Every finding on record at Amedisys Sc, LLC

An onsite unannounced Emergency Preparedness Program (EPP) Survey and survey for the Medicare COVID - 19 Staff Vaccination requirements was conducted at Neighbors Care Home Health from 02/13/2023 to 02/16/2023. Neighbors Care Home Health is in compliance with the Medicare COVID-19 Staff Vaccine requirements with 26 staff members fully vaccinated, 12 religious exemptions, and 1 medical exemption approved, and policies and procedures in place. The Home Health Agency had standard level deficiencies in the Condition at 42 CFR 484.102 (Establishment of the Emergency Program).

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on record review(s) and staff interview(s), the home health agency (HHA) failed to ensure that Emergency Preparedness (EP) procedures were implemented in Lancaster and Cherokee counties where the HHA provides patient services. The findings are: Review of the HHA's Emergency Preparedness (EP) plan on 2/16/2023 at 2:00 PM revealed the HHA had no list of personnel contact information for Lancaster and Cherokee counties for use during an emergency situation. In an interview with Administrator #1 and #2 on 1/16/23 at 2:30 PM, they confirmed that a list of personnel contacts had not been created for HHA personnel providing patient care in Lancaster and Cherokee counties.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on record reviews and staff interviews, the Home Health Agency (HHA) failed to ensure Emergency Preparedness (EP) policies and procedures for testing of the HHA's emergency plan were implemented in Chester, York, Lancaster, and Cherokee counties where the HHA provides patient services. The findings are: Review of the HHA's EP plan revealed there was no documentation of testing the HHA's EP plan for York, Lancaster and Cherokee counties. In an interview with Administrator #1 and #2 on 1/16/23 at 2:00 PM, they confirmed that no testing of the HHA's EP had taken place for York, Lancaster, or Cherokee county. Administrator #10 confirmed the HHA has patients in those localities. HHA policy, titled, COM-004 “Emergency Preparedness Planning Care Center Tasks”, dated 8/10/22, relates the purpose of the policy is to “Disseminate and communicate information obtained from the local Office of Emergency Preparedness, state, county and local government guidelines to our staff and patients”.

An onsite unannounced Recertification Survey was conducted at Neighbors Care Home Health from 02/13/2023 to 02/16/2023. The Home Health Agency is in substantial compliance with the Medicare Conditions at 42 CFR PART 484. Standard level deficiencies were cited. The census was 359.

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: This requirement was NOT MET as evidenced by: Based on observations, record reviews, and staff interviews, the Home Health Agency (HHA) failed to follow physician orders regarding blood sugar results, weights, and wound care for 2 of 17 patient charts reviewed for care and services. (Patient #1 and #13) The findings include: On 2/14/2023 at 1:30 PM, review of Patient #1's chart revealed the patient was admitted on 12/17/2022 with physician orders for Total Parenteral Nutrition (TPN) feeding through PICC line and Diabetes Mellitus Type 2. Physician orders for Skilled Nurse (SN) showed “Skilled Nurse to Report to Physician Blood Glucose Readings Greater Than 300 Or Less Than 70”. Documentation showed Patient #1 was seen by the SN on 12/17/2022, 12/19/2022, 12/28/2022, 1/03/2023, 1/09/2023, 1/31/2023, 2/07/2023 and 2/13/2023 with no documentation for glucose levels. On 2/15/2023 at 2:35 PM, review of the patient's chart with Administrator #1, he/she reported “Should have been done” and verified the finding. On 2/15/2023 at 12:13 PM, review of Patient 13's chart revealed physician orders that reads, “Report Increased Edema Or Weight Gain Of > (greater) than 2 LBS In 1 Day Or > 5 LBS (pounds) In 1 Week Or 5 LBS Or More Over Target Weight. May Measure Abdominal Girth If Unable to Weigh” and “Skilled Nurse to report to physician blood Glucose Reading Greater Than 300 Or Less Than 70” and “Skilled Nurse To Performance Form/Teach Patient/Care-Giver Wound Care Pressure Injury to Bilateral Buttocks Cleanse with Saline Pat Dry with Gauze Apply Skin Prep”. SN notes on 10/21/2022 and 10/25/2022, 11/15/2022, 11/26/202211/29/2022, 12/02/2022,12/06/2022, 12/09/2022, and 12/16/2022 had no documentation for weight or girth measurements. SN notes on 10/21/2022, 10/25/2022, 11/01/2022, 11/08/2022 and 11/15/2022 had no documented blood glucose results. Review of physician orders dated 10/25/2022 revealed “May Apply Barrier Cream to Bilateral Buttocks Wounds Daily and PRN (as needed)”. SN notes dated 11/01/2022, 11/08/2022, 11/15/2022, 11/18/2022, and 12/13/2022 documented wound care as “Cleaned with Saline Patted Dry with Gauze Applied Skin Prep”. On 2/15/2023 at 2:20 PM, after review of the patient's chart, Administrator #2 verified the findings and reported, “She didn’t update the wound orders…patient lives in a facility and not always able to weigh”.

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 chart reviews and interview, the Home Health Agency's Skilled Nurse (SN) failed to obtain physician orders prior to providing wound care treatment for 1 of 4 applicable patients. (Patient #13) The findings are: On 2/15/2023 at 12:13 PM, review of Patient #13's chart revealed the patient was admitted on 10/18/2022 with diagnoses that included Stage 2 pressure ulcers of right and left buttocks and Heart Failure. Review of the SN documentation at the patient's Start Of Care revealed “…Bilateral Lower Extremities Wrapped In Unna Boots. SN Removed Unna Boots And Patient Has No Wounds Present. Patient Did Have a Pair of Compression Stockings In His Room That SN Attempted To Place But Was Unable To. SN Wrapped Legs With Unna Boots and Notified Matt PA To Order New Compression Stockings And Measurements Provided”. There was no physician orders on the patient's chart for continuation of Unna boots. On 2/15/2023 at 2:20 PM, Administrator #2 verified the findings and reported “She needed to get that order”.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: This requirement is NOT MET as evidenced by: Based on observations, record reviews, and staff interviews, the Home Health Agency (HHA) failed to ensure physicians authenticated their orders in a timely manner for 1 of 17 sampled patients. (Patient #14) On 2/14/2023 1:15 PM, review of Patient #14's chart revealed the patient's Start of Care date was 12/19/2022 and the physician's unauthenticated orders were dated 12/19/2022. The physician orders were not authenticated by the physician until 2/09/2023 which was 52 days later. On 2/16/2023 at 2:15 PM, the HHA's Director #1 verified the finding. Agency policy titled “Physician Verbal Orders” TX-002. 4 reads “The (physician’s) order must be signed and returned to the office in accordance with specific state regulations, but no longer than 30 days”.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on observations, chart review, and interview, the Skilled Nurse (SN) failed to update the Home Health Agency's medication profile for 2 of 6 applicable patients (Patient #1 and #6) and failed to accurately update the clinical record for 2 of 17 patient charts reviewed for care and services. (Patient #1 and #13) The findings are: Observations during a home visit on 2/13/2023 from 2:03 PM to 2:25 PM revealed Patient #1's caregiver reported the patient no longer takes Magnesium 400 mg (milligrams) by mouth once a day. Magnesium was active on the HHA's medication profile. On 2/15/2023 at 2:35 PM, Administrator #1 verified the finding. Observations during a home visit on 2/14/2023 from 10:20 AM to 11:10 AM revealed Patient #6 reported taking Gabapentin 300 mg by mouth, 2 capsules in the morning and 1 capsule at nighttime. Review of the HHA's medication profile for the patient revealed Gabapentin 300 mg 1 capsule twice a day. Patient #6 reported taking Levothyroxine 25 mcg (micrograms) 1 tablet by mouth at nighttime, but review of the HHA's medication profile for the patient revealed Levothyroxine 75 mcg 1 tablet daily. On 2/15/2023 at 2:48 PM, Administrator #1 verified the findings. On 2/14/2023 at 1:30 PM, review of Patient #1's chart revealed the patient was admitted on 12/17/2022 with diagnoses peritoneal abscess, Total Parenteral Nutrition (TPN) feedings, and Diabetes Mellitus Type 2. The patient's Start of Care (SOC) assessment revealed the patient had physician orders for SN to report “Skilled Nurse To Report To Physician Blood Glucose Readings Greater Than 300 Or Less Than 70”. Patient #1 was seen by the SN on 12/17/2022, 12/19/2022, 12/28/2022, 1/03/2023, 1/09/2023, 1/31/2023, 2/07/2023 and 2/13/2023 with no documentation for the patient's blood glucose levels. On 2/15/2023 at 2:35 PM, Administrator #1 verified the findings and reported “Should have been done.” On 2/15/2023 at 12:13 PM, review of Patient #13's chart revealed the patient acquired a new skin tear on the Left Lower Extremity (LLE) on 11/08/2022 as documented in SN narrative. The SN failed to document the size, wound bed status, drainage, or wound care. Review of physician orders dated 11/15/2022 revealed wound care orders for skin tear of LLE and increased SN visit schedule. On 2/15/2023 at 2:20 PM, Administrator #2 verified the finding and reported “Don’t know why it was late”.

A survey of the Home Health Agency's (HHA) Emergency Preparedness Program (EPP) was conducted from 11/1/2021 to 11/4/2021. Based on observations, record reviews, interviews, and review of the HHA's EPP, it was determined the HHA’s EPP was in compliance with Conditions of Participation at 42 CFR 484.102.

A survey of the Home Health Agency (HHA) was conducted in conjunction with the COVID-19 focused Infection Control requirements from 11/1/2021 to 11/4/2021. Based on observations, record reviews, interviews, and review of the HHA’s policy and procedures, it was determined the HHA has standard level deficiencies at 42 CFR PART 484.

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 record review and interview, the agency staff failed to document measurable goals for all goals listed on the Plan of Care (POC) in 16 out of 17 charts reviewed (Patient #1-#7 and #9-#17). Patient #9 On 11/1/2021 at 3:18 PM, a review of Patient 9’s chart reveals the POC has goals which are not measurable (Plan of care established, changes in co-morbid condition, demonstrate effective, safe management of medication, when to call 911, and ineffective anticoagulation therapy). Verified by the Administrator 1 and Administrator 2 at 9:51 AM on 11/4/2021. Patient #10 On 11/1/2021 at 3:25 PM, a review of Patient 10’s chart reveals the POC has goals which are not measurable (exhibit signs of anticoagulant toxicity, exhibit signs of urinary tract infection, and when to call 911). Verified by the Administrator 1 and Administrator 2 at 9:53 AM on 11/4/2021. Patient #12 On 11/1/2021 at 3:36 PM, a review of Patient 12’s chart reveals the POC has goals which are not measurable (Plan of care established, changes in co-morbid condition, demonstrate effective, safe management of medication, when to call 911, and changes in skin integrity). Verified by the Administrator 1 and Administrator 2 at 9:58 AM on 11/4/2021. Patient #16 On 11/1/2021 at 3:54 PM, a review of Patient 16’s chart reveals the POC has goals which are not measurable (Plan of care established, changes in co-morbid condition, demonstrate effective, safe management of medication, when to call 911, skin integrity status, and ability to perform wound care). Verified by the Administrator 1 and Administrator 2 at 10:07 AM on 11/4/2021. Patient #17 On 11/1/2021 at 4:05 PM, a review of Patient 17’s chart reveals the POC has goals which are not measurable (plan of care established, co-morbid condition, effective, safe management of medication, and when to call 911). Verified by the Administrator 1 and Administrator 2 at 10:12 AM on 11/4/2021. Patient #11 On 11/2/2021 at 1:51 PM, a review of Patient 11’s chart reveals the POC has goals which are not measurable (Plan of care established, changes in co-morbid condition, demonstrate effective, safe management of medication, when to call 911, and ability to perform wound care). Verified by the Administrator 1 and Administrator 2 at 9:55 AM on 11/4/2021. Patient #14 On 11/2/2021 at 2:14 PM, a review of Patient 14’s chart reveals the POC has goals which are not measurable (Plan of care established, changes in co-morbid condition, demonstrate effective, safe management of medication, ineffective anticoagulation therapy, when to call 911, and skin integrity status). Verified by the Administrator 1 and Administrator 2 at 10:01 AM on 11/4/2021. Patient #15 On 11/2/2021 at 2:20 PM, a review of Patient 15’s chart reveals the POC has goals which are not measurable (Plan of care established, demonstrate effective, safe management of medication, when to call 911, and exhibit signs of urinary tract infection). Verified by the Administrator 1 and Administrator 2 at 10:04 AM on 11/4/2021. Patient #1 On 11/2/2021 at 2:49 PM, a review of Patient 1’s chart reveals the POC has goals which are not measurable (Plan of care established, changes in co-morbid condition, demonstrate effective, safe management of medication, and ineffective anticoagulation therapy). Verified by the Administrator 1 and Administrator 2 at 9:20 AM on 11/4/2021. Patient #2 On 11/2/2021 at 3:01 PM, a review of Patient 2’s chart reveals the POC has goals which are not measurable (Plan of care established, changes in co-morbid condition, demonstrate effective, safe management of medication, when to call 911, and additional orders will be received). Verified by the Administrator 1 and Administrator 2 at 9:29 AM on 11/4/2021. Patient #4 On 11/2/2021 at 3:07 PM, a review of Patient 4’s chart reveals the POC has goals which are not measurable (Plan of care established, changes in co-morbid condition, demonstrate effective, safe management of medication, and when to call 911). Verified by the Administrator 1 and Administrator 2 at 9:35 AM on 11/4/2021. Patient #3 On 11/2/2021 at 3:16 PM, a review of Patient 3’s chart reveals the POC has goals which are not measurable (Plan of care established, changes in co-morbid condition, demonstrate effective, safe management of medication, when to call 911, and skin integrity status). Verified by the Administrator 1 and Administrator 2 at 9:31 AM on 11/4/2021. Patient #13 On 11/2/2021 at 3:44 PM, a review of Patient 13’s chart reveals the POC has goals which are not measurable (Plan of care established, changes in co-morbid condition, demonstrate effective, safe management of medication, ineffective anticoagulation therapy, when to call 911, and symptoms of decompensated heart failure). Verified by the Administrator 1 and Administrator 2 at 10:00 AM on 11/4/2021. Patient #5 On 11/3/2021 at 1:41 PM, a review of Patient 5’s chart reveals the POC has goals which are not measurable (Plan of care established, changes in co-morbid condition, demonstrate effective, safe management of medication, when to call 911, changes in skin integrity and identify fall risk factors). Verified by the Administrator 1 and Administrator 2 at 9:37 AM on 11/4/2021. Patient #6 On 11/3/2021 at 2:01 PM, a review of Patient 6’s chart reveals the POC has goals which are not measurable (Plan of care established, changes in co-morbid condition, demonstrate effective, safe management of medication, when to call 911, changes in skin integrity and ineffective anticoagulation therapy). Verified by the Administrator 1 and Administrator 2 at 9:39 AM on 11/4/2021. Patient #7 On 11/3/2021 at 2:14 PM, a review of Patient 7’s chart reveals the POC has goals which are not measurable (When to call 911 and exhibit signs of urinary tract infection). Verified by the Administrator 1 and Administrator 2 at 9:43 AM on 11/4/2021.