Every finding on record at Infinity Home Care of Port Charlotte LLC

An unannounced complaint survey for complaint # 2025002004 was conducted 3/24/2025 through 3/27/2025 at Amedisys, a Home Health Agency in Port Charlotte, Florida. Complaint #2025002004 was substantiated at tag # G478, G484 and G984. Amedisys is not in compliance with Code of Federal Regulations (CFR) 42, 484.50, patient's rights and 484.1055 Organization and Administration of Services. The following is description of the Standard-level noncompliance.

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interviews, the facility failed to investigate complaints made by a patient’s family in 1 (Patient #1) out of 3 patients sampled. On 3/27/2025 during record review of Agency Policy RI-009, Patient/Caregiver Grievance/ Complaint, stated, “The employee receiving the complaint is to notify their immediate supervisor of the complaint as soon as possible to allow for timely review/intervention. Documentation of the complaint . . . is initiated by the employee to whom the complaint is received and forwarded to the appropriate supervisor (Administrator/Director of Operations/Clinical Manager) for review.” Clinical record review for Patient #1 showed a start of care date of 10/20/24. Patient #1 was admitted to home care when discharged from hospital after a fall, lives independently with spouse. Skilled nursing home care was ordered twice a week for two weeks and then once a week for 3 weeks. The discharge exam from the hospital does not list wounds. Diagnosed with new pressure sore on right heel on 11/29/24. Wound on coccyx was reported on 12/20/24. On 3/24/2025 during a record review of the Agency’s complaint log, it showed the only complaint registered from Patient #1’s family was on 2/6/2025 regarding care that was provided in December 2024. On 3/24/25 at 11:28 a.m., during an interview Patient #1’s daughter said she called the agency in December and told them that she didn’t feel her father’s wound on his bottom was being taken care of. No report was found in the Grievance log about this complaint. On 3/24/2025 during a record review of the Agency’s grievance log entry dated 2/6/2025 at 2:32 p.m., Staff A admitted to stating that she could not transfer Patient #1 on the 12/9/2024 visit. On 3/26/2025 at 12:25 p.m., during an interview, the Clinical Manager said the daughter called in December 2024 concerned about the care her father, Patient #1, was receiving. The Clinical Manager confirmed the call was not documented, saying it should have been documented as a grievance.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on record review and interviews, the facility failed to document both the existence of the complaint and the resolution of the complaint in 2 (Patients #1and 2) out of 3 patients sampled. On 3/27/2025 during a record review of Agency Policy RI-009, Patient/Caregiver Grievance/ Complaint, stated, “The agency’s Administrator is responsible for the oversight of complaint investigations. The Administrator ensures proper documentation of the complaint includes the following. . . g) Response of person involved in complaint.” Clinical record review for Patient #1 showed a start of care date of 10/20/24. Patient #1 was admitted to home care when discharged from hospital after a fall, lives independently with spouse. Skilled nursing home care was ordered twice a week for two weeks and then once a week for 3 weeks. The discharge exam from the hospital does not list wounds. Diagnosed with new pressure sore on right heel on 11/29/24. Wound on coccyx was reported on 12/20/24. On 3/24/2025 during a record review of the Agency’s complaint log, it showed the only complaint registered from Patient #1’s family was on 2/6/2025 regarding care that was provided in December 2024. On 3/24/25 at 11:28 a.m., during an interview, Patient #1’s daughter said she called the agency in December and told them that she didn’t feel her father’s wound on his bottom was being taken care of. No report was found in the Grievance log about this complaint. Clinical record review for Patient #2 showed a start of care date of 12/31/24. Patient #2 was admitted to home care for wound management. Skilled nursing care was ordered twice a week for one week, four times a week for one week, and then twice a week for four weeks. Discharged from home health agency care on 2/8/25 when goals were met. On 3/27/2025, during a record review of the Agency’s grievance log showed that Patient #2 submitted a complaint on 1/14/2025 at 8:22 a.m. regarding a clinician. No resolution of the complaint was documented. On 3/27/2024 at 10:25 a.m., during an interview with the Administrator, she said that she doesn’t have any documentation showing follow up with Patient #2 or resolving the complaint.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on record review and interviews, the facility failed to ensure that all services were provided in accordance with current clinical practice standards defined by the Agency’s own policies and procedures in 1 (patient #1) out of 3 patients surveyed. Clinical record review for Patient #1 showed a start of care date of 10/20/24. Patient #1 was admitted to home care when discharged from hospital after a fall, lives independently with spouse. Skilled nursing home care was ordered twice a week for two weeks and then once a week for three weeks. The discharge exam from the hospital does not list wounds. Diagnosed with new pressure sore on right heel on 11/29/24. Wound on coccyx was reported on 12/20/24. On 3/24/2025, during a record review of the grievance log entry for Patient #1 showed that an assessment was not done by the nurse on 12/9/2024. “(Staff A) admitted to stating she could not transfer him on the 12/9/24 visit. . . Instructed to perform head to toe assessment on every visit and not rely on caregiver reports.” On 3/26/2025 at 12:25 p.m., during an interview with the Clinical Manager, he said that (Staff A) didn’t look at Patient #1 backside, her back was out. It is supposed to be every visit that a head-to-toe assessment is done. On 3/27/25 during a record review of Agency policy AA-003, Patient Assessment/ Reassessment stated, “The adult assessment is appropriate to the type of care and services provided and will include as applicable . . . c. Physical findings/impairments. . . The Nursing reassessment will at least consist of: a. A clinical review of systems . . . e. Providing the ordered nursing interventions On 3/27/2025 during a record review of the care plan for Patient #1 dated 10/19/2024 which stated LPN/LVN (Licensed Practical Nurse/ Licensed Vocational Nurse) to observe for risk of . . . infection prevention. . . “ On 3/27/2025 during a record review of Patient #1’ file, a wound was found on the patient’s buttocks on 12/20/2024. No doctor’s orders for treatment of that wound were found in the patient’s electronic record. On 3/27/2025 during a record review of the Visit Note Report dated 12/26/24 by Staff B, showed the narrative,” Pt (patient) with no POC (plan of care) at this time.” On 3/26/2025 at 12:08 p.m., during an interview Staff A said, “I called the physician and left a message. I don’t remember if we got any orders back.” On 3/26/2025 at 3:23 p.m., during an interview Staff B said, “On 12/26/24 there was a butt wound, and he had no wound orders. He (Patient #1) had no primary physician.” On 3/26/2025 at 1:15 p.m., during an interview the Administrator said that (Staff A) called the doctor for wound orders. “They never gave us a wound care order. We were just putting butt paste on. We should have had an order.”