on 07/18/2023 at 9:49 AM, clinical manager A stated that he/she would have expected the LPN to notify the physician of the abnormal breath sounds and cough. RECORD/PATIENT #3: Review of the plan of care, dated 06/04/2023 through 08/02/2023, showed heart failure (a chronic condition in which the heart doesn’t pump blood as well at it should); the skilled nurse to assess cardiopulmonary system (relating to the heart and lungs) to identify signs of decompensation and intervene to minimize the severity of fluid overload. Assess patient ability to monitor and record daily weight. Record patient reported weight, or weigh patient as needed. Report weight gain of greater than two pounds in one day or greater than five pounds in one week or five pounds or more over target weight (there was no target weight documented). Review of the skilled nurse notes showed the following: - On 06/7/2023, the patient weighed 156.4 pounds; - On 06/12/2023, the patient’s weight was 162 pounds (weight gain of 5.6 pounds in five days). The documentation failed to include physician notification of the weight gain; - On 06/19/2023, the patient’s weight was 164 pounds; - On 06/22/2023, the patient’s weight was 167.8 pounds (weight gain of 3.8 pounds in three days). The documentation failed to include physician notification of the weight gain; - On 06/26/2023, the documentation failed to include the patient’s weight; - On 07/03/2023, the patient’s weight was 177.5 pounds (weight gain of 9.7 pounds since 06/26/2023 (11 days), the cardiovascular assessment showed abnormal findings, cardiovascular assessment showed other (specify), and indicate other cardiovascular issue(s): Congestive heart failure. The documentation failed to include physician notification of the weight gain; and - On 07/06/2023, the patient’s weight was 182 pounds, a total of 25.6-pound weight gain since 06/07/2023. Since 06/23/2023, the patient gained 15 pounds in 13 days, and 22 pounds since 06/05/2023. The physician increased the torsemide (can treat fluid retention) to 40 milligrams (mg) twice a day. The patient took all the doses and urinated twice, the physician was notified, and wanted the patient to go to the emergency room for intravenous fluid Lasix (diuretic). During an interview on 07/19/2023 at 9:39 AM , clinical manager B stated that registered nurse (RN) D called and notified the physician on 07/03/2023 due to the patient gain of 10 pounds in 11 days and this was outside the parameters. He/she notified the physician on 07/03/2023 and received new orders to increase the torsemide (the physician orders show torsemide was increased on 07/06/2023). There was no documentation to show this, and RN D will make a late entry in the chart. On the next visit, 07/06/2023 the patient had taken the increased torsemide for the past two days and still had a weight gain of four pounds in three days. The physician was notified and the patient went to the hospital on 07/06/2023 and resumed care with the provider on 07/10/2023. He/she would expect staff to notify the physician of weight gain of greater than two pounds in one day or greater than five pounds in one week.

The Emergency Preparedness regulations were also reviewed as part of the Medicare certification survey completed on 10/06/2021. One standard level deficiency was identified.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on review of the agency specific emergency management plan, employee file review and interview the agency failed to ensure one contracted employee (Employee #1) received the agency specific emergency management training during orientation in one of five employee files reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency specific emergency management plan revised 09/19, showed in part: - The administrator/director of operations or designee ensures all staff and patients are educated regarding the agency's emergency management program and the agency's specific emergency plan; and - In an emergency, all personnel should know: What is my role and where should I go? Employee #1: - Date of hire: 03/16/2021; and - The home health core policy review signed and dated by the employee showed the emergency preparedness section included: - The agency has a written plan for responding in emergency situations that threaten to interrupt patient care services. Each agency has a comprehensive emergency management plan that describes the actions that will be implemented in the event of an emergency/disaster in the company or community; - The director of operations will make the plan accessible during business hours and for on-call staff after hours; - In the event an emergency is declared, the director of operations or designee will initiate the emergency management plan and notify agency personnel and appropriate corporate personnel; - An emergency preparedness code is assigned to the patient upon admission and is updated as necessary; - All patients are educated on emergency preparedness during the admission process. This includes education on safety in the home. Appropriate, individualized emergency plans are discussed with the patient or personal representative based on risk factors identified during the safety assessment; and - There was no evidence to show the employee received the agency specific emergency preparedness plan training to ensure the employee knew his/her role in the event an emergency/disaster occurred while providing care for the agency's patients. During an interview on 10/05/2021 at 3:00 PM, the administrator stated that the employee signed he/she reviewed the core policies. When asked if the employee was trained on what to do if their emergency plan had to be initiated, he/she stated that he/she would look for further information. No further information was provided.

A partial extended survey for Medicare certification for Amedisys Home Health of Missouri was completed on 10/06/2021. The agency had 255 current patients. A COVID-19 Focused Infection Control Survey was completed in conjunction with the survey. One deficiency was identified related to the Focused Infection Control Survey.

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 policy review, review of the agency's current patient rights information, home visit observation, and interview, the agency failed to provide proper written notice in advance of the agency reducing or terminating on-going care for one (Record/Patient #3) of five full records reviewed. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency policy titled, "Home Health Change of Care Notice (HHCCN)." revised 03/25/2021, showed in part the following: -The HHCCN is issued to the traditional/Original Medicare Beneficiary before reducing or terminating most ongoing care provided by the agency. Medicare currently requires home health agencies (HHAs) to issue HHCCNs to Medicare beneficiaries receiving home health care benefits for notification of plan of care changes; -When multiple care changes occur due to simultaneous order changes and agency specific reasons for change to the HHA must give the beneficiary (2) separate HHCCN's so that he/she can identify the reason that corresponds with each change; -The beneficiary or representative must sign and date the HHCCN; -The HHCCN should be delivered far enough in advance of the care change so that the beneficiary may pursue alternatives to continue receiving the care noted on the HHCCN. "Far enough in advance" is defined by CMS as the beneficiary has time to make other arrangements. When plans for issuance of the notice are known in advance, the HHCCN should not be issued so far in advance as to cause confusion regarding the information it conveys. Issuing "far in advance" should be avoided whenever possible, but is permissible when a situation occurs prompting an immediate determination to reduce or end services that could not have been made in advance; and -Triggering events are reductions or terminations in care. Review of the agency's Patient Information Booklet, undated, showed the patient has the right to receive proper written notice, in advance of a specific service being furnished. if the agency believes that the service may be non-covered care; or in advance of the agency reducing or terminating on-going care. The agency must provide advance written notice of service termination to Medicare beneficiaries no later than 2 days before the proposed end of services as required by federal regulations. RECORD/PATIENT #3: Review of the clinical record review showed: -The plan of care (POC) dated 07/25/2021 to 09/22/2021 showed skilled nursing visits three times a week for eight weeks; -A verbal order, dated 09/17/2021 showed skilled nurse to perform wound care three times weekly and as needed for soilage or dislodgement; -A verbal order, dated 09/25/2021 showed effective 10/03/2021 skilled nursing visits one time a week for seven weeks; and -There was no HHCCN in the patient's medical record. The agency failed to provide the patient written notice in advance of reducing skilled nursing visits. Per interview conducted during a home observation on 10/05/2021 beginning at 8:00 AM, licensed practical nurse (LPN) A stated' "he/she would only be visiting once a week". During an interview on 10/06/2021 at 12:04 PM. the administrator stated that he/she would have expected an HHCCN to be provided when the agency reduced skilled nursing visits. No further information was provided.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information and interview, the agency failed to update the written notice of patient rights to include the patient has the right to be advised of the state hotline hours (7:00 AM to 8:00 PM). This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: The agency provided an admission packet for review on 10/04/2021. The agency notice of patient rights and other information given to a patient during the initial visit showed inaccurate information regarding the toll-free hotline number that included listing the hotline number hours of operation as "7:00 AM to 12:00 AM, 7 days a week," and failed to identify the correct hours of availability as "7:00 AM to 8:00 PM, 7 days a week". During an interview and review of findings with the administrator, clinical manager (CM) C and CM D on 10/06/2021 at 10:10 AM, they stated "they did not know the hotline hours had changed". A corrected version of the hours was provided to the survey staff on 10/06/2021. The administrator and clinical managers reported that a corrected version will be placed in the admission folders for future patients and a copy will be provided to all the current patients.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review, and interview, the agency failed to complete a comprehensive assessment that accurately reflected the patient's status to include the patient's psychosocial, status in one (Record/Patient #3) of five full records reviewed. This deficient practice has the potential to impact all patients served by the agency. Review of the plan of care (POC) dated 09/23/21 to 11/21/21, showed the patient was admitted on 03/27/21. He/she had a current diagnosis of pressure ulcer of other cite, stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguinous (composed of serum and blood) filled blister. Other diagnoses included, in part, pressure ulcer stage 2 of left buttocks, and pressure stage 2 right buttocks. Review of a skilled nursing note, dated 09/15/2021, showed the patient's granddaughter was concerned about the patient's mental health and was interested in finding out if perhaps there was something that the patient could take for depression, as the patient had lost his/her spouse in the last four to five months. Review of the recertification comprehensive assessment, dated 09/20/2021, showed no emotional/behavioral assessment. During an interview on 10/06/2021 at 9:47 AM, the administrator clinical manager (CM) C and CM D stated they did not know why the recertification did not have the emotional/behavioral assessment component, other than the program they used, it did not show up as part of the recertification assessment. They said the agency used to have a nurse that was a psych nurse and when he/she left the agency that part of the recert assessment quit being completed.

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 policy review, record review, home visit observation, record review and interview, the agency failed to ensure a complete/accurate medication review and/or update of the patient's medications was completed in, but not limited to, two (Record #1 and #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Drug Regimen Review," revised 01/2020, showed in part: - The purpose is to identify appropriateness, inconsistencies, and/or significant drug interactions in the patient's current medication regimen, as well as ensure the comprehensive list of medications are updated any time there is a medication change including dose changes, new medications, and any medications discontinued; - The clinician completing the OASIS (outcome assessment information set, a federally mandated assessment) must complete a comprehensive drug regimen review of all medications the patient is currently taking at the time of admission, recertification, resumption of care and with any major change in condition; - The medication profile is completed by documenting all the patient's medications which includes medications on written prescriptions and medication bottles, over-the-counter medications, herbal products, vitamins, supplements and oxygen; and - When patients are admitted from acute or post acute facilities it is the responsibility of the admitting clinician to assure they review the discharge paperwork from the facility to assure all medications with current dosages are captured. RECORD/PATIENT #1: Observation and interview on 10/06/2021 beginning at 10:50 AM, during the patient's home visit, showed the following medication discrepancies with the agency medication profile: - The medication profile showed an order for tramadol (pain medication) 50 milligrams (mg) one tablet every six hours as needed. The patient's spouse stated that he/she did not recognize this medication, and the patient only took acetaminophen for pain; - The patient had a bottle of lortadine (allergy medication) 10 mg one tablet daily. The patient's spouse stated that the patient had taken this for years. He/she kept it on hand for allergy symptoms. The patient last took it about two and one-half weeks ago; - The patient had a bottle of Protonix (stomach acid reducer) 40 mg one tablet every morning. The patient's spouse stated that the patient had been on this since November of 2019; - The patient had a box of Mucinex DM (used for cough and congestion) which contained 1200 mg guaifensen and 60 mg dextromethorphan one tablet every 12 hours and another box of Mucinex DM which contained 600 mg guaifenesin one to two tablets every 12 hours. The patient had last used it that morning. He/she has kept it on hand for years. This was not included on the medication profile; - The patient had a tube of diclofenac gel 1% (topical pain gel) apply to affected area four times a day. The patient's spouse stated that the patient had used this at night for about a year. This was not included on the medication profile; - The patient also used vitamin C 500 mg one tablet daily if he/she had a cold. This was not included on the medication profile; and - The medication profile showed an order for B12 1000 micrograms (mcg) two tablets daily. The patient's spouse had a bottle of super B complex which contained several vitamins including vitamin B12 15 mcg. The patient's spouse stated this was what he/she has used since the patient has been home. The findings were reviewed with the administrator and clinical manager (CM) C and CM D on 10/06/2021 beginning at 2:20 PM. During an interview on 10/06/2021 at 2:45 PM CM C stated that they can pull information from certain physician groups through their computer system. He/she pulled the patient's physician medication list which listed tramadol as a current medication. RECORD/PATIENT #4: Review of the patient's record showed the following discrepancies between the physician's medication list dated 09/08/2021 and the agency medication profile dated 09/08/2021: - The physician list showed orders for for tramadol 50 mg one tablet every eight hours as needed for pain, fentanyl transdermal patch (narcotic pain patch) 12 mcg/hour one patch topical every 72 hours, diclofenac 1% use two grams topically four times a day; multivitamin with minerals one time a day, odansetron four mg every eight hours as needed for nausea and vomiting, potassium chloride (supplement) ten milliequivalents (meq) one tablet two times a day, magnesium oxide (supplement) 400 mg one tablet daily, and ferrous gluconate (iron) 324 mg one tablet daily. These medications were not included on the agency medication profile; and - The physician list showed an order for lorsartan (high blood pressure medication) 50 mg tablet, 25 mg (1/2 tablet) two times a day. The agency medication profile showed an order for lorsartan 50 mg one tablet two times a day. Review of the comprehensive assessment dated 09/08/2021 showed: - Diagnoses that included hypertensive heart disease without heart failure, migraines, chronic pain with drug dependence and low back pain; - No issues found during the drug regimen review; - The patient was on a fentanyl patch and also had tramadol which he/she could take every eight hours; and - No documentation that the medication discrepancies were clarified with the physician. During an interview on 10/05/2021 at 4:15 PM the administrator stated that the nurse at the start of care reviews the medications on the referral and what is in the home and looks for any discrepancies. Any discrepancies should be clarified with the physician. During an interview on 10/06/2021 beginning at 8:45 AM the administrator stated that the patient's family member kept the medications at their home. The nurse should have clarified the medications with the family member and physician. The tramadol and fentanyl patch should have been added to the medication list.

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 policy review, record review, and interview, the agency failed to complete an individualized plan of care that specified the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment in one (Record/Patient #3) of five full records reviewed. This deficient practice has the potential to affect accurate and consistent care is provided to all the agency's patients. Findings included: Review of the agency's policy titled, "Plan of Care (POC)/Care Planning Process," revised 06/24/2021, showed in part, the following: - Purpose: A POC 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, as well as patient's choice; - 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 disciplines, and measurable outcomes that the agency anticipates will occur as a result of implementing and coordinating the plan of care; - The POC will be established through the use of the admission evaluation assessment and initiated by a physician/allowed practitioner order; - The Clinical Manager is responsible for facilitating coordination among all disciplines; and - The individualized plan of care must include a description of the patient's risk for emergency department visits and hospital readmission, and all necessary interventions to address the underlying risk factors. RECORD/PATIENT #3: The patient was admitted on 03/27/2021 with admitting diagnosis of pressure ulcer of other site, stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguinous (composed of serum and blood) filled blister). Other diagnoses included, in part, pressure ulcer stage 2 of left buttocks, pressure ulcer stage 2 right buttocks, chronic pulmonary edema (a liquid accumulation in the tissue and air spaces of the lungs), alcoholic cirrhosis of the liver with ascites (cirrhosis is a late stage of scarring of the liver from drinking too much alcohol. Ascites is the buildup of fluid in the abdomen), orthostatic hypotension (low blood pressure when standing), thrombocytopenia (a condition in which you have a low blood platelet count), and peripheral vascular disease (a slow and progressive circulation disorder). Review of the comprehensive assessment dated 03/27/2021, showed: - All the above diagnoses; - Edema to lower right and left extremities; - Short of breath with moderate exertion (for example, while dressing, using commode or bedpan, walking distances less than 20 feet); - Immune compromised; and - At risk for emergency department visits or hospitalizations due to multiple chronic co-morbid disease processes and polypharmacy. Review of the POC dated 09/23/2021 to 11/21/2021 showed: -The patient still had all the above listed diagnoses; and -The agency failed to individualize the patient's plan of care to include, patient-specific measurable outcomes and goals for the patient's chronic pulmonary edema, alcoholic cirrhosis of the liver with ascites, orthostatic hypotension, thrombocytopenia, and peripheral vascular disease. During an interview and review of the record findings on 10/06/2021 at 9:47 AM, the administrator stated he/she would have expected the POC to include, patient-specific measurable outcomes and goals for all the diagnoses listed above. No additional information was provided at time of exit.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure the plan of care was revised/updated to address the patient's needs for one (Record/Patient #3) of six full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Plan of Care (POC)/Care Planning Process," revised 06/24/2021, showed in part, the following: -Purpose: A POC 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, as well as patient's choice; - Modifications to the POC will be based upon the patient's individual condition, problems, needs, and reassessments; and - Changes to the POC are communicated to the patient and/or caregiver prior to the initiation of the change whenever possible and are documented in the clinical record. RECORD/PATIENT #3: Review of a skilled nurse visit note, dated 09/15/2021, showed the patient's granddaughter was very concerned about the patient's mental health and was interested in finding out if there was something that the patient could take for depression. The patient had lost his/her spouse in the last four to five months and the patient had appeared to be less motivated since the passing of his/her spouse. Review of a skilled nurse visit note, dated 09/17/2021, showed the caregiver reported the patient had a telehealth visit with the primary care physician on 09/16/2021 and was prescribed a new antidepressant. The new antidepressant was not in the home at the time of the visit. Review of the recertification assessment, completed on 09/20/2021, showed the nurse added Lexapro (antidepressant) to the medication list and educated the patient and caregiver about it. Review of the POC dated 09/23/2021 to 11/21/2021, failed to show that the POC had been updated/revised to show the new diagnosis of depression and any patient-specific measurable outcomes and goals for depression. During an interview on 10/06/2021 at 9:47 AM, the findings were reviewed with the administrator and clinical manager (CM) C and CM D. They acknowledged the findings and provided no additional information.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on policy review, record review, and staff interview, the agency failed to ensure integration of services and coordination of care between all disciplines caring for the patient whether provided directly or under arrangement in one (Record/Patient #3) of five full records reviewed. This deficient practice has the potential to affect all patients on service with the agency. Findings included: Review of the agency's policy titled, "Coordination of Care," revised 04/2019, showed in part, the following: -Purpose: The patient's care and services will be coordinated among staff and branches; -To utilize/recommend appropriate internal and external resources as needed throughout the length of service; and -To ensure consistent documentation, communication, coordination, and retrieval of significant administrative and patient/family information. RECORD/PATIENT #3: Review of a skilled nurse visit note, dated 09/15/2021, showed the patient's granddaughter was very concerned about the patient's mental health and was interested in finding out if there was something that the patient could take for depression. The patient had lost his/her spouse in the last four to five months and the patient had appeared to be less motivated since the passing of his/her spouse. Review of a skilled nurse visit note, dated 09/17/2021, showed the caregiver reported the patient had a telehealth visit with the primary care physician on 09/16/2021 and was prescribed a new antidepressant. The new antidepressant was not in the home at the time of the visit. Review of the recertification assessment, completed on 09/20/2021, showed the nurse added Lexapro (antidepressant) to the medication list and educated the patient and caregiver about it. The assessment failed to include an emotional/behavioral assessment. Review of the clinical record showed there was no documentation of communication between staff regarding the patient's depression. The agency failed to communicate/coordinate the patient's depression. During an interview on 10/06/2021 at 9:47 AM, the findings were reviewed with the administrator and clinical manager (CM) C and CM D. They acknowledged there should have been communication regarding the patient's depression and provided no additional information.

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 nationally-recognized standards, policy review, home visit observation and interview the agency failed to ensure staff followed acceptable standards of practice for infection control in one (Record/Patient #1) of three home visit observations. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the centers for disease control (CDC) website (cdc.gov/hand hygiene in healthcare settings) showed in part that gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment and perform hand hygiene immediately after removing gloves. Review of the agency policy titled, "Hand Hygiene," revised 06/24/2021, showed in part to perform hand hygiene: - Before having direct contact with patients; - Before donning gloves; - After contact with a patient's skin; - After contact with inanimate object (e.g. medical equipment) in the immediate vicinity of the patient; - After removing gloves; - Remove gloves after caring for a patient. Do not wash gloves between uses with different patients; and - Healthcare personnel should not apply multiple layers of gloves in place of the performance of hand hygiene with reapplication of a new set of gloves during patient care. Review of the agency policy titled, "Bag Technique," revised 09/08/2021, showed: in part - Nothing inside the bag should ever be dirty or soiled; - Staff should not re-enter the bag with used gloves. Always perform hand hygiene before entering bag; - Alcohol based hand sanitizer, liquid antibacterial soap and paper towels are placed in an outside compartment for ease of access; - The staff member cleanses hands prior to accessing materials from the supply bag; - Wash hands again if you need to re-enter the bag for additional supplies during patient care. Do not go back into the bag without removing gloves and performing hand hygiene; and - Hands are cleansed prior to returning clean equipment and supplies to the bag. RECORD/PATIENT #1: Observation on 10/06/2021 beginning at 10:50 AM, during the patient's home visit, showed: - The occupational therapist (OT) wore gloves when he/she entered the home; - Removed hand sanitizer from a plastic bag inside his/her bag; - Used hand sanitizer over the gloves then placed the hand sanitizer back inside the plastic bag; - Removed vital sign equipment from his/her bag; - Took the patient's vital signs; - Reached into bag and removed another barrier to lay the used equipment on without removing gloves or sanitizing hands then took out the bottle of hand sanitizer from the bag and used hand sanitizer over the gloves; - Cleaned equipment and placed equipment into bag then took the patient to the shower; - After the shower, the OT reached into his/her bag with gloved hands and removed hand sanitizer from the plastic bag inside his/her bag then used the hand sanitizer over the gloves then placed the hand sanitizer back in the bag; - At the end of the visit, the OT shook the patients hand with the same gloves, removed the bottle of hand sanitizer from the bag and used over the gloves, placed the bottle of hand sanitizer back in the bag then exited the home with gloves on. During an interview on 10/06/2021 beginning at 2:20 PM, the administrator stated that he/she did not know why the staff would sanitize over the gloves. Clinical manager (CM) C stated that staff have a dirty pocket in their bag to keep their hand sanitizer. CM D stated that they will instruct the OT to remove his/her gloves to sanitize his/her hands.

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 policy review, record review, and interview the agency failed to provide services as directed by the physician ordered plan of care (POC) in one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Plan of Care/Care Planning Process." revised 06/24/2021, showed: Purpose: A POC 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; and - To provide physician ordered care, treatment and services through an organized process and plan. RECORD/PATIENT #1: Review of the POC dated 08/30/2021 showed: -Diagnoses that included chronic diastolic congestive heart failure (a condition in which the heart does not pump blood as well as it should); -Interventions included for the skilled nurse (SN) to assess the patient's ability to monitor and record daily weights and record patient's reported weight or weigh patient as needed. Report a weight gain of two pounds in one day or five pounds in one week. May measure abdominal girth if unable to weigh; and - Physical therapy (PT) and occupational therapy (OT) to assess and record patient reported weight and notify the clinical manager/RN case manager for physician notification for signs and symptoms of exacerbation (two pound weight gain in one day and five pound weight gain in one week). Review of the physical therapy admission OASIS (outcome assessment and information set, a federally mandated assessment) showed the patient required moderate assistance with sitting to standing and turning, transfers with a two wheeled walker for immediate standing support with a chair lift being utilized for commode, recliner, wheelchair and bed. The caregiver reported some days the patient required the use of a Hoyer lift (mechanical) for transfers. Review of the registered nurse (RN) evaluation dated 08/31/2021 showed no documentation regarding the patient's ability to weigh or an abdominal girth measurement. Review of the SN, PT and OT notes showed sporadic documentation of weights and no documentation of abdominal girth measurements. Observation on 10/06/2021 beginning at 10:50 AM, during the patient's home visit, showed the OT assisted the patient to weigh. The OT had to hold the patient with the gait belt so an accurate weight could not be obtained. The patient's spouse stated that he/she had been instructed about weight gain but did not think anyone had measured the patient's abdomen. During an interview on 10/06/2021 beginning at 2:20 PM the administrator stated that he/she would expect staff to obtain abdominal girth measurements if accurate weights could not be obtained.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure staff documented follow up with the physician in one (Record/Patient #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORD/PATIENT #4: Review of the plan of care (POC) dated 09/08/2021 showed: - Diagnoses that included hypertensive heart disease without heart failure, low back pain, headache and other chronic pain; - Physical therapy (PT) once a week for one week, twice a week for three weeks then once a week for two weeks; and - Interventions included for PT to monitor pain management. Review of a physical therapy assistant (PTA) note dated 09/23/2021 showed the patient rated pain in his/her right ankle and foot a level of nine (pain is rated on a scale of zero to ten with zero meaning no pain and ten meaning the worst pain). The patient reported his/her heel started hurting last night and had not stopped. The patient stated that he/she took tramadol but it had not helped. The patient stopped moaning while the PTA was on the phone with the licensed practical nurse (LPN) after being advised the emergency room would probably give tramadol which the patient took. The patient did not moan again. The LPN will discuss with the physician to see if something for nerve pain might be more beneficial. The PTA also left a message with the physician. Review of the record showed no documentation of follow-up of the phone calls to the physician. The findings were reviewed with the administrator on 10/05/2021 beginning at 4:15 PM. He/she will look for documentation. During an interview on 10/06/2021 beginning at 8:45 AM the administrator stated that the PTA did talk with the physician's nurse but forgot to put in a note. He/she would expect documentation of follow up with the physician at the time the PTA talked with the nurse. Review of a late entry note dated 10/05/2021 showed the PTA documented a note regarding the physician's nurse return call on 09/24/2021 after the PTA's phone call on 09/23/2021. The PTA had informed the nurse of all events of the 09/23/2021 visit. The patient verbalized pain. The PTA observed no visible signs of injury to the patient's foot. The patient denied any incident or event to cause injury. After the patient was reminded that the emergency room would more than likely not give him/her anything stronger for pain than the tramadol that they had offered at the last emergency room visit, the patient almost immediately stopped complaining of pain. The patient then participated in therapeutic exercises. The PTA instructed left lower extremity only, but patient volunteered to do bilaterally and denied pain when questioned. The patient then ambulated without limp or complaint of pain. The patient was instructed to elevate and rest his/her feet at the end of the therapy session and contact the on call nurse if symptoms returned. The physician's nurse indicated this wasn't the first time they have experienced something like this with the patient. He/she also stated that our instructions were appropriate, and they would make note of the events. No new orders were given at that time.

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: Based on policy review and interview the agency failed to ensure that their qualifying service for Medicare was provided in its entirety by the agency's own employees. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Administrator/Clinical Supervision Authorization," revised 06/24/2021, showed in part: - An administrator must be responsible for maintenance of compliance with federal, state, local laws and regulations and standards, administrative policies of the agency, and administratively supervising the provision of all services; - The administrator ensures that the home health agency employs qualified personnel, including assuring the development of personnel qualifications and policies; and - The agency must adhere to the most stringent regulations (state, federal, accreditations, professional practice, etc.). During an interview on 10/04/2021 beginning at 12:10 PM, the administrator stated that physical therapy was their qualifying service for Medicare. They had two contracted physical therapists that worked in an assisted living facility and provided physical therapy for any home health patients they had at the assisted living facility. Their direct staff physical therapists did the start of care assessments, reassessments and discharge assessments, and the contracted physical therapists provided the therapy in between those visits.