Every finding on record at Amedisys Sp-In LLC

An Emergency Preparedness Survey was conducted by the Indiana State Department of Health in accordance with 42 CFR 484.102. Survey Dates: 1/9/2023-1/13/2023 and 1/17/2023-1/18/2023 Census: 136 At this Emergency Preparedness survey, Amedisys Home Health was not found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102. QR Completed on 1/30/2023 A4

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to conduct an exercise opposite the full-scale or functional exercise with testing results, response, and analysis documented so the plan could be updated for 1 of 1 Emergency Preparedness Program review. Findings include: A revised 09/19 SE-001 policy titled GUIDELINES RELATED TO SPECIFIC EMERGENCIES/DISASTERS was provided by the Director of Operations (A1-Administrator) on 1/12/2023 at 8:40 a.m. The policy indicated, but was not limited to, "**This information should be utilized in the Mitigation/Development, Education/Preparation, Response, and Recovery Phases of Emergency Management Plan**…". During and interview on 1/12/2023 at 2:44 p.m. A1 was asked if there was any documentation indicating what was completed for the mock disaster drills or actual active shooter emergency that occurred in December. A1 indicated he/she was not aware those activities could be used as part of the Emergency Preparedness program for the agency. A1 indicated there was no formal documentation that had been put together for the drills or the active shooter emergency the agency went through that activated the program. Review of the Emergency Preparation (EP) Binder along with the Director of Operations (A1) on 1/12/2023 at 8:40 a.m. A1 was asked to locate the tabletop and community based emergency exercises within the binder. A1 indicated the agency experienced an actual emergency regarding an active shooter that required activation of the emergency plan on 12/20/2022. Documentation of the incident was not in the binder for review. A1 indicated he/she would look on the computer for more information. During an interview on 1/12/2023 at 10:50 a.m. A1 was asked to provide the active shooter documentation for emergency preparedness program for review. At that time, A1 provided a document titled Annual Emergency Preparation Activities Update which did not indicate the facility’s analysis, response, and how the facility updated its emergency program based on analysis. During an interview on 1/13/2023 at 10:50 a.m. A1 was asked again to provide documentation for review of the real time active shooter exercise.

This visit was for a Federal Recertification and State Re-licensure survey of a Provider. Survey Dates: 1/9/2023-1/13/2023 and 1/17/2023-1/18/2023 Census: 136 A partially extended survey was announced on 1/10/2023 and a fully extended survey was announced on 1/12/2023. This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment reflected the patient's relevant medical history and current health problems; the patient's psychosocial status, such as ability to participate in care, ability to identify and meet one's needs, and support systems available; and education, knowledge level, and ability to understand and learn for 2 of 13 active records reviewed (Patients 7,10). Findings include: 410 IAC 17-14-1 (a)(1)(B) 1. A review of the comprehensive assessment for Patient #7, dated11/14/22, failed to evidence the patient was a diabetic, and failed to evidence the patient was knowledgeable concerning diabetic management such as diet management, need for regular foot exams, obtaining blood sugars, and delayed wound healing, The comprehensive assessment failed to evidence the patient had recent heart surgery and complained of unresolved incisional pain. The assessment indicated the patient lived with a spouse and failed to indicate whether the spouse was educated to and correctly provided dressing changes to the patient's left heel wound. The assessment failed to indicate how the patient's hygiene needs, shopping and grocery needs were met, how transportation to medical appointments occurred, and the patient's and spouse's level of understanding for disease and medication management. During a home visit on 1/11/22 at 2:30 p.m., the patient indicated having pain over a healed incision to the chest. The patient indicated having recent surgery on a heart valve but declined to give further history. The patient confirmed living with a spouse and indicated not receiving any help. 2. A review of the comprehensive assessment for Patient #10, dated 11/28/22, failed to evidence the patient was assessed for alcohol dependency and its impact on current care and services; failed to indicate the patient's level of understanding of the current disease process, nutritional needs related to weight loss, ability to understand and safely take medications. The assessment indicate the patient's daughter provided some assistance and failed to indicate the type and frequency of assistance provided. 3. On 1/17/23 at 11:30 a.m., the administrator indicated the comprehensive assessments don't contain patient specific detail related to the patient's cognitive abilities, health problems and pertinent history, progress toward goals, and ability to participate in one's own care.

Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient's strengths, goals, and care preferences, including information that may be used to demonstrate the patient's progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all patients received a comprehensive assessment that included assessment of the patients' strengths for 4 of 13 active records reviewed (Patients 7, 8, 10, 11). Findings include: Added for ability to edit writing. 1. A review of the comprehensive assessment for Patient #7, dated 11/14/22, failed to evidence the patient's strengths were assessed. 2. A review of the comprehensive assessment for Patient #8, dated 12/30/22, failed to evidence the patient's strengths were assessed. 3. A review of the comprehensive assessment for Patient #10, dated 11/28/22, failed to evidence the patient's strengths were assessed. 4. A review of the comprehensive assessment for Patient #11, dated 12/6/22, failed to evidence the patient's strengths were assessed. 5. On 1/17/22 at 4:49 p.m. the administrator indicated the clinicians do not specifically assess the patient's strengths when completing a comprehensive assessments and indicate she was not aware of the requirement to include patient strengths.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure all discharge summaries included all goals and outcomes related to the home health episodes of care, the patient's post-discharge goals, discharge instructions such as home exercise programs, follow-up appointments and referrals, and all pertinent medical information related to the patient's current illness and reason for home health care, including but not limited to the patient's current health, psychosocial, and cognitive status, and a summary of the patient's support systems and living situation for 2 of 5 closed records reviewed (Patients 6, 9). Findings include: 1 1. A review of the clinical record for Patient #6, discharge date 2/8/22, evidenced a plan of care (POC) for the certification period of 1/12/22 - 3/12/22. The POC indicated a primary diagnosis of other chronic pain and indicated goals of independent transfer with a rollator within 4 weeks, independent ambulation with a rollator within 5 weeks, improved five times sit to stand test score to 14 seconds within 5 weeks, return demonstration of the established home exercise program within 5 weeks, patient/caregiver adherence to fall reduction self-management by discharge, maintenance of oxygen saturation >90% after 10 minutes, patient/caregiver understanding of signs and symptoms for risk of hospitalization and when to notify therapist/nurse or when to call 911, absence of signs and symptoms of anticoagulant toxicity, and patient/caregiver understanding of pain management by discharge. A patient expressed goal indicated "To be pain free." The POC failed to indicate the meaning of “after 10 minutes” and failed to identify the caregiver relationship included in the teaching and goals. A review of a document titled "Discharge-Transfer Summary Report," dated 2/8/22, indicated the patient was independent in the home at the time of discharge and was discharged to "home or self-care" for goals met. The discharge summary failed to indicate the caregiver that was included in the goals and teaching, whether the patient's oxygen saturation was maintained at >90% after 10 minutes, failed to define the meaning of "after 10 minutes," and failed to indicate how the patient would ensure or maintain the oxygen saturation after discharge. The discharge summary failed to evidence the patient's pertinent health, psychosocial, and cognitive status at the time of discharge, failed to evidence the patient was pain-free per their expressed goal, whether the patient was educated on and understood the signs, symptoms, and management of anticoagulation toxicity, the techniques for management and mitigation of pain, the patient's pain level at discharge, the patient's ability to manage and mitigate their pain ongoing, post-discharge pain goals, or whether the patient achieved the expressed goal to be pain free. The discharge summary failed to include the patient's home exercise program or instructions for continuing the program after discharge, failed to evidence post-discharge plans such as post-discharge goals, support systems, management for fall and hospitalization risk, medication management, physician follow-up, and whether the patient required formal community support services such as assistance with shopping and transportation. A review of the discharge comprehensive assessment, dated 2/8/22, indicated a patient expressed goal to be pain free. The patient's pain level during the assessment was 3/10 and had reached 9/10 in the last 24 hours. The patient experienced pain in the lumbar spine and left hip/groin, thigh, and lower leg daily but not constantly and utilized ice/heat, medication, and movement/exercises for pain relief. Medication provided relief for 2 - 3 hours. The discharge comprehensive assessment failed to evidence the patient had achieved a pain level of zero and failed to evidence the medical and non-medical treatments provided pain management for more than 3 hours. 2. A review of the clinical record for Patient #9, discharge date 2/9/22, evidenced a plan of care for the certification period of 12/21/21 – 2/23/22. The POC indicated a primary diagnosis of nutritional marasmus (severe malnutrition resulting from overall lack of calories causing an inability to maintain normal body functions) and secondary diagnoses including, but not limited to, malignant neoplasm of retroperitoneum and peritoneum, neoplasm related pain (acute and chronic), malignant neoplasm of bone and articular cartilage, COPD (Chronic Obstructive Pulmonary Disease – a group of diseases that cause airflow blockage and breathing related problems that cause mild to severe difficulty breathing). The patient’s expressed goal was to stay out of the hospital. A review of the patient’s “Discharge-Transfer Summary Report,” dated 2/9/22, indicated the patient was discharged/transferred to a hospital and required moderate assist with transfer/ambulation/ADLs (Activities of Daily Living) at the time of transfer. The discharge/transfer summary failed to evidence the patient’s current health, psychosocial, and cognitive status at the time of discharge, failed to evidence the patient’s understanding of their cancer and its prognosis, failed to evidence the patient had been evaluated for hospice services prior to home health services, failed to evidence the patient’s eating and nutritional habits and compliance, presence of nausea/vomiting, specific food preferences to aide in calorie intake, BMI (Body Mass Index), progress toward meeting nutritional goals in the plan of care, and failed to evidence interventions attempted and the patient’s response to those interventions. The summary failed to indicate the patient’s respiratory status, understanding of COPD and its management, interventions attempted, prognosis, smoking status, and ability to manage medications. The summary indicated multiple goals not met but failed to evidence what interventions were attempted related to unmet goals and failed to evidence progress over four certification periods other than unmet goals. The summary indicated a low and high weight of 97 pounds and failed to evidence the patient had continued weight loss and weighed 91 pounds as reported on a visit note dated 12/30/21. The summary failed to indicate the patient’s constipation was addressed during care, failed to evidence the patient was admitted to the hospital for a bowel obstruction, failed to evidence the patient missed 2 skilled nurse visits prior to admission to the hospital. 3 3. On 1/17/23 at 10:30 AM, the director of clinical services was interviewed concerning the content of the discharge summaries. The director indicated the agency’s EMR (Electronic Medical Record) pulled information from assessments, notes, plans of care, and care coordination notes to compile the “Discharge-Transfer Summary Report” and included much of the information that was on the plan of care, orders, and clinician narratives. When asked what information was required to be on a discharge or transfer summary the director indicated not being aware of the specific content required. added to edit writing

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 record review and interview, the agency failed to ensure all medications were listed on the Plan of Care (POC) for 1 of 2 patient’s receiving Intravenous (IV) medications (Patient 13); failed to ensure all physicians / allowed practitioners were specified in the POC for 2 of 13 active records reviewed (Patients 5 and 12); and failed to ensure the plans of care included all pertinent diagnosis, accurate mental and psychosocial status, accurate prognosis, activities, nutritional requirements, safety, and discharge planning to facilitate discharge for 3 of 18 records reviewed (Patient 7, 8, 10). Findings include: 1. A revised 5/9/2022 policy titled Plan of Care (POC)/Care was provided by the Director of Operations (A1) on 1/11/2023 at 8:19 a.m. The policy indicated, but was not limited to, “Procedure … 6. The individualized plan of [care] must include the following: … k. All medication and treatments … 10. … the attending physicians/allowed practitioner should specify in the plan of care the name of any additional physicians/allowed practitioners from which the agency can receive orders.” 2. The complete clinical record for patient 12, Start of Care (SOC) date 12/2/2022, certification date 12/2/2022 to 1/30/2023, included a POC signed by the physician indicating the agency may accept orders from Consulting Physicians Baptist Health Floyd Wound Care Center. The agency failed to specify the names of the physicians or allowed practitioners in the POC. 3. The complete clinical record for patient 13, SOC date 12/3/2022, certification date 12/3/2022 to 1/31/2023, included a POC signed by the physician indicating the skilled nurse to flush the PICC line access with 10 cc (cubic centimeter) normal saline before and after antibiotics. Review of patient 13’s Visit Note Reports indicated the PICC line was flushed with 10 cc normal saline and 5 cc’s of Heparin (medication to prevent clotting) for the follow home visit dates: 12/3/2022, 12/5/2022, 12/12/2022, 12/19/2022, and 12/27/2022. The agency failed to include an order for Heparin on the plan of care or obtain a clarification order from the physician. 4. During an interview on 1/11/2023 at 1:00 p.m. A1 agreed the Heparin dosage and the names of specific physicians the agency receives orders from should have been included on the plan of care. 410 IAC 17-13-1(a)(1)(D)(i-xiii) 1. A review of a history and physical/referral for Patient #7, dated 5/23/22, indicated a left heel wound (5/19/22), epilepsy (9/30/21), and diabetes mellitus (date unknown). A review of the comprehensive assessment, dated 11/14/22, indicated diagnoses of a pressure ulcer of the left heel, unstageable, and epilepsy. Wound documentation indicated a left heel wound, 0.3cm x 0.2cm x 0cm, intact granulation tissue, indistinct edges, 100% epithelialization, 0-25% slough and eschar. A review of the plan of care for the certification period of 11/19/22 - 1/17/22 indicated a diagnosis of epilepsy and failed to evidence a seizure plan. The plan of care indicated the patient had an unstageable left heel wound which was not supported by the wound assessment on 11/14/22. The plan of care failed to indicate the patient was a diabetic and failed to indicate blood sugar parameters; failed to include all DME (Durable Medical Equipment) such as a sharps container, lancets, Calmoseptine, skin prep, and walker; failed to include the patient's significant surgical history of a recent heart surgery; indicated discharge plans of "family and caregiver/PCP (primary care physician) and failed to include individualized discharge plans indicating interventions and progress towards discharge, anticipated needs at discharge, and progress towards discharge goals; failed to accurately reflect safety including Covid - 19 infection control precautions; indicated a mental status of oriented and failed a detailed and accurate mental status such as awareness, orientation to person/place/time, mental function; indicated a nutritional requirement of "diabetic" and failed to indicate the specific type of diet required, such as carb counting, calorie counting, low concentrated sweets; indicated cardiac precautions and failed to indicate what precautions to follow, such as low salt, monitor blood pressure, notify physician for increased heart rate; failed to include patient specific, measurable, and pertinent goals and interventions; failed to include the patient's psychosocial status, such as ability to meet needs, obtain transportation, shop, and meet financial obligations. On XXXX at XXXXX the administrator and director were interviewed concerning the patient's plan of care. The director indicated interventions and goals for plans of care look the same because the clinician must pick interventions and goals from a drop down menu, but they consider them individualized because they pick what is appropriate for the patient's diagnoses and needs. The administrator indicated the patient was not a diabetic. Upon review of the referral information and comprehensive assessment, she indicated the the patient was diabetic and the diabetic related information should be on the plan of care. 2.A review of the plan of care for Patient #8 for the certification period of 12/31/22 - 2/28/23 failed to evidence infection control safety measures including Covid 19 precautions; indicated the patient's mental status was oriented and failed to indicate the patient's psychosocial and cognitive status, such as orientation to person/place/time, the ability to meet their own care needs, ability to shop and obtain transportation, effect of alcohol dependence on behavior and treatment, and presence of support systems; indicated activities permitted of "walker" and failed to indicate the extent of activities, such as up as tolerated, use of bedside commode at night, use of shower chair, or independent with walker; indicated fall and safety precautions but failed to specify the precautions, such as use of shower chair for bathing. On 1/10/22 at 11 AM, a home visit was conducted with Patient #8. During an interview with LPN (Licensed Practical Nurse) 1, the LPN indicated the patient had tried to quit drinking but was suspected of drinking alcoholic beverages regularly throughout the day. The LPN denied knowing if an agency clinician had tried to speak to the patient about consuming alcohol, its effect on the patient's health and safety, and the patient's belief or acceptance of addiction. 3. A review of the history and physical/referral for Patient #10, dated 11/23/22, evidenced the patient experienced frequent lightheadedness and dizziness, had a history of alcohol abuse and confirmed recent alcohol consumption within the last 4 days. A review of the plan of care for Patient #10, for the certification period of 11/28/22 - 1/26/23, indicated a medication allergy of Neurontin and failed to evidence the patient was allergic to statins and zanaflex (Tizanidine). The plan of care failed to evidence patient specific goals and interventions related to the patient's history of alcohol abuse, weight loss, nausea, nutritional needs; failed to indicate specific strategies to minimize falls, how the patient will adhere to fall reduction self-management and life-style changes at discharge, and how the patient will meet a personal goal to get stronger. Discharge plans indicated "Family and Caregiver/PCP" and failed to evidence a discharge plan that included goals and interventions for preparing the patient to discharge and how the patient will successfully remain at home after discharge. The safety measures failed to specify what cardiac precautions were implemented and failed to evidence Covid 19 precautions. Nutritional requirement failed to evidence the patients boost/ensure or fruit juice supplements supplements and failed to reflect caloric needs or a diet consistent with cardiac precautions indicated under safety. On 1/10/22 at 11 AM, a home visit was conducted with Patient #10. During an interview with LPN (Licensed Practical Nurse) 1, the LPN indicated the patient had tried to quit drinking but was suspected of drinking alcoholic beverages regularly. The LPN denied knowing if a clinician had tried to speak to the patient about drinking water and abstaining from alcohol. On 1/10/22 at 3 PM the plan of care findings were reviewed with the administrator. The administrator indicated if the patient only told the clinician about the Neurontin allergy and didn't include the other allergies the clinician wouldn't know about the other allergies. When asked if the clinicians have access to a patient's referral and history and physical the administrator indicated yes. When asked for documentation that indicated the clinician confirmed the allergy discrepancy with the patient and physician, the administrator was unable to locate any documentation which indicated the medication allergies were confirmed as Neurontin only and all medication allergies should be listed in the patient's plan of care. 4. On 1/18/23 at 10 AM, the content of the plan of care was discussed with the administrator. The administrator indicated feeling frustrated because she felt they provided good care to all patients. The administrator indicated she sees that use of a drop down menu causes the appearance of redundant or repetitive goals and interventions between certification periods and between patients. The administrator agreed the plans of care lack detail and patient specific, pertinent content related to the patients course of illness and care. 4. The complete clinical record for patient 5, Start of Care (SOC) date 6/16/2022, certification date 10/14/2022 to 12/12/2022, included a POC signed by the physician indicating the agency may accept orders from Consulting Physicians. The agency failed to specify the names of the physicians or allowed practitioners who orders can be accepted from in the POC.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review, observation, and interview, the agency failed to ensure that current visit schedules, including visit type and frequency, were kept within the patients home for 3 of 6 patients observed (Patients 5, 15, and 17). Findings include: 3. During a home visit on 1/12/2023 at 10:33 a.m. patient 5’s home admission binder was reviewed and failed to evidence a current written patient visit schedule that indicated the frequency of visits by the HHA (Home Health Agency) personnel and personnel acting on behalf of the HHA. At that time, Registered Nurse (RN2) was unsure why the visit schedule had not been updated or current. During a home visit on 1/10/2023 at 9:30 a.m. patient 17’s home admission binder was reviewed and failed to evidence a written patient visit schedule that indicated the frequency of visits by the HHA (Home Health Agency) personnel and personnel acting on behalf of the HHA. At that time, Speech Therapist (ST1) and patient 17 was unsure why the visit schedule was not in the admission binder. During a home visit on 1/11/2023 at 2:00 p.m. patient 15’s home admission binder was reviewed and failed to evidence a written patient visit schedule that indicated the frequency of visits by the HHA (Home Health Agency) personnel and personnel acting on behalf of the HHA. At that time, Occupational Therapist (OT2) and patient 15 was unsure why the visit schedule was not in the admission binder. During an interview on 1/18/2023 at 12:27 p.m. A1 and A2 confirmed the written visit schedule was placed above the written list of medications provided to the patients. If the current written copy of medications was not in the home, then neither was the visit schedule.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to provide the patient with a current copy of written home exercise instructions and medication instructions for 2 of 3 therapy home visits. (OT2, & ST1) Findings include: 1. An undated Home Health Care Patient Bill of Rights located in the Patient Admission Binder was provided by the Director of Operations (A1) on 1/9/2023 at 3:00 p.m. The document indicated, but was not limited to, “Patients have the right to receive proper written notice, in advance of a specific service being furnished …” 2. A revised 3/7/2022 policy titled Patient Rights and Responsibilities was provided by A1 on 1/17/2023 at 10:25 a.m. The policy indicated, but was not limited to, “Indiana: Rule 12. Home Health Administration and Management … (1) Provide the patient with a written notice of the patient’s right: (A) In advance of furnishing care to the patient: … (2) The patient has the right to the following: (D) Be informed about the care to be furnished and of any changes in the care to be furnished as follows: … (AA) disciplines that will furnish care; and (BB) frequency of visits proposed to be furnished.” 3. During a home visit on 1/10/2023 at 9:30 a.m. Speech Therapist (ST1) acknowledged there were no written instructions regarding speech therapy exercises in the home for patient 17. Patient 17’s binder was without a medication list / instructions prior to the visit. The agency failed to provide current written instruction regarding medications and Speech Therapy Home Program exercises. 4. During a home visit on 1/10/2023 at 2:00 p.m. Occupational Therapist (OT2) performed a series of exercises with patient 13. Patient 13’s admit binder included undated instructions for exercises. OT2 was asked if the exercises performed at the visit were the same as the instructions in the admit binder to which he/she stated “no”. OT2 acknowledged there were no current OT exercises or medication instructions left in the home for patient 13.

Administrator must: CFR(s): 484.105(b)(1) Standard: Administrator. The administrator must: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the administrator reported directly to the Governing Body without the use of intermediaries for 1 of 1 home health agency. A revised 5/9/22 LD-001 policy titled Governing Body was provided by the Director of Operations (A1) on 1/17/2023 at 11:59 a.m. The policy indicated, but was not limited to, "PURPOSE: The Governing Body assumes full legal authority and responsibility for the policies and procedures that govern the day-to-day operation of each home health agency owned by the direct and indirect operating subsidiaries of Amedisys, Inc…PROCEDURES: …4. … a. The Governing Body will develop an organizational structure for each Amedisys home health agency: the Administrator/Director of Operations (DOO)(or regional DOO/Acting or Interim DOO, or person with similar function) of each home health agency shall report to the Governing Body in Compliance with this policy and each state’s regulatory requirements for licensure. Additionally, the regional leadership structure supporting the Administrator/Director of Operations (DOO) shall include the following: the Administrator/Director of Operations (DOO) shall also report to a designated Area Vice President (AVP), who reports to a designated Vice President of Operations, who reports to a designated Senior Vice President of Operations. The Administrator/Director of Operations (DOO), with the support of his/her regional leadership team, shall ensure all pertinent information is properly, and directly, reported to the Governing Body, in compliance with the above..." A November 2021 document titled “Job Title: Director of Operations” was provided by the Business Office Manager (A3) on 1/17/2023 at 12:45 p.m. The document indicated, but was not limited to, “Reports to: Area Vice President of Operations; Administrator; Direct Reports: Clinical Manager, Office Manager, and other care center staff as applicable; Job Code: 100101, 120101, 130101…Job Summary: Reports to the Administrator and AVP Operations and is responsible for overall organization and financial management of the care center, director of care center operations and functions according to the approved policies, procedures, and standards…Essential Functions: …8. Develops care center budgets in coordination with the Administrator and Area Vice President of Operations…11. Consults and collaborated with the Administrator and Area Vice President of Clinical Operations in implementation of clinical operations, standards, and processes…”. This document was the first job description provided and signed by A1 on 6/13/2022. An undated Organizational Chart document for Amedisys Home Health Parent 1821-Jeffersonville, IN Provider Number 15-7221 was provided by A1 on 1/9/2023 at 11:55 a.m. A1 stated he/she reported to the Governing Body directly. A1 also indicated he/she directly reported to the Area Vice President of Operations (AVPO-C1) and the Area Vice President of Clinical (AVPC, C2). During review of the chart, it shows A1 indirectly reports to Vice President of Business Development (C6) and Area Vice President of Business Development (C5) who are not direct employees of the agency or on the Governing Body. A1 indicated C1, C2, C5 and C6 were direct and indirect reports because they were who oversees what was implemented for how the agency operated, clinical services are provided, and the requested budget was approved through the Governing Body. A March 2021 document titled “Job Title: Director of Operations/Administrator” was provided by the Director of Operations (A1) on 1/17/2023 at 3:55 p.m. The document indicated, but was not limited to, “Reports to: Area Director of Operations; Area Vice President of Operations; Direct Reports: Clinical Managers, Office Managers; Job Code: 100103, 120103, 130103…Job Summary: Responsible for overall organization and financial management of the care center, direction of care center operation and functions according to approved policies, procedures, and standards…Essential Functions: …19. Assists the Area Vice President of Operations with the care center’s budget development process, including implementation and evaluation. Provides oversight and approval of Payroll at the care center. 20. Provides guidance and assistance to the Area Vice President of Operations in matters related to the delivery of quality home health services. Provides reports, as directed, related to fiscal information and statistical trends within the care center. This document was the second job description provided and signed by A1 on 6/13/2022. During an interview on 1/17/2023 at 2:40 p.m., A1 indicated he/she is the administrator and did not know why the job description given by A3 showed A1 reported directly to the Administrator and C1. A1 reached out to the Governing Body to get clarification on why Administrator was used in the job description. On 1/17/2023 at 3:55 p.m. A1 provided the 2nd job description and indicated the first job description provided by A3 was the incorrect one, but both the first and the second documents provided were in the personnel record. 410 IAC 17-12-1(b)(1)

Must have a written agreement CFR(s): 484.105(e)(2)(i-iv) An HHA must have a written agreement with another agency, with an organization, or with an individual when that entity or individual furnishes services under arrangement to the HHA's patients. The HHA must maintain overall responsibility for the services provided under arrangement, as well as the manner in which they are furnished. The agency, organization, or individual providing services under arrangement may not have been: (i) Denied Medicare or Medicaid enrollment; (ii) Been excluded or terminated from any federal health care program or Medicaid; (iii) Had its Medicare or Medicaid billing privileges revoked; or (iv) Been debarred from participating in any government program. This ELEMENT is not met as evidenced by: Based on record review and interview, the administrator failed to ensure contracts or written agreements that allowed overall responsibility to be maintained were in place for corporate employees who furnished services as direct employees for 1 of 1 agency. Findings include: During an interview on 1/17/2023 at 4:10 p.m., the Director of Operations (A1) indicated no contract or written agreement was implemented for corporate employees who worked as remote clinical managers within the agency. 410 IAC 17-12-2 (d) Review of patient 15’s Client Coordination Note Report dated 12/28/2022 indicated a Touch Call note entry was made into the electronic medical report by Corporate non-employee (C3). Patient 15 did not answer the call. Review of patient 15’s Client Coordination Note Report dated 12/9/2022 indicated a Touch Call note entry was made into the electronic medical record by Corporate non-employee (C4). Patient 15 answered 2 of 3 questions asked regarding new or worsening symptoms, thoughts of going to the emergency room, and concerns about his /her health. During an interview on 1/11/2022 at 1:00 p.m. A1 indicated the non-employee would call the patient and ask if the patient felt tired or anxious. If the patient answered yes to the questions a call would be placed to the agency and an email sent to the Alternate Administrator (A2) to follow up. The A1 was unable to provide a written contract or agreement with the non-employee that provide services. During an interview on 1/11/2023 at 3:10 p.m. A2 indicated the Touch Call program was companywide. The patient receives a phone call from an automated nurse asking if the patient felt tired or anxiety. If the patient answered yes to any of the questions A2 would receive a phone call or email to check on the patient. A2 acknowledge entries are made into the electronic medical record by the Corporate non-employee.

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 record review and interview, the agency failed to ensure the POC (Plan of Care) was complete, clear, and accurate for 2 of 2 records reviewed with IV (Intravenous) orders (Patient 13 & 16); and failed to accurately document the date and time of the Covid-19 screening assessment for 3 of 6 home visit observations. (Patient 14, 15, 17) Findings include: 1. A revised 6/24/2021 policy titled Clinical Record Contents was provided by the Director of Operations (A1) on 1/17/2023 at 10:55 a.m. The policy indicated, but was not limited to, “Procedure: … 2. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. … i. All interventions, including medication administration, treatments, and services, and responses to those interventions … 5. Documentation is incorporated into the medical record at least daily but no longer than seven (7) days. … 7. The patient visit begins when the home health caregiver enters the patient’s home and ends when the Home Health Caregiver leaves the patient’s home, meaning that when they complete the patient visit – this ends the visit” 2. A revised 7/1/2022 policy titled Exposure to Coronavirus (Covid-19): Disease Response & Management was provided by the Direct of Operations (A1) on 1/9/2023 at 5:04 p.m. The policy indicated, but was not limited to, “Direct patient care—means hands-on, face-to-face contact with patients for the purpose of diagnosis, treatment, and monitoring. … Screen- means asking questions to determine whether a person is COVID-19 positive or has symptoms of COVID-19. … Visit Prescreening for COVID-19: COVID Prescreening is conducted prior to all home visits where direct care staff will encounter the patient and/or caregivers by all direct care staff following the agency’s screening guideline. Prior to each clinician visit (nurse, therapist …) a call is made to the home, whereby the clinician should perform a brief screening of the patient (and any caregivers that will be present) in the residence. Clinician documents completion of screening in the record. 3. A reviewed 12/9/2022 policy titled Removal of PICC, Midline, Non-Tunneled, CVAD and Short Peripheral [Catheter] was provided by (A1) on 1/11/2023 at 8:19 a.m. The policy indicated, but was not limited to, “Documentation in the Clinical Record: … Condition and length of the catheter and appearance of the tip …” 4. The complete clinical record for patient 16, SOC (start of care) date 4/7/2022, certification period 4/7/2022 to 6/5/2022, included a POC with signed physician orders indicating the SN (skilled nurse) to perform site care for an infusion site device Midline (catheter inserted into the upper arm with the tip located just below the arm pit) and for the SN to remove the PICC line (catheter inserted into the upper arm with the tip resting near the heart) on 4/11/2022. Review of the Client Coordination Note Report dated 4/11/2022 indicated Registered Nurse (RN2) placed a call to schedule appointment for patient 16’s PICC line removal. Review of the Client Coordination Note Report dated 4/12/2022 indicated RN2 approval of patient 16’s PICC line removal. Review of the Visit Note Report Narrative dated 4/12/2022 indicated RN2 removed patient 16’s Midline. The same Visit Note Report Interventions section indicated the PICC line was removed. The agency failed to accurately document the type of catheter (Midline or PICC line) access for patient 16 and failed to record the condition and length of the catheter and appearance of the tip upon removal. 5. During an interview on 1/11/2023 at 5:01 p.m. Alternate Administrator (A2) agreed the RN should have followed agency policy and recorded the condition and length of the catheter upon removal. 6. The complete clinical record for patient 13, SOC date 12/3/2022, certification date 12/3/2022 to 1/31/2023, included a POC signed by the physician indicating the skilled nurse to flush the PICC line access with 10 cc (cubic centimeter) normal saline before and after antibiotics. Review of patient 13’s Visit Note Reports indicated the PICC line was flushed with 10 cc normal saline and 5cc’s of Heparin (medication to prevent clotting) for the follow home visit dates: 12/3/2022, 12/5/2022, 12/12/2022, 12/19/2022, and 12/27/2022. The agency failed to ensure all medications were listed on the POC. 7. During an interview on 1/11/2023 at 1:00 p.m. A1 (Administrator) agreed that all information including the Heparin dosage should have been included on the plan of care. 8. During a home visit on 1/10/2023 at 9:30 a.m. Speech Therapist (ST1) was observed entering patient 17’s home, proceeded to set up equipment (blood pressure cuff, bag) on paper barrier, assess open area on patient 17 left arm, and took vital signs (blood pressure, temperature, pulse, respirations) prior to screening for Covid-19. ST1 failed to screen for Covid-19 prior to providing face to face direct patient contact. At that time, ST1 indicated he/she screens the patients for Covid-19 by phone the night before the home visit. Reviewed the Visit Note Report dated 1/10/2023. In the Report ST1 indicated the Covid-19 pre-visit screening was completed prior to initiating patient care. The Visit Note Report did not accurately reflect the home visit observation. 9. During a home visit on 1/10/2023 at 2:00 p.m. Occupational Therapist (OT1) was observed entering patient 15’s home, proceeded to set up equipment on paper barrier, assess vital signs and record, and listen to lung sounds with a stethoscope prior to screening patient 15 for Covid-19 signs/symptoms. OT1 indicated he/she screens the patient for Covid-19 by phone the day before the home visit. OT1 failed to screen for Covid-19 prior to providing face to face direct patient contact. Reviewed the Visit Note Report dated 1/10/2023. In the Report OT1 indicated the Covid-19 pre-visit screening was completed prior to initiating patient care. The Visit Note Report did not accurately reflect the home visit observation. 10. During a home visit on 1/11/2023 at 9:00 a.m. RN1 was observed setting up vital sign equipment on a paper barrier. RN1 indicated he/she screened patient 14 the night before the home visit then documented the assessment at the time of the home visit. Reviewed the Visit Note Report dated 1/11/2023. In the Report RN1 indicated the Covid-19 pre-visit screening was completed prior to initiating patient care. The Visit Note Report did not accurately reflect the home visit observation. 11. During an interview on 1/10/2023 at 4:43 p.m. A1 was asked what the process was for screening home patients for Covid-19 (communicable virus). A1 indicated agency staff call the patient the night before the home visit and ask if the patient or anyone in the home was exposed to Covid-19. A1 indicated that information was not documented on the date and time the call took place. A1 indicated the information would be documented the next day during the home visit. The agency failed to accurately document the correct date and time patient assessments took place. 12. During an interview on 1/17/2023 at 3:45 p.m. A1 indicated agency staff screen patients for Covid-19 by phone call the night before the visit. A1’s expectation was for agency staff to open the tablet (documentation device), then screen the patient again at the time of the home visit. A1 was asked if the expectation was for the agency staff to provide face to face direct patient care before screening the patient for Covid-19. A1 indicated the agency staff should screen the patient for Covid-19 before care was provided. 410 IAC 17-15-1(a)(7)