Every finding on record at Amedisys North Carolina, LLC

An onsite recertification and follow up survey was conducted 8/21/23-8/23/23. No deficiencies to the Emergency Preparedness Program were identified.

An onsite recertification and follow up survey was conducted 8/21/23-8/23/23. Deficiencies to the Medicare Conditions of Participation were identified. The following tag was put back into compliance: G590.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to provide accurate information on the OASIS [The Outcome and Assessment Information Set-used to collect standardized data for home health agencies] for 3 of 17 patients [#8, 14 and 17]. The findings included: The policy, OASIS Outcome and Information Set [6/23/23], was provided by the agency director on 8/23/23 at 8:36 am. The policy stated, “…OASIS date will be accurate…” 1. Patient # 8 had a Start of Care date of 7/27/23 and admitting diagnoses of paroxysmal atrial fibrillation [rapid irregular heartbeat] and chronic obstructive pulmonary disease [COPD-lung condition]. Review of the Plan of Care [POC] for the certification period 7/27/23-9/24/23 included orders for SN [skilled nursing] 1 time a week for 9 weeks. The OASIS [The Outcome and Assessment Information Set-used to collect standardized data for home health agencies] was completed on 7/27/23 by RN # 7. Further review of the OASIS question N0415 indicated the patient was prescribed an antibiotic. Review of the POC revealed no order for an antibiotic. The POC did include an order for Xarelto [anticoagulant]. NO415 did not capture the use of the anticoagulant. During an interview with the agency director on 8/23/23 at approximately 10:30 am, the director confirmed the OASIS was not accurate. 2. Patient # 14 had a Start of Care date of 7/8/23 and admitting diagnoses of encounter for other orthopedic aftercare, spinal stenosis [narrowing of the spinal canal] and type 2 diabetes mellitus without complications. Review of the Plan of Care for the certification period 7/8/23 to 9/5/23 included orders for PT [physical therapy] 1 time a week for 3 weeks, 1 time every 2 weeks for 2 weeks, 1 time a week for 4 weeks. Review of the clinical record revealed PT #15 [physical therapist] completed the OASIS [The Outcome and Assessment Information Set-used to collect standardized data for home health agencies] on 7/8/23. Review of the Endocrine/Hematopoietic section of the OASIS revealed the question “Does the patient have a diagnosis of diabetes” was answered “no”. During an interview with the agency director on 8/23/23 at approximately 10:30 am, the director confirmed the OASIS was not accurate. 3. Patient # 17 had a Start of Care date of 7/6/23 and an admitting diagnosis of vitamin B12 deficiency anemia. Review of the Plan of Care for the certification period 7/6/23 to 9/3/23 included orders for SN [skilled nursing] 1 time a week for 9 weeks. Review of the clinical record revealed RN # 7 completed the OASIS [The Outcome and Assessment Information Set-used to collect standardized data for home health agencies] on 7/6/23. Review of the OASIS question NO415 indicated the patient was receiving an antipsychotic medication. Review of the Plan of Care revealed the patient did not have an order for any antipsychotic medication. During an interview with the agency director on 8/23/23 at approximately 10:30 am, the director confirmed the OASIS was not accurate.

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 and procedure review, observation, clinical record review, and staff/caregiver interview, the agency failed to include all medications on the plan of care for 5 of 7 home visits observed (#11, 12,15, 10, 13 ); failed to update the Plan of Care with the current/correct medications for 1 of 1 patients (#10); failed to include the correct diet/nutrition on the plan of care for 1 of 1 patient with a gastrostomy tube (#12); failed to include interventions related to diabetes for 1 of 2(#14). Findings included: Review of policy, “Plan of Care”, revised 05/09/22, was received from the agency executive director on 08/22/23 at 8:30 a.m. The policy stated”, …the individualized plan of care must include the following: all medications and treatments…the types of services, supplies, and equipment required…” 1a. Patient #10 was admitted was admitted on 06/19/23 with diagnoses of hemiplegia following a cerebral infarction (stroke), hypertensive heart disease, chronic obstructive pulmonary disease (lung disease), and chronic pain syndrome. The plan of care for 08/18/23 to 10/16/23 had orders for physical therapy 1 time a week for 8 weeks. A home visit with the physical therapy assistant was observed on 08/21/23 at 3:39 p.m. The medication review during the home visit revealed the following discrepancy: famotidine 20 mg (milligrams) 1 tablet by mouth as needed for heartburn. Interview with the caregiver confirmed she started this medication 2 weeks ago. Acetaminophen 325 mg 1 as needed for pain. Interview with the caregiver confirmed the patient has been taking this for a long time. 1b. Patient #10 was admitted was admitted on 06/19/23 with diagnoses of hemiplegia following a cerebral infarction (stroke), hypertensive heart disease, chronic obstructive pulmonary disease (lung disease), and chronic pain syndrome. The plan of care for 06/19/23 to 08/17/23 had orders for skilled nursing 1 time a week for 8 weeks. The skilled nursing visit note on 06/26/23 had documentation of the nurse requesting nystatin powder instead of nystatin ointment (used for yeast infections). The medication was not listed on the medication profile. Interview with the skilled nurse on 08/23/23 at 8:57 a.m. revealed, “I must have forgotten to update the medication profile”. 2.Patient #13 was admitted on 05/02/23 with diagnoses of varicose vein of the right lower extremity with leg ulcers, non-pressure ulcer to right lower leg, lymphedema (swelling), and rheumatoid arthritis. The plan of care for 07/01/23 to 08/29/23 had orders for skilled nursing 1 time a week for 9 weeks. A home visit was observed on 08/22/23 at 10:19 a.m. with the licensed practical nurse. The medication review during the home visit revealed the following discrepancy: vitamin b (supplement) 500 mg 1 tablet by mouth as needed. Interview with the patient confirmed he has been taking this supplement for a couple of years. 1. Patient # 11 had a Start of Care date of 6/6/23 and admitting diagnoses of dysphagia [difficulty swallowing] and Parkinson’s Disease [disorder that causes uncontrollable movements]. Review of the Plan of Care [POC] for the certification period of 8/5/23-10/3/23 included orders for ST [speech therapy] effective 8/6/23 1 time every 2 weeks for 2 weeks, 1 time a week for 2 weeks, 1 time every 2 weeks for 2 weeks and 1 time a week for 2 weeks. A joint visit was made with ST # 10 on 8/22/23 at approximately 12:30 pm. During the visit, a medication review was conducted using a medication profile provided by the agency. The medication profile listed Triamcinolone Acetonide 0.1% Topical Cream [topical steroid]. Apply to skin as needed PRN [as needed]. The POC did not include the frequency or the indication for the use of the medication. During an interview with the agency director on 8/23/23 at approximately 9:15 am, the director confirmed the POC did not include the indication or the frequency of the medication. 2A. Patient # 12 had a Start of Care date of 7/20/23 and an admitting diagnosis of ALS [amyotrophic lateral sclerosis-neuromuscular disorder that causes muscle weakness]. Review of the Plan of Care [POC] for the certification 7/20/23-9/17/23included orders of OT [occupational therapy] 1 time a week for 9 weeks. Review of the clinical record revealed the patient had a G Tube [gastrostomy tube-tube inserted into the abdomen that allows nutrition/medications to be administered]. During an interview with the caregiver on 8/22/23 at 12 noon, the caregiver reported the G tube was placed in October 2022. The caregiver also stated, “He can’t swallow anything. He gets everything by G tube.” A joint visit was conducted with OT #14 on 8/22/23 at approximately 12 noon. During the visit a medication review was conducted using a medication profile provided by the agency. The medication profile listed the following medications: - Lorazepam [anti-anxiety] 0.5 mg. Take 1 tablet daily po [by mouth]. During the interview with the caregiver, the caregiver reported the patient only uses the Lorazepam as needed for anxiety. The caregiver gives the medication by G tube. - Tizanidine [skeletal muscle relaxant] 4 mg. Take 4 mg every 12 hours po. The caregiver presented a bottle of the medication with a start date of 7/14/23. The dosage of these medications 2 mg every 12 hours and was incorrect on the plan of care. The medication was given by G tube. - The following medications were on the medication profile were listed with the instructions to be taken po: Celecoxib [non-steroidal anti-inflammatory], Cholecalciferol [vitamin D3] 2,000-unit capsule, Duloxetine [anti-depressant] and Trazodone [anti-depressant]. The instructions should have been to give via Gtube. During an interview with OT # 14 on 8/23/23 at approximately 11:15 am, the OT confirmed POC did not include the correct medications or the route the medications were given. 2B. Patient # 12 had a Start of Care date of 7/20/23 and an admitting diagnosis of ALS [amyotrophic lateral sclerosis-neuromuscular disorder that causes muscle weakness]. Review of the Plan of Care [POC] for the certification 7/20/23-9/17/23included orders of OT [occupational therapy] 1 time a week for 9 weeks. A review of the POC revealed the following documentation: Diet: Regular Review of the clinical record revealed the patient had a G Tube [gastrostomy tube-tube inserted into the abdomen that allows nutrition/medications to be administered]. During an interview with the caregiver on 8/22/23 at 12 noon, the caregiver reported the G tube was placed in October 2022. The caregiver also stated, “He can’t swallow anything. He gets everything by G tube. The caregiver reported the patient received Two Cal HN 2.0 8 oz tube feeding 2 times per day. During an interview with the agency director on 8/23/23 at approximately 10:30 am, the director confirmed the POC was incorrect. 3. Patient # 14 had a Start of Care date of 7/8/23 and admitting diagnoses of encounter for other orthopedic aftercare, spinal stenosis [narrowing of the spinal canal] and type 2 diabetes mellitus without complications. Review of the Plan of Care for the certification period 7/8/23 to 9/5/23 included orders for PT [physical therapy] 1 time a week for 3 weeks, 1 time every 2 weeks for 2 weeks, 1 time a week for 4 weeks; OT [occupational therapy] effective 7/9/23 1 time a week for 5 weeks, 1 time every 2 weeks for 2 weeks, 1 time a week for 1 week. Further review of the POC revealed no interventions related to diabetes. During an interview with the agency director on 8/22/23 at 4 pm, the director confirmed if the patient has a diagnosis of diabetes the clinicians should always include interventions related to the diabetes on the POC. 4A. Patient # 15 had a Start of Care date of 7/6/12 and admitting diagnoses of encounter for other orthopedic aftercare and congenital spondylolisthesis [condition that occurs when the bones do not form correctly during fetal development]. Review of the Plan of Care [POC] for the certification period 7/6/12-9/3/23 included orders for Physical therapy [PT] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 2 weeks. On 8/23/23 at approximately 8:30 am a joint visit was made with PTA [physical therapy assistant] # 3. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: - The medication profile listed Hydrocodone 5 mg/Acetaminophen 325 mg [pain medication]. Take 1-2 tablets every 4 hours as needed for pain. - Methocarbamol [muscle relaxer] 500 mg. Take 1 tablet three times a day as needed for pain. - Tamsulosin 0.4 mg [used to treat men who have enlarged prostate gland]. Take 1 pill daily. - Zonisamide 100 mg [used to treat migraine headaches] Take 1 daily. During an interview with the patient on 8/22/23 at approximately 9 am, the patient advised he was no longer taking any of the medications for pain, or the medication for the enlarged prostate gland. “I haven’t taken any of those pills since probably just before I came home from the hospital. I only take 25 mg of the Zonisamide every day.” During an interview with PTA # 3 on 8/22/23 at approximately 9:25 am, the PTA confirmed the medications listed on the POC were not correct. 4B. Patient # 15 had a Start of Care date of 7/6/12 and admitting diagnoses of encounter for other orthopedic aftercare and congenital spondylolisthesis [condition that occurs when the bones do not form correctly during fetal development]. Review of the Plan of Care [POC] for the certification period 7/6/12-9/3/23 included orders for Physical therapy [PT] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 2 weeks. On 8/23/23 at approximately 8:30 am a joint visit was made with PTA [physical therapy assistant] # 3. During the visit, the patient was noted to be wearing a bone growth stimulator [device that sends energy to healing bone surface via pulsed electromagnetic or ultrasound waves]. During an interview with the patient, he stated, “I wear this 2 hours a day and I wear the back brace at all other times.” Review of the POC did not list the bone stimulator device or the back brace. During an interview with the agency director on 8/23/23 at approximately 10 am, the director confirmed the POC should include any equipment or DME’s [durable medical equipment] used by the patient.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on policy and procedure review, clinical record review and staff interview the agency failed to include correct/signed physician orders related to visit frequency for 1 of 12 patients receiving physical therapy (#8); failed to have timely visit documentation in the medical record for 1 of 17 records reviewed (#6). Findings included: Review of policy, “Plan of Care”, revised 05/09/22, was received from the agency executive director on 08/22/23 at 8:30 a.m. The policy stated”, …the individualized plan of care must include the following: …the frequency and duration of visits to be made…” 1.Patient #6 was admitted on 07/24/23 with diagnoses of unspecified fracture of right tibia (leg), essential hypertension, heart disease, and low back pain. The plan of care for 07/24/23 to 09/21/23 had orders for physical therapy 2 times a week for 4 weeks, and 1 time a week for 5 weeks. Review of the clinical record revealed only 1 visit note was in the medical record for the week of 08/14/23. The visit note in the record was for 08/18/23. Interview with the physical therapist assistant on 08/23/23 at 10:11 a.m. revealed, “he missed the other visit last week secondary to pain” I just put the missed visit in today, I just called the doctor”. Interview with the agency director on 08/23/23 at 10:17 a.m. revealed, “documentation is due the same day as the visit is done at midnight”. 1. Patient # 8 had a Start of Care date of 7/27/23 and admitting diagnoses of paroxysmal atrial fibrillation [rapid irregular heartbeat] and chronic obstructive pulmonary disease [COPD-lung condition]. Review of the Plan of Care [POC] for the certification period 7/27/23-9/24/23 included orders for PT [physical therapy] effective 7/30/23 1 time a week for 1 week, 2 times every 2 weeks for 2 weeks, 2 times a week for 1 week, 1 time a week for 4 weeks. Review of the clinical record revealed a supplemental order dated 7/30/23 for a PT frequency of 1 time a week for 1 week, 2 times a week for 3 weeks and 1 time a week for 4 weeks. The order was marked “do not send to physician.” Review of the clinical record revealed the patient received a PT visit on 7/31/23, no visit the week of 8/6/23, a visit on 8/15/23, 8/17/23 and 8/23/23 [the visit frequency did not correspond with either order]. During an interview with PT # 13 on 8/23/23 at approximately 12 noon, the PT stated, “I don’t know how that happened. The orders are not the same and it should have been sent to the physician.”

An onsite recertification survey was conducted 06/14/21-06/15/21. No deficiencies to the Emergency Preparedness program were identified.

An onsite recertification survey and follow-up survey was conducted 06/14/21-06/15/21. Standard deficiencies to the Medicare Conditions of Participation were identified. The following tags were put back into compliance: G536. -MB

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 2 of 4 patients on oxygen (#2, and #17). Findings included: Review of a policy “Plan of Care (POC)/Care Planning Process”, revised 12/04/20 was received from the executive director on 06/15/21 at 3:04 p.m. The policy stated,” ….the individualized plan of care must include the following…all medications and treatments…”. 1a. Patient #2 was admitted on 04/30/21 with diagnoses of sarcoidosis (disease involving abnormal collection of inflammatory cells), unspecified; chronic obstructive pulmonary disease; pulmonary fibrosis (lung tissue is scarred); chronic respiratory failure with hypoxia, and dependence on supplemental oxygen. Review of the plan of care and skilled nursing visit on 04/30/21 revealed the patient was on oxygen therapy, but it was not included on the plan of care. Interview with Employee # 2 on 06/15/21 at 1:28 p.m. revealed, “ I must have missed it, it should have been on the med list”. 1b. Patient #17 was admitted on 11/11/20 with diagnoses of pressure ulcer of other site, stage 2; venous insufficiency(not enough blood flow) ; type 2 diabetes, chronic obstructive pulmonary disease; and dependence on supplemental oxygen. Review of the plan of care dated 01/10/2021 to 03/10/2021, and skilled nursing visit of 01/14/21 revealed the patient was on oxygen therapy, but it was not included on the plan of care. Interview with Employee #2 on 06/15/21 at 2:25 p.m. revealed, “it should have been on the medication list on the plan of care”.

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 policy review, record review and staff interview, the agency failed to communicate changes in the patient’s condition to the physician in 2 of 18 (Patients #9 and #16) total patient records reviewed. Findings include: Policy MSC-001 “Pain Assessment and Management” revised 12/04/20 and Policy TX-002 “Coordination of Care” revised 04/2019 were received from the Executive Director, Employee #5, on 06/15/21 at approximately 3:00 PM. Review of Pain Assessment and Management policy revealed, “The physician should be notified when there are new complaints of pain or when prescribed interventions do no result in adequate pain relief.” Review of the Coordination of Care policy revealed, “Relevant physicians are notified promptly of any changes in the patient’s condition or needs that suggest than [sic] outcomes are not being achieved and/or that the plan of care should be altered.” 1. Patient #9 was admitted to the agency on 04/28/21 with diagnoses including bloodstream infection due to central venous catheter, sepsis (systemic infection), mastoiditis (bacterial infection affecting the mastoid bone) and related conditions of the left ear, and propionic acidemia (a genetic disorder that affects the body’s ability to process protein). Patient #9 was legally blind and developmentally delayed. Plan of Care dated 04/28/21 to 06/26/21 revealed orders for skilled nursing 1 time per week for 1 week, 2 times per week for 2 weeks and 3 PRN (as needed) visits. Review of the skilled nursing visit of 05/24/21 revealed that Patient #16 “Has pain from ears aching” with the pain level documented as 8 on a 0 to 10 pain scale, with 0 being the lowest possible level of pain and 10 being highest possible level of pain. The pain is further assessed and documented during this visit as not being relieved according to the patient’s goals. Narrative documentation of the same visit revealed “Pt (patient) only c-o [sic] (complains of) is her ears…pt does have appt (appointment) with specialist Monday…” In a telephone interview with Employee #2, licensed practical nurse, on 06/15/21 at approximately 1:15 PM, Employee #2 stated, “I believe it (the appointment with the specialist) was the following Monday that she was going to be seen…this was chronic for her. ” Employee #2 confirmed that “the following Monday” that she referenced was 10 days after the 05/24/21 skilled nursing visit and stated that she did not report this pain to anyone. In an interview with Employee #3, the clinical manager, on 06/15/21 at 2:30 PM, Employee #3 stated, “…if the chronic pain was 5 to 7 and it (the patient’s pain level) was above, I would say that it needs to be reported.” 2. Patient #16 was admitted to the agency on 12/24/20 with diagnoses including status-post right total hip arthroplasty following right femur fracture, atrial fibrillation, essential hypertension, and Type 2 diabetes. Plan of care dated 12/24/20 to 02/21/21 revealed orders for physical therapy 1 time per week for 8 weeks and occupational therapy 1 time per week for 4 weeks, 2 times per week for 1 week, and 1 time every 2 weeks for 2 weeks. Clinical Record review revealed a 02/16/21 occupational therapy visit with a documented blood pressure of 178/98. This was an atypical finding for Patient #16 as evidenced by the systolic blood pressures recorded for Patient #16 between 12/24/20 and 02/21/21 were not greater than the 150s. Review of the occupational therapy discharge OASIS (outcome and assessment information set) of 02/16/21 revealed “yes” to the question regarding the patient being treated for a urinary tract infection in the last 14 days. The narrative summary from the same visit revealed, “…pt (patient) however presents today with some weakness from recent UTI (urinary tract infection) …” There is no evidence of communication with the physician regarding these changes in the patient’s condition. In a telephone interview with Employee #1, occupational therapist, on 06/15/21 at approximately 1:00 PM, Employee #1 confirmed that it is “not standard practice” to discharge patients with an elevated blood pressure and increased weakness. Employee #1 did not recall having any additional communication regarding changes in the patient’s condition during the 02/16/21 visit. In an interview with Employee #3 on 06/15/21 at 2:25 PM, Employee #3 stated, “I would expect my OT (occupational therapist) to call me and ask me…my advice would be to call and get nursing orders.”