Every finding on record at Amedisys Tennessee LLC

An Emergency Preparedness recertification and re-licensure survey was conducted on 6/8/2026 - 6/10/2026. The facility meets all of the requirements for Emergency Preparedness. There were no deficiencies identified.

A recertification and complaint #106363 survey was conducted on 6/8/2026 – 6/10/2026. An entrance conference was held on 6/8/2026 at 10:30 AM with the Director of Operations. An exit conference was held on 6/10/2026 at 12:30 PM with the Director of Operations, Vice President Operations Central Tennessee, Regional Director of Operations, Quality Directors of Louisiana Home Care, Director of Operations of Dickson and Director of Operations of Lebanon. Based on the investigation conducted on 6/8/2026-6/10/2026, this facility complies with all requirements reviewed pertaining to the allegations for Intake #106363.

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 policy review, medical record review, observation and interview, the agency failed to ensure medications were accurately documented in the medical record for 5 of 7 (Patient #2, #3, #4, #5 and #6) sampled patients observed during home visits. 1. Review of the agency's "Drug Regimen Review" policy revised 1/15/2026 revealed, "...To ensure safe and effective drug therapy by reviewing all prescription and non-prescription medications upon admission and throughout care, identifying potential adverse effects, drug reactions, ineffective therapy, significant side effects...duplicate therapies, and issues with adherence or compliance...Nurse Clinicians will periodically ask the patient and/or caregiver about any changes in medications. This includes updates to dosage or frequency, new medications, discontinued medications and use of over-the-counter drugs, herbal remedies, vitamins, supplements..." 2. Medical record review for Patient #2 revealed a Start of Care (SOC) date of 6/6/2026 with diagnoses which included Spinal Stenosis. Observations in Patient #2's home on 6/9/2026 at 1:30 PM, revealed the following medications in the home which were not listed in the Patient's medication profile: a. Over the Counter (OTC) L-Arginine (helps manage high blood pressure) 1,000 milligrams (mg) b. OTC Fern Valley Farms Delta 8 THC Gummies (helps relaxation) 250 mg c. OTC Naproxen Sodium (treats inflammation) 220 mg d. OTC Pygeum Prostate Health e. OTC Chlorpheniramine Maleate (treats allergies) 4 mg f. OTC Glycocept (helps metabolic health) g. Diclofenac Sodium (treats inflammation) 1 % (percent) as needed filled on 5/4/2026 During an interview on 6/9/2026 at 1:35 PM, Patient #1 stated he took the supplements as needed because he has a big prostate problem. 3. Medical record review for Patient #3 revealed a SOC date of 10/22/2025, with diagnoses which included Pressure Ulcer of Sacral Region, Heart Failure and Diabetes Mellitus. Review of Patient #3's medication profile revealed Pramipexole (treats tremors) 0.5 mg by mouth 3 times a day. Observations in Patient #3's home on 06/09/2026 at 11:00 AM, revealed the following medications in the home which were not listed in the Patient's medication profile: a. Serevent (treats breathing difficulties) Discus 50 micrograms (mcg) 1 puff twice Daily b. Iron (treats anemia) 65 mg by mouth daily c. Potassium (supplement to treat low potassium) Chloride 20 milliequivalents (mEq) by mouth daily d. Pramipexole 1 mg 2 tablets by mouth three times a day During an interview on 06/09/2026 at 11:25 AM, Patient #3’s spouse stated the patient had been on Potassium Chloride for a long time. She stated that she was the one who filled the patient’s medication planner. 4. Medical record review revealed Patient #4 revealed a Start of Care (SOC) date of 09/28/2023 with diagnoses which included Encounter for Fitting an Adjustment of Urinary Device and Hemiplegia Following Cerebral Infarction. Observations in Patient #4's home on 06/09/2026 at 9:30 AM, revealed the following medications were not included on Patient #4’s medication profile: a. Magnesium Oxide (over the counter supplement) 400 mg by mouth daily The following medications were listed on the medication profile, but the patient no longer used: a. Ketoconazole (used to treat skin irritation) 2% topical cream apply 1 inch topically two times a day for up to four weeks ordered on 02/18/2022. b. Naloxone (treats opioid overdose) 4 mg 1 spray in each nostril as needed for opioid overdose. c. Nystatin (treats mouth irritation)100,000 unit/ml 10 ml by mouth four times a day for mouth irritation, ordered on 09/28/2023. d. Ondansetron (treats nausea) 4 mg disintegrating tablet by mouth every six hours as needed for nausea, ordered on 06/21/2024. e. Terbinafine (treats fungal infection) hydrochloride 1% topical cream 1 inch topically daily, ordered on 09/28/2023. During an interview on 06/09/2026 at 10:45 AM, Patient #4 stated that the home care nurses did not take out his medication bottles for review, but they used a list that the (government agency) nurses use to fill his medication planners. 5. Medical record review revealed Patient #5 revealed a Start of Care (SOC) date of 12/18/2025 with diagnoses which included Diabetes Mellitus, External Operation Surgical Wound, Cellulitis of Back, and Stage 3 Pressure Ulcer of Right Buttock. Observations in Patient #5's home on 06/10/2026 at 9:12 AM, revealed the following medications were not included on Patient #5’s medication profile: a. Levothyroxine (treats thyroid) 112 mcg one capsule by mouth daily During an interview on 06/10/2026 at 9:12 AM, Patient #5 stated he has been taking the Levothyroxine for 10 years. 6. Medical record review revealed Patient #6 revealed a Start of Care (SOC) date of 11/16/2024 with diagnoses which included Diabetes Mellitus, Heart Failure, Chronic Kidney Disease, and Anemia. Observations in Patient #6's home on 06/9/2026 at 9:49 AM, revealed the following medications were listed on the medication profile, but the patient no longer used: a. Droxidopa (used to treat low blood pressure) 200 mg capsule one capsule by mouth three times a day b. Droxidopa 300 mg capsule one capsule by mouth three times a day c. Fludrocortisone (used as a hormone replacement) 0.1 mg one tablet by mouth daily During an interview on 06/9/2026 at 9:49 AM, Patient #6 stated the doctor stopped Droxidopa 6 months ago and Fludrocortisone was stopped by the doctor 3-4 months ago. 7. During an interview on 06/09/2026 at 1:30 PM, the Director of Operations for Branch #1 stated that every clinician should ask the patients if there have been medication changes since the last home visit. She stated the staff do not look at the medication bottles at every home visit. The medication bottles should be taken out and reviewed during any Outcome and Assessment Information Set (OASIS) visit, nurse supervisory visits, and therapy reassessments. During an interview on 6/10/2026 at 12:20 PM, the Director of Operations stated the staff are to reconcile the medications each time they are in the home, they should ask, verify and look at the bottle.

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 policy review, observation and interview, the agency failed to ensure measures to prevent the spread of infectious agents were followed by 2 of 7 (Licensed Practical Nurse (LPN) #5 and LPN #7) staff observed providing direct patient care in the home setting. 1. Review of the agency's "Hand Hygiene" policy dated 07/10/2025, revealed, "...The agency must follow accepted standards of practice, including the use of standard precautions (includes hand hygiene) to prevent the transmission of infections…GUIDELINES:…4. Perform hand hygiene as follows: a. Before having direct contact with patients…. b. Before donning gloves…c. Before performing a procedure …g. After contact with inanimate objects (e.g. [for example] medical equipment) in the immediate vicinity of the patient…h. After removing gloves…” Review of the agency's "Urinary Catheter Insertion-Indwelling or Suprapubic Catheter" policy dated 05/01/2025, revealed, “…For Suprapubic Insertion/Care: …8. Open the catheter kit…10. Perform hand hygiene …11. Don sterile gloves…” Review of the agency's "Digital Wound Photography" policy dated 02/05/2026, revealed, "...PROCEDURE:…9. Measure the wound…10. Remove gloves…11. Perform hand hygiene…13. Don non-sterile gloves…15. Obtain photos…” 2. Observations in Patient #3’s home on 06/09/2026 at 9:30 AM revealed LPN #7 providing direct patient care. LPN #7 performed hand hygiene, donned gloves, and obtained wound measurements. Without removing her gloves, LPN #7 charted on her device and used the device to photograph the patient’s wound. LPN #7 failed to perform hand hygiene following wound measurements and before taking wound photographs with her device. LPN #7 removed soiled gloves, performed hand hygiene, donned gloves, and provided wound care. Soiled gloves were removed and LPN #7 failed to perform hand hygiene before clean gloves were donned. LPN #7 failed to perform hand hygiene after being in direct contact with the patient and prior to donning gloves. Observations in Patient #4’s home on 06/09/2026 at 9:30 AM, revealed LPN #5 provided direct patient care. LPN #5 performed hand hygiene, donned gloves, and placed equipment into his bag. Without removing his gloves, LPN #5 assisted the patient to bed, got supplies ready for a catheter change, moved a trash bag that was sitting in the floor, picked up a phone charger that had fallen into a basin in the floor, and removed the old suprapubic catheter from the patient’s catheter insertion site. Gloves were removed, and hand hygiene was performed. Gloves were donned, and LPN #5 opened the sterile catheter change kit that was sitting in the patient’s wheelchair seat at bedside. Gloves were removed and LPN #5 failed to perform hand hygiene before sterile gloves were donned. LPN #5 inserted a new catheter. LPN #5 failed to perform hand hygiene in between contact with the patient, inanimate objects, and in between glove changes repeatedly. 3. During an interview on 06/09/2026 at 11:30 AM, LPN #7 stated hand hygiene should be performed when getting in and out of the bag, between obtaining vital signs and providing wound care, after removing the old wound dressing and before applying a new dressing. LPN #7 stated she should have removed her gloves after being in contact with Patient #3’s wound.

A complaint survey (2971530) was initiated on 4/6/2026. An entrance conference was held with the facility Director. An exit survey was conducted on 4/7/2026 at 11:45 AM. The following facility staff attended: Director, Office Manager, Regional Director of Operations, Clinical Manager and Assistant Vice President of Clinical Service (via telephone). The findings were shared with the facility staff, and they were provided the opportunity to ask questions.

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 policy review, medical record review, and interview, the facility failed to ensure wound measurements and/or wound photographs were documented in the medical record for 1 of 3 (Patient #1 and #3) sampled patients. The findings included: 1.Review of the facility policy “Digital Wound Photography” revised 2/5/2026, revealed, “Purpose: Provide guidance for obtaining digital photography of wounds. Considerations:…Digital photography of wounds should be completed: At the start of care…Wound photographs should be uploaded to the EMR [electronic medical record]…” Review of the facility policy “Provision of Wound and Skin Care”, revised 3/31/2026, revealed, “Purpose: To provide general guidance on wound and skin care…To provide standardization around the practice of wound and skin care…General Guidance…Documentation: Documentation on the skin and any wound(s) will take place in the EMR in the areas provided each time a wound or skin care is provided…Measuring: In accordance with best practice and standard of care, wounds will be measured a minimum of one time a week preferably the first visit of the week…” 2. Medical record review for Patient #1 revealed an elderly female with an admission date of 3/6/2026 with a physician order for skilled nursing services 1 time per week for 9 weeks that included wound care to her left great toe. Patient #1 had diagnoses that included Type 2 Diabetes Mellitus with foot ulcer and Non pressure chronic ulcer of the left foot. Review of the Start of Care nursing assessment and visit dated 3/6/2026, revealed no photographs of the wound. During an interview on 4/6/2026 at 2:30 PM, the Director stated there was one photograph of Patient #1’s wound in the EMR. The Director provided the photograph to the surveyor dated 4/3/2026. During an interview on 4/7/2026 at 11:00 AM, the Director stated she was unable to find any other photographs for Patient #1’s wound and verified there should have been a photograph uploaded at the start of care visit. 3. Medical record review for Patient #3 revealed an admission date of 3/22/2026 with a physician order for skilled nursing services 2 times per week for 9 weeks that included wound care to his left foot. Patient #3 had diagnoses that included Type 2 Diabetes Mellitus with foot ulcer, Osteomyelitis, and Non pressure chronic ulcer of the left heel and mid foot with necrosis. Review of the Start of Care nursing assessment and visit dated 3/22/2026, revealed no wound measurements or photographs of the wound. During an interview on 4/6/2026 at 11:30 AM, the Director from office of a sister facility stated if the admission nurse removed the wound vac and changed the dressing, there should be would measurements and wound photographs. The Director from the sister facility then logged into the electronic medical record and verified there were no measurements or photographs for the initial nursing visit/admission on 3/22/2026. During an interview on 4/6/2026 at 11:45 AM, the Director stated the nurse Registered Nurse (RN) #1 that completed the admission for Patient #3 was on leave for the birth of his child and not available for interview. The Director stated when she spoke with RN #1, he reported he took pictures of the wound but was unable to get them to upload to the EMR. The Director verified there were no wound photographs or measurements in the electronic medical record. During an interview on 4/6/2026 at 2:30 PM, the Director stated the facility changed their system about 2 months ago that they used to upload photographs to the EMR. The Director stated staff had reported if they were in an area with little to no service, they had difficulty getting the wound photographs to upload.