Every finding on record at Tender Loving Care Health Care Services Southeast, LLC

A recertification survey of Amedisys Home Health- Largo for the Condition for Coverage of Home Health Agencies was conducted March 31, 2021 through April 1, 2021. After the review of the agency's emergency preparedness program and plan, the agency was found to be in compliance with all Conditions of Participation and related standards found at 42 CFR (Code of Federal Regulations) Part 484.102.

A standard survey was completed at Amedisys Home Health Care located in Largo, Maryland on March 31, 2021 through April 1, 2021. The survey included the review of patient medical records, personnel files, on-call logs, and complaint/incident logs. Outcome and Assessment Information Set data, patient rights information, selected policies and governing body meeting minutes were also reviewed. No home visits were conducted, however, a total of fourteen clinical records were reviewed during the survey. The represented scope of services as follows: Skilled Nursing Services-Twelve Physical Therapy Services- Ten Occupational Therapy Services-Nine Medical Social Worker- One Speech Language Pathology Services- One Home Health Aide Services -Two Findings in this report were based on data present in the clinical record at the time of review. The agency's administrative staff was kept informed of the survey findings as the survey progressed. The agency staff was given the opportunity to present information relative to the findings during the course of the survey. A patient keycode and a copy of the plan of correction verification form was provided to the agency administrator during the exit conference.

Completion of the comprehensive assessment CFR(s): 484.55(b) Standard: Completion of the comprehensive assessment. This STANDARD is not met as evidenced by: Based on review of patient records and interview with agency staff, the agency's registered nurse failed to assess the patients' diet requirements for one out of fourteen patients reviewed. Failure to correctly assess and document the patients' dietary needs placed the patients at risk for receiving inadequate nutrition. Patient: #5 Findings include: A skilled assessment must include any special diet that the patient has been prescribed to follow by the ordering physician and must be documented in the patient's medical record. Examples of special diets include diabetic diet, low salt diet, low cholesterol diet, and a heart healthy diet. On 3/31/2021 review of clinical records revealed that client #5 found inconsistencies in assessment of the patient's diet. No documentation of any agency registered nurse (RN) communicating or seeking clarification of patient's dietary orders. Patient admitted with stage 3 pressure ulcer (sores primarily caused by prolonged pressure on the skin) and is an insulin dependent type 2 diabetic. Patient performs daily blood sugar finger stick monitoring. On 3/10/2021, 3/11/2021, and 3/12/2021 modification of the 485 notes the patient diet as heart healthy. The recertification nursing assessment noted that the RN communicated with the physician regarding the plan of care (p. 12 of 16), however, the details of the discussion states "POC". The next four RN visit notes address the patient's diet as: 3/17/2021 "good appetite", 3/19/2021 "low salt diet, 3/24/2021 "good appetite and adequate hydration", 3/29/2021 "regular diet within normal limits". During the interview agency staff was unable to provide any additional information or documentation.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on review of patient records and interview with agency staff , the agency staff failed to coordinate patient care effectively for 1 out of 14 patients reviewed. Failure to ensure effective coordination of patient care placed patients at risk for inadequate interventions and negative health care outcomes. Patients: #12 Findings included: All clinical staff members have the responsibility to communicate changes in the patient's clinical status to the patient's physician to ensure the provision of optimal health services and to prevent adverse outcomes. The patient's clinical record revealed that lab results received on 3/1/2021 had not been reported to MD or the agency clinical manager. The patient's red blood cell count was 2.47 normal range is 3.77-5.28, hemoglobin (part of the red blood cell that carries oxygen to all the cells in your body) value was 7.2 and the normal range is 11.1-15.9 and Hematocrit (measures the red blood cells in a person's blood) was 22.8 the normal range is 34.0-46.6, all critical lab values are to be communicated with the patient's physician. There was no documentation noting that the lab results were communicated with the ordering physician or any other clinical leadership staff.