Every finding on record at Amedisys Sc, LLC.

An onsite unannounced Emergency Preparedness Program survey and a COVID - 19 Staff Vaccination Survey were conducted at Amedisys Beaufort Home Health from 05/01//2023 to 05/04/2023. The facility is in substantial compliance with the Condition for Coverage (CFC) at 42 CFR PART 484.102 with the following standards. The home health agency is in compliance with the Medicare COVID-19 Staff Vaccine requirements with 30 staff members fully vaccinated and 6 approved religious exemptions.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record reviews and interview, the home health Agency (HHA) failed to ensure that the Emergency Preparedness Program was reviewed and updated annually. Review of the HHA's Emergency Preparedness Program on 05/03/2023 at 12:00 PM revealed the last Emergency Preparedness Program review/update was dated 09/23/2021. On 05/03/2023 at 12:00, Administrator #1 verified the finding. HHA's y policy, TX-012: Procedure: Item 3. "The plan is reviewed annually and updated as needed".

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(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:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on review of the Home Health Agency (HHA) Emergency Preparedness Program and interview, the HHHA failed to ensure the Emergency Preparedness Program had listings for emergency officials of both counties that the agency services. During review of the HHA's Emergency Preparedness Program and interview with the Administrator #1 on 05/03/2023 at 12:00 PM, Administrator #1 revealed the HHA is licensed in Beaufort and Jasper Counties, South Carolina. The Emergency Preparedness Program had emergency officials listed for Beaufort County, but none listed for Jasper County. Administrator #1 confirmed the finding during the interview adding the HHA does have a number of current patients in Jasper County.

An onsite unannounced Recertification Survey was conducted at Amedisys Beaufort Home Health from 05/01//2023 to 05/04/2023. The Home Health Agency (HHA) is in substantial compliance with the Conditions for Participation at 42 CFR PART 484. Standard level deficiencies were cited.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on patient chart reviews and interview, the Home Health Agency (HHA) failed to perform initial nursing assessments for 3 of 16 patient charts within 48 hours of the physician referral. (Patient #12, #14 and #15) On 05/02/2023 at 3:35 PM, review of Patient #12's chart revealed Patient #12 was admitted on 02/09/2023. The referral date was 02/06/2023 for Physical therapy (PT). On 05/03/2023 at 3:47 PM, the Administrator reported there was no documentation in the patient's chart for delayed Start of Care (SOC) and verified the finding. On 05/02/2023 at 4:30 PM, review of Patient #14's chart revealed the patient was admitted on 03/28/2023. The referral date was 03/25/2023 for PT. On 05/03/2023 at 3:33 PM, the Administrator reported there was no documentation in the patient's chart for delayed Start of Care (SOC) and verified the finding. On 05/02/2023 at 3:55 PM, review of Patient #15's chart revealed the patient was admitted on 04/25/2023. The referral date was 04/19/2023. On 05/03/2023 at 3:345 PM, the Administrator reported there was no documentation in the patient's chart for delayed Start of Care (SOC) and verified the finding.

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 observations, chart reviews, and interviews, the home health agency staff failed to ensure an accurate medication list for 2 of 4 applicable patients. (Patient #13 and Patient #15) Observations during Patient #13's home visit on 05/02/2023 between 10:23 AM and 11:19 AM revealed inaccuracies in the home health agency's medication profile for the patient when compared with medications in the home that Patient #13 reports actively taking: Linzess 10 mg (milligrams) capsule 1 by mouth daily. HHA profile lists Linzess 10 mg as discontinued. Potassium 10 meq (milliequivalent) 1 tablet by mouth daily. HHA profile lists Potassium 10 meq as discontinued. Famotidine 40 mg 1 by mouth daily. HHA listed Famotidine 40 mg as discontinued. Loratadine 10 mgs 1 tablet by mouth daily. HHA list Loratadine 10 mgs as discontinued. Interview on 05/02/2023 at 11:00 AM with Licensed Practical Nurse #2 (LPN #2), LPN #2 reported medications were missing and verified the finding. Observation during a home visit with Patient #15 on 05/02/2023 between 1:56 PM and 2:35 PM revealed inaccuracies between the HHA profile for the patient when compared with medications in the home. Patient #15 reported using Latanoprost 0.005% (percent) eye drops twice a day 1 drop in each eye. HHA profile did not instruct for each eye and reported only taken at bedtime. Patient reported taking Fluticasone Propionate 50 mcg/actuation (micrograms) nasal spray suspension 1 spray in each nostril twice a day. HHA profile did not instruct for each nostril. Patient reported taking vitamin D once a week, but unable to find the bottle and the HHA profile did not have Vitamin D. Interview on 05/02/2023 at 2:30 PM with LPN #1, LPN #1 reports medications were missing and instructions on the patient's medication profile were inaccurate.

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 patient chart reviews and interview, the home health agency (HHA) staff failed to follow physician orders regarding visit schedules and therapy evaluations for 4 of 16 patient charts reviewed for care and services. (Patient #1, #2, #5 and #6) Patient #1 Chart review on 05/03/2023 at 12:30 PM reveals Patient #1 admitted to service on 01/27/2023 with orders for skilled nursing and physical therapy evaluation. There is no documentation of a Physical Therapy (PT) evaluation being performed. Interview on 05/03/2023 at 3:24 PM, Administrator reports no documentation in the chart of reason why PT did not evaluate Patient #1 and verifies the finding. Patient #2 with a Start of Care date of 12/22/2022 and diagnosis of Diabetes and Hypertension has Physical Therapy (PT) orders effective 12/11/2022 for 1 PT visit per week for 8 weeks. The PT missed a visit in Week 4, yet no Missed Visit Note is found in the chart to explain the absence. Administrator #1 was shown these records during an interview on 05/03/2022 2:00 PM and concurs with the facts. Patient # 5 with a Start of Care date of 09/04/2022 and a diagnosis of Chronic Heart Failure, Diabetes and Chronic Kidney Disease has Physical Therapy (PT) orders for an evaluation. There is no indication in the chart that the PT went on the evaluation, and no Missed Visit Note to explain the absence. Administrator #1 was shown these records during an interview on 05/03/2022 2:00 PM and concurs with the facts. Patient #6 with a Start of Care date of 12/01/2022 and a diagnosis of Left Hip Replacement and Hypertension has orders for Occupational Therapy for 1 visit per week for 5 weeks. The order is dated 12/02/2022. The Occupational Therapist made a first visit on 12/07/2022, 4 days after the order. The Physical Therapist has orders for 1 visit per week for 8 weeks. The orders are dated 12/04/2022. The Physical Therapist made the first visit on 12/08/2022, 4 days after the order. Administrator #1 was shown these records during an interview on 05/03/2022 2:00 PM and concurs with the facts.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observations and interview, the home health agency (HHA) failed to ensure staff adhered to infection control principles in the provision of patient care to prevent cross transmission of infectious agents in the home setting for 1 of 1 patient observed for care. (Patient #11) Observations during a home visit with Patient #11 and Registered Nurse (RN)#2 on 05/02/2023 at 12:30 PM revealed RN #2 failed to don sterile gloves when performing a peripherally Inserted Central Catheter (PICC) line dressing change. On 05/02/2023, RN #2 verified the finding and stated, "The facility that sent this patient home did not send enough supplies." HHA policy, IV-009, specifically states "donning sterile gloves after the old dressing is removed, and the area thoroughly cleansed, prior to putting the new dressing on the open wound."