Every finding on record at Amedisys North Carolina, L.L.C.

An onsite, unannounced recertification survey was conducted 10/14/24 to 10/16/24. No deficiencies to the Emergency Preparedness program were identified.

An onsite, unannounced recertification survey was conducted 10/14/24 to 10/16/24. Deficiencies to the Medicare Conditions of participation were identified.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, and staff interview, the agency failed to document consistent wound measurements for 1 of 15 records reviewed (Patient #2) and failed to notify the physician of documented changes in the patient condition for 2 of 15 records reviewed (Patients #6, #8). Findings included: Policy WC-001, titled “The Provision of Wound and Skin Care” was received from the agency director on 10/15/24 at 11:45 AM. This policy revealed, “In accordance with best practice and standard of care, wounds will be measured a minimum of one time a week” and “…anytime during the plan of care a wound is discovered upon assessment…the physician is to be contacted to update and obtain orders for care…” 1. Patient #2 was admitted to the agency on 04/04/24 with diagnoses including a right-sided pelvic fracture, right and left knee pain, muscle wasting, high blood pressure, and high cholesterol. Plan of Care from 04/04/24 to 6/02/24 revealed orders for skilled nursing one time per week for five weeks, physical therapy two times per week for one week and one time per week for seven weeks, occupational therapy one time per week for one week, and medical social work one time per month for two months. On 04/10/24, 04/18/24, and 04/25/24, Employee #11, licensed practical nurse, documented the presence of a Stage 2 pressure ulcer wound (an open wound extending into lower skin layers) on Patient #2’s right buttocks. For each visit, Employee #11 documented the presence and treatment of the Stage 2 wound including teaching pressure relief, using and barrier ointment and eating healthy protein rich food.” There were no documented wound measurements and there was no evidence that the physician was notified regarding the wound in the clinical record. In an interview on 10/16/24 at approximately 11:30 AM, Employee #1, agency director, stated that the expectation would be that the physician would be notified, and treatment orders would be obtained as necessary. 2. Patient #6 was admitted to the agency on 04/24/24 with diagnoses including hypertensive (related to high blood pressure) heart and chronic kidney disease with heart failure (heart’s inability to pump blood effectively). Plan of Care from 04/24/24 to 06/22/24 revealed orders for skilled nursing one time per week for four weeks and physical therapy one time per week for one week, two times per week for one week, and one time per week for seven weeks. On 04/24/24, Employee #10, registered nurse, conducted the initial skilled nursing visit for Patient #6. For this visit, Employee #10 documented that the patient was not checking her blood sugar levels and she needed a glucometer (machine used to check blood sugar levels). There was no documented evidence that the physician was notified that the patient was not checking her blood sugar levels. In an interview on 10/16/24 at 11:10 AM, Employee #10 stated that she did not remember whether or not she notified the doctor and stated that the agency had worked with the patient’s daughter on getting her a glucometer. In an interview on 10/16/24 at approximately 11:30 AM, Employee #1, agency director, stated that the expectation would be that the physician would be notified, and treatment orders would be obtained as necessary. 3A. Patient #8 was admitted to the agency on 09/10/24 with diagnoses including alcoholic cirrhosis of the liver with ascites, acute kidney failure and chronic kidney disease, encounter for fitting and adjustment of urinary device, and unspecified protein-calorie malnutrition. Plan of Care from 09/10/24 to 11/08/24 revealed orders for skilled nursing one time per week for five weeks, physical therapy once per week for nine weeks, and medical social worker one time per week for one week. On 09/17/24, Employee #13, licensed practical nurse, conducted a skilled nursing visit and documented that Patient #8 was “not taking lactulose [oral medication to help reduce ammonia levels] as prescribed due to increased BMs [bowel movements]” There was no evidence that the physician was notified that Patient #8 was not taking medication as prescribed. On 09/26/24, Employee #13 conducted a skilled nursing visit and documented that Patient #8’s abdomen was more distended (a swollen abdomen) and “pt [patient] states it feels a little more distended too…attempted to call primary MD [medical doctor] to report findings. Office closed for lunch. Will attempt later.” There was no documented evidence of any follow-up contact with the physician regarding abdominal distention. On 10/03/24, Employee #5, registered nurse, conducted a skilled nursing visit and documented that Patient #8’s abdomen was noted to be distended and that the patient felt it was a little more distended too. There was no documented evidence that the physician was notified regarding abdominal distention following this visit. In an interview on 10/16/24 at 11:24 AM, Employee #13 stated, “I more than likely probably followed up at the end of the day and did not document as I should have…” In an interview on 10/16/24 at 10:42 AM, Employee #5 stated, “… She had already been in contact with her doctor about the constipation and they were going to set her up with a GI [gastrointestinal] doctor so she wouldn’t have to go to the hospital…If I didn’t [document contact with the physician] I guess I should have. I thought because she had already had these issues it was documented somewhere.” In an interview on 10/16/24 at 11:30 am, Employee #1, agency director, stated, “I would expect them to document that but then I would expect them to call back again until they could speak to somebody or get a message to somebody.” 3B. On 09/17/24, Employee #8, physical therapy assistant, conducted a physical therapy visit and documented, “Pt [patient] states it hurts when she pees” and “she has difficulty getting comfortable with the [urinary] catheter.” There was no documented evidence in the clinical record that Employee #8 reported this information. In an interview on 10/16/24 at 10:50 AM, Employee #8 stated, “I don’t believe I did [notify anyone regarding the patient’s reported discomfort]. I think she was going to discuss it with the doctor but, I didn’t follow up myself.”In an interview on 10/16/24 at 10:51 AM, Employee #1, agency director, stated that the expectation would be that clinicians, “…call the doctor and notify them of that. Even if the caregiver says that they had done so…” and they should also notify the clinical manager or director.

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 direct observation, agency policy, and staff interview, the agency failed to maintain a current medication record for 1 of 3 observed home visits with medication reviews (Patients #14). Findings included: Policy MA-002, last reviewed 12/01/23 and titled, “Drug Regimen Review” was received from the agency director on 10/15/24 at 3:28 PM. This policy revealed, “ Patient #14 was admitted to the agency 06/04/24 with diagnoses including hemiplegia followed by a cerebral infarction (paralysis to one side of the body after a stroke) and dysphagia (difficulty swallowing). Plan of Care from 10/02/24 to 11/30/24 revealed orders for skilled nursing, speech therapy, and occupational therapy services. Employee #3, certified occupational therapy assistant, conducted an observed home visit on 10/15/24. During the visit, Employee #3 asked to see Patient #14’s medications and identified In an interview on 10/16/24 at 10:35 AM, Employee #4, clinical manager, stated that it was the expectation for clinicians to review medications during each visit and said, “Usually they go through them one by one. They enter what’s in the home in the chart. Every visit.” In an interview on 10/16/24 at 11:00 AM, Employee #3 stated, “We do medication review every visit.”

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the agency failed to provide services as ordered for 1 of 12 active patients. (patient #7) Findings included: A policy, Initial Referral/Admission Process (reviewed 10/10/24) received on 10/15/2024 at approximately 11:45 AM from the Director of Operations stated, “If the agency cannot provide services as ordered, the physician/allowed practitioner/referral source will be notified…” The agency received the referral for services on 08/14/2024. The referral included orders for skilled nurse (SN), physical therapy (PT), occupational therapy (OT), home health aide (HHA), medical social worker (MSW), and speech therapy (ST). Clinical record review revealed the OT and ST assessments were not conducted and there was no evidence of the physician, allowed practitioner, or referral source being notified. An interview with the Area Vice President on 10/16/24 revealed that the agency documentation system will only allow 3 disciplines to be added at 1 time and it may have been an oversight.

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 direct observation, agency policy, and staff interview, the agency failed to meet standard infection prevention practices for 3 of 6 home visits observed (Patients #14, #16). Findings included: A policy, Hand Hygiene (reviewed 06/26/24) received on 10/15/24 from the Director of Operations at approximately 3:28 PM stated, “Perform hand hygiene as follows: Before donning gloves… After removing gloves.” 2. Patient #16 was admitted on 10/11/24 with a diagnosis of Parkinson’s disease. The plan of care for 10/11/24-12/09/24 included orders for physical therapy (PT) 1 time a week for 1 week, 2 times a week for 6 weeks, and 1 time a week for 2 weeks. During a home visit conducted on 10/15/24 at approximately 11:15 AM PT #6 donned clean gloves, assessed vital signs and applied an alcohol-based hand sanitizer to the gloves, disinfected the thermometer, pulse oximeter, and blood pressure cuff, and applied alcohol-based hand sanitizer to the gloves. During an interview at 10:55 AM on 10/16/24 with PT # 6 “No [I don’t usually use hand sanitizer on gloves], I think it was because I was nervous, I accidently did that. Normally I wouldn’t wear gloves to take vital signs.” During an interview conducted on 10/15/24 at 12:05 PM the clinical manager stated, “We [agency] don’t use hand sanitizer on gloves.” Policy PCP-001, last reviewed 06/26/24 and titled, “Hand Hygiene” was received from the agency director on 10/15/24 at 3:28 PM. This policy revealed “The term hand hygiene includes both handwashing with soap and water and use of alcohol-based products that do not require the use of water…Perform hand hygiene as follows…before having direct contact with patients, before donning gloves, after contact with a patient’s intact skin, after contact with…wound dressings, after contact with inanimate objects [e.g. medical equipment] in the immediate vicinity of the patient, after removing gloves…” 1. Patient #14 was admitted to the agency 06/04/24 with diagnoses including hemiplegia followed by a cerebral infarction (paralysis to one side of the body after a stroke) and dysphagia (difficulty swallowing). Plan of Care from 10/02/24 to 11/30/24 revealed orders for skilled nursing, speech therapy, and occupational therapy services. Employee #3, certified occupational therapy assistant, conducted an observed home visit on 10/15/24. During the visit, Employee #3 obtained vital signs and worked directed Patient #14 in a set of exercises. After the exercises were completed, Employee #3 gave the patient a rest-break. During the break, Employee #3 used a cleansing wipe to clean the equipment used to obtain vital signs, placed the equipment on a clean barrier, and returned to assisting the patient with a new set of exercises without performing hand hygiene. In an interview on 10/16/24 at 11:00 AM, Employee 3 stated that she was nervous during the observed home visit and said, “I usually do clean my hands [after cleaning equipment]”….

An onsite recertification and follow up survey was conducted 12/13/21-12/14/21. Deficiencies to the Medicare Conditions of Participation were identified. No deficiencies were identified to the Emergency Preparedness program. The following tag was put back into compliance: G169. ABH

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, clinical record review and staff interview, the agency failed to review and update the medication list with a reported medication dosage change for 1 of 24 records reviewed (Patient #15). Findings included: Policy MA-001, titled Medication Administration, last reviewed and revised 04/29/21, was received from the agency director on 12/14/21 at 5:05 PM and read, “Incomplete medication orders should be corrected by the clinician in the medical record and on the medication profile in the home” and “Medication management is assessed at the start of care and ongoing. This assessment includes a drug regimen review with follow-up as indicated…” Patient #15 was admitted to the agency on 11/15/21 with diagnoses including Type 2 diabetes with foot ulcer, chronic venous hypertension with ulcer and inflammation of left lower extremity, Parkinson’s, chronic kidney disease, dialysis dependence, and insulin dependence. Plan of Care from 11/15/21 to 01/17/22 revealed orders for skilled nursing effective 11/21/21, 2 times per week for 1 week, 3 times per week for 6 weeks, 2 times per week for 1 week and 2 PRN (as needed), physical therapy 2 times per week for 4 weeks and 1 time per week for 5 weeks, medical social worker 1 time per week for 1 week and 1 time every 2 weeks for 2 weeks. A physical therapy visit note on 11/22/21 from Employee #7, a Physical Therapy Assistant, revealed, “GABAPENTIN [used for nerve pain] WAS INCREASED TO 300 MG (milligrams) ONCE A DAY…” There was no evidence of gabapentin on the Plan of Care or the Client Medication Report. In an interview on 12/14/21 at 4:10 PM, Employee #9, the Area Vice President of Operations, revealed, “You’re right on the gabapentin. It’s in the visit note but it did not carry over to the med (medication) profile.”

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on policy review, client record review, and staff interview the agency failed to include all medications on the plan of care for 1 of 2 patients on oxygen (#17). Findings included: Review of a policy “Plan of Care/Care Planning Process”, revised 12/2019 was received from the agency director on 12/14/21 at 5:05p.m. The policy stated,” ….the individualized plan of care must include the following …all medications and treatments…the frequency and duration of visits…patient specific interventions and education…”. Patient #17 was admitted on 11/27/21 with diagnoses of encounter for surgical aftercare following surgery on respiratory system, malignant neoplasm of lung, malignant pleural effusion, chronic kidney disease, copd (chronic obstructive pulmonary disease), and dependence on supplemental oxygen. Review of the start of care oasis visit on 11/27/21 revealed the patient was on oxygen therapy, but it was not included on the plan of care. Interview with the agency director on 12/14/21 at 4:15 p.m. confirmed oxygen should have been included on the medication list on the plan of care.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review and staff interview, the agency failed to obtain orders for care of a newly inserted PICC (peripherally inserted central catheter) line for 1 of 1 patient with PICC lines (Patient #24). Findings included: Policy TX-002, titled Coordination of Care, last revised 04/2019, was received on 12/14/21 at 5:05 PM from the agency director. This policy read, “…The HHA (home health agency) must…Coordinate care delivery to meet the patient’s needs…” Patient #24 was admitted to the agency on 06/14/21 with diagnoses including cellulitis of the mouth (an infection of the oral tissue), osteomyelitis (a bone infection), and long-term use of antibiotics. Plan of Care from 06/14/21 to 08/12/21 revealed orders for skilled nursing 1 time per week for 9 weeks with 3 PRN (as needed) and medical social work 1 time per week for 1 week. In a skilled nursing note on 08/03/21, Employee #2, a Licensed Practical Nurse, documented, “…PATIENT HAS PICC LINE IN UPPER RT (right) ARM. MANAGEMENT BY DR. (physician’s name) OFFICE.” There is no evidence in the clinical record of care orders for management of the PICC line or care coordination with the physician on 08/03/21. Orders for PICC line care were obtained by the Registered Nurse Case Manager, Employee #6, on 08/10/21. In an interview on 12/14/21 at 4:10 PM, Employee #9, the Area Vice President of Operations, revealed, “(Employee #2) did say that she measures the circumference but did not document.” Employee #9 agreed that Employee #2 should have obtained orders for management of the PICC line during the skilled nursing visit on 08/03/21.

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, client record review, and staff interview the agency failed to follow the physicians order to assess vital signs for 1 of 2 patients with parksinson’s disease (#11), follow visit frequency for 1 of 8 patients with a wound (#9), assess blood sugars for 2 of 11 patients with diabetes (#16 and #15). Findings included: 4. Patient #15 was admitted to the agency on 11/15/21 with diagnoses including Type 2 diabetes with foot ulcer, chronic venous hypertension with ulcer and inflammation of left lower extremity, Parkinson’s, chronic kidney disease, dialysis dependence, and insulin dependence. Plan of Care from 11/15/21 to 01/17/22 revealed orders for skilled nursing effective 11/21/21, 2 times per week for 1 week, 3 times per week for 6 weeks, 2 times per week for 1 week and 2 PRN (as needed), physical therapy 2 times per week for 4 weeks and 1 time per week for 5 weeks, medical social worker 1 time per week for 1 week and 1 time every 2 weeks for 2 weeks. Orders of Disciplines and Treatments revealed, “BLOOD GLUCOSE TESTING DAILY FREQ (frequency). SKILLED NURSE TO ASSESS PATIENT/CAREGIVER ABILITY TO PERFORM AND RECORD BLOOD GLUCOSE TESTING AS ORDERED AND TO REPORT ABNORMAL FINDINGS TO PHYSICIAN. SKILLED NURSE MAY PERFORM BLOOD GLUCOSE TEST AS NEEDED. Employee #8, a Licensed Practical Nurse, documented the Endocrine/Hematopoietic assessment as, “NO PROBLEMS IDENTIFIED” during skilled nursing visits on 11/26/21 and 11/29/21. There was no evidence in the clinical record of an assessment of the patient/caregiver’s ability to perform and record blood glucose testing on 11/26/21 or 11/29/21 as ordered on the Plan of Care. In an interview on 12/14/21 at 4:10 PM, Employee #9, the Area Vice President of Operations, stated, “She (Employee #8) said that she did go into the home and asked about the blood glucose levels but she didn’t document it. We’ve talked to her about it.” Review of a policy “Plan of Care/Care Planning Process”, revised 12/2019 was received from the agency director on 12/14/21 at 5:05p.m. The policy stated,” ….the individualized plan of care must include the following …the frequency and duration of visits…patient specific interventions and education…”. 1. Patient #11 was admitted on 11/05/21 with diagnoses of parksinson’s disease, heart failure, primary generalized osteoarthritis, and anemia. The plan of care for 11/05/21 to 01/03/21 had orders for physical therapy for 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 1 week, and 2 time a week for 1 week. Licensed professional to report vital signs falling outside of the following established parameters: temp less than 96, greater than 100, pulse less than 60, greater than 100, respirations less than 12, greater than 20, systolic blood pressure less than 90, greater than 180 and diastolic blood pressure less than 50 and greater than 100. Review of the physical therapist visit notes for 11/15/21 and 11/17/21 revealed no blood pressures were obtained during these visits. Interview with the area vice president of operations at 12/14/21 4:12 p.m. revealed “ the clinicians blood pressure monitor broke, so she didn’t do it”. 2. Patient #9 was admitted on 11/15/21 with diagnoses of encounter for orthopedic aftercare following surgical amputation, acquired absence of left great toe, and type 2 diabetes. The plan of care for 11/15/21 to 01/13/22 had orders for skilled nursing visits 2 times a week for 8 weeks, then 1 time a week for 1 week. Review of the clinical record on 12/13/21 revealed only 1 skilled nursing visit was conducted the week of 11/30/21. No other visit was in the record for the week of 11/29/21. Interview with the agency director on 12/14/21 at 4:11 p.m. revealed, “there should have been a missed visit, but there wasn’t one”. 3. Patient #16 was admitted on 11/20/21 with diagnoses of encounter for orthopedic aftercare following surgical amputation, type 2 diabetes, and other acute osteomyelitis (bone infection). Skilled nursing orders were to assess patient/caregiver ability to perform blood glucose test as needed. Skilled nurse to report to physician blood glucose readings greater than 300 or less than 60. Review of skilled nursing visits conducted on 11/20/21 and 12/07/21 revealed no blood sugars were documented in the record. Interview with agency director on 12/14/21 at 4:13 p.m. revealed, “ blood sugars were not documented in the record, they should have been”.