Every finding on record at Amedisys North Carolina, LLC

An unannounced on-site complaint investigation was conducted 5/26/26-52727. Standard level deficiencies to the Medicare Conditions of Participation were identified.

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 agency policy, clinical record review, and staff interviews, the clinical record failed to include all prescribed medications in the plan of care for 2 of 5 patients with record reviews conducted (patients #1 & 5). Findings included: A policy, Drug Regime Review (Home Health Only) (reviewed 1/16/26), received on 5/26/26 at 4:38 PM from the Vice President of Operations stated, “Conducting a drug regime review requires the Assessing RN [registered nurse] complete the following steps: … Recording a complete and accurate list of all medications…” 1. Patient #1 was admitted 4/2/26 with diagnoses of STEMI (heart attack), long term (current) use of anticoagulants (blood thinning medication), and long term (current) use of antithrombotic/antiplatelet (blood thinning medication). The plan of care (POC) for 4/2/26-5/31/26 included orders for skilled nurse visits 1 time a week for 4 weeks with 2 PRN (as needed). Review of the clinical record revealed that at the start of care registered nurse (RN) #4 discontinued the orders for Eliquis (anticoagulant, blood thinning medication) 2.5mg 1 tablet 2 times daily and Plavix (antiplatelet, blood thinning medication) 75mg 1 tablet daily due to the medications not being available in the home and contacted the physician. Further review revealed that on 4/8/26 RN #4 documented, “Cardiologist wanted patient to restart dual antiplatelet therapy at home.” Further review revealed that the dual antiplatelet medications were not included in the POC. An interview conducted on 5/26/26 at 3:42 PM with the clinical manager revealed that during a start of care, the medication orders should be documented clearly and precisely including the drug names, route of administration, frequency of administration, and dose.” An interview conducted on 5/26/26 at 4:46 PM with RN #4 revealed that they normally would add the medications to the POC. 2. Patient #5 was admitted on 9/12/25 with a diagnosis of multiple sclerosis (chronic disease of the central nervous system). The plan of care (POC) for 9/5/25-11/10/25 included orders for physical therapy visits 1 time a week for 9 weeks and occupation therapy visits 1 time a week for 5 weeks and 1 every other week for 2 weeks. Review of the clinical record revealed that a history and physical dated 9/19/25 provided by the primary care physician included the following medication orders: Doxycycline Monohydrate (antibiotic) 100mg 0.5 tablet by mouth every day in the morning and aspirin (blood thinning medication) 81mg 1 capsule(s) PO [by mouth] daily. Further review revealed that there were no medications included in the POC. During an interview conducted on 5/27/26 at 10:48 AM the clinical manager stated, “There should be a medication reconciliation at each visit, they [medications] should be added to the plan of care.”

An unannounced on-site recertification survey was conducted on 06/16/2025-06/18/2025. No deficiencies for emergency preparedness were identified.

An unannounced on-site recertification survey was conducted on 06/16/2025-06/18/2025. Standard level deficiencies to the Medicare Conditions of Participation were identified.

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 agency policy, observations, clinical record review, and staff interviews, the Plan of Care failed to include all/current medications for 2 of 5 patients who received a home visit. (#11 and #16) The findings included: A policy, Drug Regimen Review, (revised 12/1/2023), received from the agency director on 6/17/2025 at 3:40 pm stated, “… the comprehensive list of medications are updated any time there is a medication change including dose change, new medications, and any medications discontinued. The clinician completing the OASIS (Outcome and Assessment Information Set-a group of standard data elements used to compare home health patient outcomes) 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 changes in condition.” 1.Patient #11 was admitted on 6/12/2025 with a diagnosis of peritoneal abscess (a localized collection of pus within the abdominal cavity). The plan of care for 6/12/2025- 8/10/2025 included orders for SN (skilled nurse) 1 time a week for 4 weeks, 1 time every other week for 4 weeks, 1 time a week for 1 week. During a home visit, conducted on 6/17/2025 at approximately 9:15 am with RN (registered nurse) #13, a medication review was conducted and the following discrepancies were noted: Not included in the Plan Of Care: Nexium (used to reduce the amount of acid in the stomach) 20 mg daily. The patient states they have taken it for years; Pregabalin (used to treat nerve and muscle pain) 15 mg 2 times a day. The patient stated that they have been taking it since last summer; Genfibrozil (used to treat cholesterol) 600 mg daily. The patient stated that they have taken it for years; Metronidazole (used to treat chronic facial rash) 0.75% cream 2 times a day to face. The patient stated that they have used it for years; Estrace (used to treat vaginal dryness) 0.01% 1 gram on Wednesday and Sundays. The patient stated that they have used it for 2 years; Magnesium (mineral supplement) 400 mg daily. The patient stated that they have taken it for years; Centrum Silver (multivitamin) daily. The patient stated they have taken it for years; Zinc (mineral supplement) 50 mg every other day. The patient stated they have taken it for 4 months; Tylenol (used to treat minor pain and fever) 325 mg 2 tabs every 4 hours as needed for pain. The patient stated that they have taken it for years. Cyclobenzaprine (used to treat muscle spasms) 5 mg was listed as 1 tablet 2 times a day on the Plan of Care. The patient stated they have been taking 1 tablet 3 times a day. Amoxicillin 875 mg/Potassium Clavulanate 125 mg (combination antibiotic) 1 tablet daily was listed on the Plan of Care as “discontinued effective 6/14/2025”. The patient stated that this medication was extended for another 21 days. During a phone interview on 6/19/2025 at 11:53 am, RN #13 stated “I typically compare discharge instructions and patient’s (pill) bottles in the home. I’m not sure how I missed those” and confirmed that the medications on the plan of care were incorrect. During an interview conducted on 6/19/2025 at 11:54 am, The director stated, “Do a complete med rec [medication reconciliation] between discharge instructions and med bottles” and confirmed that the medications on the plan of care were incorrect. 2.Patient #16 was admitted on 4/7/2025 with a diagnosis of non-displaced fracture of olecranon process (elbow fracture). The plan of care for 6/6/2025- 8/4/2025 included orders for PT (physical therapy) 1 time a week for 4 weeks, 1 time every other week for 4 weeks. During a home visit on 6/17/2025 at approximately 3:50 pm with PTA (physical therapy assistant) #6, a medication review was conducted, and the following discrepancies were noted: Not listed on the Plan of Care: Vitamin B12 (used to support energy production and nerve and blood cell health) 1000 mcg daily and Vitamin B complex (a group of B vitamins used to support energy production, brain function, and cell health) 1 tablet daily. The patient stated that they have taken both of these medications since January, 2025. Aranesp (used to treat low red blood cell count) 150mcg injection every 6 weeks, Heparin (used to help prevent blood clots) 5,000 units injection every 8 hours, and Thiamin (Vitamin B1 used for healthy blood cell development) 100 mg daily. The patient stated that these were all discontinued in April, 2025. During an interview on 6/19/2025 at 11:05 am, PTA #6 stated, “I do it [medication review] every visit” and confirmed that the medications on the Plan of Care were incorrect.

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 agency policy, clinical record review, and staff interviews, the agency failed to include an infection requiring the use of contact precautions (increased personal protective equipment, PPE) for 1 of 1 patient with a diagnosis of Methicillin-resistant Staphylococcus aureus (antibiotic resistant infection) in the plan of care. Patient #8 Findings included: A policy, Plan of Care (POC)/Care (reviewed 01/31/2025) received on 06/17/2025 at 3:40 PM from the agency director stated, “The individualized plan of care must include the following: … All pertinent diagnoses.” Patient #8 was admitted on 05/19/2025 with a diagnosis of unspecified wound. The plan of care (POC) for 05/18/2025-07/16/2025 included orders for skilled nurse (SN) visits 2 times a week for 4 weeks and 1 time a week for 5 weeks, “RN/LPN/LVN [registered nurse, licensed practical nurse, or licensed vocational nurse] to perform/teach patient/caregiver wound care to right elbow abrasion: cleanse with wound cleanser and gauze. Pat dry with gauzeapply [sic] calcium alginate AG/equivalent [silver antimicrobial dressing], apply skin barrier to periwoundcover [sic] with roll gauze, secure with tape. Change dressing twice a week and PRN [as needed] for soilage or dressing replacement.”, and “Diagnostic culture/LPN/LPN to collect wound specimen for culture via swab week of 05.18.25.” Review of the clinical record revealed that the culture was collected on 05/23/2025 by LPN #13 and the results reported on 05/28/2025 stated, “Heavy growth of Methicillin resistant Staphylococcus aures (MRSA).” Further review revealed that there was no update to the POC to include MRSA or the need for increased PPE. An interview conducted on 06/18/2025 at 11:18 AM with LPN #13 revealed that they are new to home health and unaware of agency protocols for updates to the POC, orders for increased PPE use, and documentation related to PPE use. An interview conducted on 06/18/2025 at 11:20 AM with the agency director revealed that there was no expectation of updating the POC to include MRSA or orders for increased precautions.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (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 agency policy, clinical record review, and staff interviews, the agency failed to notify the physician of the patient and caregiver’s non-compliance with blood sugar monitoring, wound care, and medications as ordered in the Plan of Care for 1 out of 7 patients with diabetes. (#1) The findings included: A policy, Coordination of Care (revised 5/22/2024), received from the agency director on 6/18/2025 at 12:47 pm stated “Agency staff involved in the patient’s plan of care (clinicians, clinical managers) provide patient related updates in a timely manner to the physician/allowed practitioner…” Patient #1 was admitted on 6/13/2024 with a diagnosis of infection and inflammatory reaction due to indwelling urethral catheter subsequent encounter (infection and inflammation caused by a urinary catheter on more than one episode of care, type 2 Diabetes (condition in which the body has trouble controlling blood sugar) with hyperglycemia (high blood sugar), abscess of corpus cavernosum and penis (a rare and potentially serious infection of the erectile tissue of the penis). The plan of care for 8/12/2024-10/10/2024 included orders for SN (skilled nursing) 1 time a week for 5 weeks, 1 time every other week for 4 weeks. Review of the clinical record revealed that on the 8/14/2024, 8/28/2024, 9/5/2024, 9/11/2024, and 9/26/2024 SN visits, the nurse documented the patient’s ongoing non-compliance with checking blood sugar levels, taking insulin, and performing wound care on non-skilled nurse visit days. Further review revealed that there was no documentation that the physician had been notified. During an interview with the clinical manager on 6/17/2025 at approximately 8:28 am, the clinical manager revealed that there was no documentation in the clinical record of physician being notified and stated “It [physician notification] should be documented within the visit.”

An unplanned, unannounced complaint investigation was conducted 09/18/23 to 09/19/23. Deficiencies to the Medicare Condition of Participation were identified.

Investigation of complaints CFR(s): 484.50(e)(1) Standard: Investigation of complaints. The HHA must-- This STANDARD is not met as evidenced by: Based on policy review, clinical record review, complaint log review, and staff interview, the agency failed to follow the complaint/grievance process for 1 of 1 record reviewed with a complaint referenced in the clinical record (Patient #1). Findings included: Policy RI-009 titled “Patient/Caregiver Grievance/Complaint”, and last reviewed 12/14/22, was received from an agency director on 09/19/23 at 1:07 PM. This policy revealed, “The agency is to initiate a complaint investigation within 10 business days of the agency’s receipt of the complaint and document all components of the investigation.” Patient #1 was admitted to the agency on 07/24/23 with diagnoses including encounter for surgical aftercare following surgery on the circulatory system, chronic obstructive pulmonary disease with acute lower respiratory infection, and hypertensive chronic kidney disease. Plan of care from 07/24/23 to 09/21/23 revealed orders for skilled nursing one time per week for one week effective 07/30/23, physical therapy two times per week for three weeks, one time per week for two weeks, and one time every two weeks for two weeks, and occupational therapy one time per week for nine weeks. On 09/06/23, Employee #3, occupational therapist, conducted an occupational therapy reassessment. This visit note revealed that Patient #1 informed Employee #3 that he was upset about the timeframes for therapists calling to schedule their visits. Employee #3 documented that Patient #1 stated he and his wife were “highly upset” regarding the inability of home health staff to coordinate visit schedules [several] days in advance. There was no evidence on the agency’s complaint log addressing the complaint of 09/06/23. Patient #1 was discharged from the agency on 09/13/23 following a request from the patient’s wife. In an interview on 09/19/23 at 12:00 PM, Employee #3 stated that there was no additional follow-up or coordination performed regarding the complaint received on 09/06/23.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to conduct a timely occupational therapy assessment for 1 of 3 records reviewed with orders for an occupational therapy evaluation (Patient #2). Findings included: Patient #2 was admitted to the agency 07/29/23 with diagnoses including liver cell carcinoma, hypertension, and adult failure to thrive. Plan of care from 07/29/23 to 09/26/23 revealed orders for physical therapy one time per week for one week, two times per week for two weeks, and one time per week for seven weeks, and occupational therapy one time per week for one week effective 08/06/23. The occupational therapy evaluation was conducted on 09/12/23. In an interview on 09/19/23 at approximately 12:30 PM, Employee #1, agency director, referenced a care delivery note dated 08/08/23 in which the care team collaboration section of the note selected physical therapy and clinical manager but did not select occupational therapy. Employee #1 agreed that the OT order on the plan of care should have been conducted as part of the initial comprehensive assessment and within five days of the start of care.

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, clinical record review, and staff interview, the agency failed to conduct a skilled nursing assessment for 1 of 1 record reviewed with orders for a skilled nursing evaluation (Patient #3). Findings included: Policy TX-001 titled, “Physician Orders and Medical Supervision of the Plan of Care” and last reviewed 06/22/23, was received from the agency director on 09/18/23 at 12:30 PM. This policy revealed, “Each patient receives the home health services that are written in an individualized plan of care…” Patient #3 was admitted to the agency on 07/17/23 with diagnoses including encounter for surgical aftercare following surgery on the circulatory system, hypertensive heart disease with heart failure and atrial fibrillation (an irregular heart rhythm). Plan of care from 07/17/23 to 09/14/23 revealed orders for skilled nursing one time per week for one-week, physical therapy two times per week for three weeks and one time per week for six weeks, and occupational therapy one time per week for one week effective 07/23/23. There was no evidence of a skilled nursing evaluation for Patient #3. In an interview on 09/19/23, Employee #1, agency director, stated “We should have gotten the order discontinued because the patient didn’t want it.”

An onsite complaint investigation was conducted June 20, 2023. Standard level deficiencies to the Medicare Conditions of Participation were identified and the complaint was substantiated.

Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This STANDARD is not met as evidenced by: Based on policy review, clinical record review, and staff interviews the agency failed to discharge a patient when the responsible person requested that the patient be discharged. (#1) 1 of 1 patient that requested a discharge. Findings included: A Policy, “Discharge of Patients” (revised 01/23/23) was received from The Agency Director at 10:23 A.M. on 06/20/2023. The policy stated, “The Home Health Agency may only transfer or discharge a patient for: … Patient’s choice… Patient elects to be transferred or discharged.” A Policy, “Patient Information Booklet, North Carolina” was received at 9:13 A.M. on 06/20/2023 from the Clinical Manager. The policy stated, “Patient Transfer or Discharge Policies, Transfer or discharge occurs… The patient or legal representative … elects to be transferred or discharged.” Patient #1 was admitted on 02/14/2023 with diagnoses of panlobular emphysema (a condition in which the air sacs of all lung lobes are damaged and enlarged), chronic respiratory failure, congestive heart failure, and chronic kidney disease. The Plan of Care for 04/15/2023-06/12/2023 included orders for physical therapy 1 time a week for 6 weeks and 1 every 2 weeks for 2 weeks. There was no evidence in the clinical record that the patient’s spouse agreed to a delayed discharge after requesting a discharge. An interview was conducted on 06/20/2023 at 9:30 A.M. with the spouse of patient #1. The spouse stated, “I called on 05/25/2023 and requested a telephone discharge and was told no one could come until after the holiday (05/30/2023).” An interview was conducted on 06/20/2023 at 2:00 P.M. with physical therapist (PT) #3. PT #3 stated, “I think it was the Friday before Memorial Day that they (patient #1) requested a discharge, she was talking to the scheduler (employee #4). The discharge was scheduled for the Wednesday after Memorial Day (05/31/2023). An interview was conducted with employee #4 on 06/20/2023 at 2:00 P.M. Employee #4 stated, “The first time she (patient #1 spouse) called was on the 25th or 26th (of May 2023) to ask for a discharge. I told her it (the discharge) would be scheduled at the next available PT discharge date and she agreed to it.” An interview was conducted with the Agency Director on 06/20/2023 at approximately 2:45 P.M. The Agency Director stated that the telephone call with employee #4 and spouse of the patient should have been documented in the clinical record.

An onsite, unannounced complaint investigation was conducted 05/16/23. A deficiency to the Medicare Conditions of Participation was identified. The complaint regarding timeliness of the comprehensive assessment was unsubstantiated. -mb

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to accurately document patient-related events in the clinical record as reported for 1 of 3 records reviewed (Patient #1). Findings include: Patient #1 was admitted to the agency on 04/06/23 with diagnoses including metabolic encephalopathy (a chemical imbalance in the brain which leads to further problems). Plan of Care from 04/06/23 to 6/4/23 revealed orders for skilled nursing once every week for five weeks and once every two weeks for four weeks; physical therapy effective 04/09/23 once every week for one week; occupational therapy effective 04/09/23 once every week for one week, once every two weeks for six weeks, and once every week for one week; speech therapy effective 04/09/23 once every week for five weeks; and medical social worker effective 04/09/23 once every week for one week. On 04/15/23, Employee #5, physical therapist, documented a missed visit note. This missed visit note documented the reason for this missed visit as “Family emergency/illness.” In an interview on 05/16/23 at 4:00 PM, Employee #1, agency director, stated, “(Employee #5) reports that he called the wife (Patient #1’s wife) to schedule the day before, went to the home the day of the scheduled visit, and there was no answer. He (Employee #5) waited for 15 minutes and left.” Employee #1 and Employee #5 were not able to explain the reason why the documentation in the clinical record differed from what Employee #5 reported verbally. Employee #1 agreed that the clinical documentation should reflect the verbal report.

An unannounced complaint investigation and follow up survey was conducted on 02/28/23. The complaint was substantiated. A deficiency to the Medicare Conditions of Participation was identified. The following tag was put back into compliance on 02/28/23: G590. ABH

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, clinical record review, and staff interview, the agency failed to follow the physician order for skilled nursing evaluation for 1 of 3 records reviewed (#1). Findings included: Policy AA-014 titled Plan of Care/Care Planning Process, revised 05/09/22, was received from the agency director on 02/28/23 at 5:15 p.m. This policy stated, “…modifications to the plan of care will be based upon the patient’s individual conditions, problems, needs, and assessments…the physician is notified if the agency does not provide care and services in accordance with the physician/allowed practitioner orders…” Patient #1 was admitted on 01/10/23 with diagnoses of unilateral primary osteoarthritis, hemiplegia following cerebral infarction (stroke), heart failure, and history of falling. The plan of care for 01/10/23 to 03/10/23 had orders for skilled nursing 1 time a week for 1 week effective 01/22/23. Review of the clinical record revealed a physician order dated 01/19/23: SN (skilled nurse) to eval (evaluate) patient after ER (emergency room) visit for skin tear and fluid. Further review of the record confirmed no nursing visit had occurred the week of 01/22/23. No documentation was in the record for the physician being notified of the order not being followed. Interview with the agency director on 02/28/23 at 4:55 p.m. revealed “the SN eval was on _____RN (registered nurse) schedule for 1/23/23 but when the nurse called on 01/22/23 the patient had gone to hospital”. The agency director confirmed the documentation was not in the record.

An onsite, unannounced recertification survey was conducted 06/27/22-06/30/22. No deficiencies to the Emergency Preparedness Program were identified. -MHB

An onsite, unannounced recertification survey was conducted 06/27/22-06/30/22. Deficiencies to the Medicare Conditions of Participation were identified. -MHB

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: Findings include: Policy PI-001, Incident/Occurrence Reporting System, was received from the agency director on 06/30/22 at 10:09 AM. This policy revealed, “…An incident/occurrence is any situation occurring ‘out of the ordinary’ from what is routine and expected during the patient’s length of service and/or the employee’s workday…An Incident/Occurrence Report is completed by the employee/staff member who is involved in incident/occurrence, or who initially receives information from the patient or family regarding an occurrence (patient incident/occurrence). The incident/occurrence is reported by the employee/staff member to their immediate supervisor…The patient’s Physician is informed of the incident/occurrence as soon as possible after discovery as documented in the incident/occurrence report. The Administrator/Director of Office Operations ensures notification to the patient’s physician…” Patient #2 was admitted to the agency on 05/09/22 with diagnoses including laceration of left lower leg, hypertension, attention-deficit hyperactivity disorder, depression, and repeated falls. Plan of Care from 05/09/22 to 07/07/22 included orders for skilled nursing 2 times per week for 2 weeks and 1 time per week for 7 weeks. Employee #5, a licensed practical nurse, conducted a skilled nursing visit on 06/01/22. This visit note revealed, “…Patient and caregiver report fall 05/30/22 when ambulating with walker, states [sic] she lost balance, bruise noted to chin, patient states ‘it hurt a little, but I didn’t have a headache or any dizziness.’ Patient denies any pain at this time. Patient refused to call EMS (emergency medical services) with fall…” There was no evidence in the clinical record that Employee #5 reported the fall to the physician. In an interview on 06/30/22 at 11:10 AM, Employee #1, an agency director, stated, “…they [agency clinicians] would fill out the incident report and report it to the physician…” Employee #1 confirmed that there was no evidence that the fall that Patient #2 reported to Employee #5 on 06/01/22 was reported to the physician at the time of survey. Based on policy review, clinical record review, and staff interview, the agency failed to notify the physician of a patient fall for 1 of 3 patients (Patient #2) with documented falls.

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, clinical record review, and staff interview, the agency failed to consistently document a complete cardiovascular assessment, including patient weights, for 2 of 14 patients (Patient #12 and Patient #20) with heart failure and failed to consistently document wound measurements for 1 of 4 patients with wounds (Patient #12). Findings include: Policy AA-014 titled Plan of Care (POC)/Care Planning Process, revised 05/09/22, was received from the agency director on 06/30/22 at 10:09 AM. This policy revealed, “…The physician/allowed practitioner is notified if the Agency does not provide care and services in accordance with the physician/allowed practitioner order…” and “…Modifications to the POC will be based upon the patient’s individual condition, problems, needs, and reassessments. Modifications to the plan of care will be documented in a Verbal Order as obtained from the Physician/allowed practitioner…” Policy WC-001 titled The Provision of Wound and Skin Care, revised 01/20/22, was received from the agency director on 06/29/22 at 10:57 AM. This policy revealed, “…Measuring: In accordance with best practice and standard of care, wounds will be measured a minimum of one time a week…” 1a. Patient #12 was admitted to the agency on 02/28/22 with diagnoses including cutaneous (skin) abscess of groin, squamous cell carcinoma of skin (skin cancer), and chronic systolic heart failure (weakened pumping of the left heart ventricle). Plan of Care from 04/29/22 to 06/27/22 revealed orders for skilled nursing 2 times per week for 9 weeks. This Plan of Care also included the following skilled nursing orders: “Heart failure; skilled nurse to assess cardiopulmonary system to identify signs of decompensation and intervene to minimize the severity of fluid overload. Assess patient ability to monitor and record daily weights…record patient reported weight, or weight patient as needed. Report increased edema or weight gain of > (greater than) 2 lbs (pounds) in 1 day or >5 lbs in 1 week or 5 lbs or more over target weight. May measure abdominal girth if unable to weigh…” Employee #10, a licensed practical nurse, conducted skilled nursing visits on 05/05/22, 05/12/22, 05/16/22, 05/26/22, 06/02/22, 06/06/22, and 06/09/22. Each of the visits conducted by Employee #10 included the documented cardiovascular assessment as “no problems identified”. There were no weights documented during any of the noted visits conducted by Employee #10. The 05/05/22, 05/12/22, 06/02/22, and 06/09/22 visit notes included documentation regarding a need for reinforced teaching required due to Patient #12 being “noncompliant with checking daily weights”, however, there was no evidence that Employee #10 notified the physician regarding Patient #12’s noncompliance. Employee #6, a registered nurse, conducted skilled nursing visits on 05/23/22, 06/13/22, 06/17/22, and 06/21/22. Each of the visits conducted by Employee #6 included the documented cardiovascular assessment as “no problems identified”. There were no weights documented during any of the noted visits conducted by Employee #6. In an interview on 06/30/22 at approximately 3:05 PM, Employee #2, an agency director, confirmed that there were no weights documented for Patient #12 between 05/05/22 and 06/23/22 and stated, “…if they [the patient] are not following the plan of care, they [the clinician] should be notifying the physician of the noncompliance…” 1b. Plan of Care from 04/29/22 to 06/27/22 included orders for skilled nursing to “…perform/teach incision care to non-healing open wound of right groincleanse [sic] wound with soap and waterpat [sic] dryapply[sic] [brand name] green mesh to the open wound and cover with [brand name]…change daily or as needed for increased drainage or dressing malfunction…” Patient #12 received skilled nursing visits with documented wound care on 05/05/22, 05/12/22, 05/16/22, 05/23/22, 5/26/22, 06/02/22, 06/06/22, 06/09/22, 06/13/22, 06/17/22, 06/21/22, and 06/23/22. Of these skilled nursing visits, 06/23/22 was the only visit that included documented wound measurements. In an interview on 06/30/22 at approximately 11:47 AM, Employee #2, an agency director, stated, “…It [Patient #12’s wound] should have been measured the first visit of the week...” 2. Patient #20 was admitted to the agency on 12/04/21 with diagnoses including chronic obstructive pulmonary (lung) disease, respiratory failure, and chronic systolic congestive heart failure (weakened pumping of the left heart ventricle). Plan of Care from 12/04/21 to 02/01/22 included orders for skilled nursing 1 time per week for 6 weeks and 1 time every 2 weeks for 4 weeks, physical therapy 1 time per week for 1 week and occupational therapy 1 time per week for 1 week. This Plan of Care also included the following skilled nursing orders: “Heart failure; skilled nurse to assess cardiopulmonary system to identify signs of decompensation and intervene to minimize the severity of fluid overload. Assess patient ability to monitor and record daily weights…record patient reported weight, or weight patient as needed. Report increased edema or weight gain of > (greater than) 2 lbs (pounds) in 1 day or >5 lbs in 1 week or 5 lbs or more over target weight. May measure abdominal girth if unable to weigh…” Employee #11, a licensed practical nurse, conducted a skilled nursing visit on 12/22/21. The cardiovascular assessment revealed, “no problems identified” and there was no evidence of a weight obtained during this visit. Employee #12, a registered nurse, conducted a skilled nursing on 12/31/21. The cardiovascular assessment revealed, “no problems identified” and there was no evidence of a weight obtained during this visit. Employee #13, a licensed practical nurse, conducted a skilled nursing visit on 01/04/22. The cardiovascular assessment revealed, “no problems identified” and there was no evidence of a weight obtained during this visit. In an interview on 06/30/22 at approximately 1:20 PM, Employee #3, an agency director, stated that she would expect to see documentation that either the clinician weighed the patient or that the clinician verified that the patient was weighing daily and stated, “…with CHF (congestive heart failure) they [clinicians] should be teaching them [patients] related to weighing and our role would be to educate the patient so that they could do it themselves when we are no longer in the home…”