Every finding on record at Amedisys Pennsylvania LLC

Based upon the findings of an unannounced onsite Medicare recertification survey conducted March 6-9, 2023, Amedisys Home Health was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an unannounced onsite Medicare recertification survey conducted March 6-9, 2023, Amedisys Home Health was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on review of clinical records (CRs), agency policies, and an interview with the agency office manager (EF#11) and Director of Operations (DOO), the agency failed to obtain a physician signature on verbal orders within seven (7) days on three (3) of seventeen (17) CRs (CR#9, CRs#14-15). Findings include: Conducted review on March 9, 2023, at approximately 10 AM, of agency policies: "IM-010(a) Electronic Signatures with Physician or Facility", policy includes Procedure #6 "Physician rubber stamp signatures are not acceptable or clinical record documentation ... ."; reviewed "Office Operations Processes: Orders Management" revealed: "Physican signature/date may not be rubber stamped ... ."; and policy TX-001 "Physician Orders and Medical Supervision of the Plan of Care" revealed: "The agency requires submission and return of physician orders according to state-specific minimum standards, but not longer than 30 days." Conducted review of CRs on March 8, 2023, between 8:30 AM to 3:30 PM revealed: CR#9 start of care (soc) 11/19/2022, EF#11 requested physician signature as per office process; written physician signature finalized orders on 12/21/2022; physician signature was two days late. CR#14 soc 10/2/2022, EF#11 faxed requests for physician signature on 10/19/2022, 10/21/2022, and 11/1/2022; written physician signature finalized orders on 11/7/2022; physician signature was 6 days late. CR#15 soc 9/21/2022 stamped physician signature faxed to agency on 9/30/2022 and EF#11 approved/processed this signature; random internal agency audit in 1/2023 identified physician signature as "stamped"; EF#11 faxed physician on 1/18/2023 for signature; finalized written physician signature obtained on 2/14/23; Physician signature was 146 days late. Conducted an interview on March 9, 2023, at approximately 11 AM, with EF#11 and DOO confirmed the above findings.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based upon review of employee files (EFs), agency policy, and interview with agency office manager (EF#11), the agency failed to obtain a Pennsylvania (PA) State Police criminal history record (PATCH) at the time of application for two (2) of ten (10) EFs (EF#6, EF#8). Findings Include: Conducted a review on March 6, 2023, at approximately 1:00 PM, agency policy HR-007(a) Pennsylvania Background Checks requiring the agency to obtain "a report of criminal history record information from the state police or a statement from the state police that their central repository contains no such information relating to that person." Conducted a review of EFs on March 6, 2023, at approximately 11:30 AM. Date of Hire (doh) is listed below. EF#6 doh 1/27/2021, no on-hire PA PATCH located in employee file. EF#8 doh 9/21/2020 no on-hire PA PATCH document maintained in employee file. Evidence of completed request on 9/29/2020. Interview conducted on March 9, 2023, at approximately 11 AM, with EF#11 and Director of Operations confirmed the above findings.