Every finding on record at Amedisys North Carolina , LLC

An unannounced onsite complaint survey was conducted on 06/09/2025. Standard level deficiencies to the Medicare Conditions of Participation were identified.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the skilled nurse failed to perform wound care as ordered for 1 of 1 patient with a wound. (patient #1) Findings included: A policy, The Provision of Wound and Skin Care (revised 02/26/2025) received on 06/09/2025 at 3:35 PM stated, “Wound care orders are in effect until documentation supports wound care is no longer needed or an order is received to change the wound care or discontinue it.” Patient #1 was admitted on 09/25/2024 with a diagnosis of type 2 diabetes mellitus with other skin complications. The plan of care for 09/25/2024-11/23/2024 included orders for skilled nurse [SN] visits 1 time a week for 1 week, 2 times a week for 7 weeks with 2 PRN (as needed) and “RUE [right upper extremity] hand registered nurse/licensed practical to perform/teach incision care … irrigate/cleanse with NSAPPLY [sic, normal saline apply] MEDIHONEY [for debridement, removal of dead tissue] to wound bedmay [sic] apply skin barrier to periwound [tissue surrounding the wound] PRN to prevent maceration… change every other day and ORN [sic, PRN], SN to change 2 week, CG [caregiver] changes on non SNV [skilled nurse visit] days.” A review of the clinical record revealed the following discrepancies: On 10/04/2025 licensed practical nurse (LPN) #3 documented that wound care was completed as ordered and “No Medihoney in the home.” During an interview conducted on 06/09/2025 at 2:35 PM LPN #3 stated, “I remember that there was a point when there was no Medihoney in the home… I don’t remember what I did.” On 10/14/2025 LPN #3 documented, “Betadine [used for disinfection] completed” and that the wound care was completed as ordered.” Further review revealed that there was no order for betadine. During an interview conducted on 06/09/2025 at 2:40 PM LPN #3 stated, “I don’t remember why I put betadine.” On 10/18/2025 LPN #3 documented, “No debridement” and that wound care was completed as ordered. During an interview conducted on 06/09/2025 at 2:42 PM LPN #3 stated, “I don’t know why I put no debridement, maybe it was accidental.” During an interview conducted on 06/09/2025 at 3:58 PM the agency director stated, the expectation is for the nurses to “Follow the company’s policy on completing documentation… complete thorough wound care documentation. We can’t make those decisions [wound care changes] on our own. They should contact the doctor, document, and put the order in.”

Registered Nurse CFR(s): 484.115(k) Standard: Registered nurse. A graduate of an approved school of professional nursing who is licensed in the state where practicing. This STANDARD is not met as evidenced by: Based on clinical record review, personnel record review, and staff interviews, the agency permitted an LPN (licensed practical nurse) to include RN (registered nurse) in her title when signing documents for 1 of 2 licensed practical nurses. (LPN #4) Findings included: Patient #2 was admitted on 03/26/2024 with a diagnosis of Pressure ulcer of sacral region, stage 2 (wound with participial thickness skin loss at the base of the spine). The plan of care for 03/26/2024-05/24/2024 included orders for skilled nurse (SN) visits 1 time a week for 2 weeks, 1 every other week for 2 weeks, and 1 time a week for 5 weeks. A review of the clinical record revealed that 5 of 5 SN visits conducted by LPN #4 included RN (registered nurse) on the signature. A review of LPN #4’s personnel record revealed that LPN #4 was not licensed as a registered nurse. LPN #4 was not available for an interview. An interview conducted on 06/09/2025 at 4:02 PM with the agency director revealed that LPN #4 did not have a registered nurse license and the expectation is for the lsignature to be correct. The agency director stated, “In December 2023, someone added the RN [registered nurse]. We do not do that here in the care center.” In a statement received on 06/09/2025 at 5:26 PM the Director, Talent, Operations & Compliance stated, “The process for license renewals requires the Office Manager so [sic] submit documentation (point source verification from the website) of the renewed license via license renewal form via Microsoft Forms. It appears the Office Manager initially submitted the RN license (which was updated in PeopleSoft by the Compliance Specialist). It appears the Office Manager submitted the LPN license three days later (which was also updated in PeopleSoft by the Compliance Specialist). The process is that the Compliance Specialist validates the license(s) submitted prior to updating in PeopleSoft. This will be addressed with both the Office Manager and the Compliance Specialist.”