Staff Builders Home Health, An Amedisys Company

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on clinical record reviews, personnel file reviews, review of policy titled “Sub-Policy of Code of Conduct,” and staff interviews, it was determined that the Governing Body failed to ensure overall management of the agency to ensure that staff followed the agency’s policies and procedures for code of conduct for the protection of one patient (P) (P#2) of three patients reviewed. Findings included: Review of the policy titled “Sub-Policy of Code of Conduct,” revised 8/16/2024 revealed the following: Purpose: To provide and establish parameters for the giving of gifts to and the receipt of gifts from, individuals within or external to the organization who have a business relationship with the company. Policy: No employee shall give, receive or solicit or accept for personal use or for the use of others any gift, favor, or anything of monetary value that might influence or appear to influence the judgement or conduct of employee regarding (facility) or its business. P#2 was admitted to home health services on 1/7/25. The speech therapist (ST) was scheduled to visit P#2 one time a week for one week, then two times a week for five weeks effective 1/26/25. The clinical record revealed the ST visited the patient as scheduled and no concerns were identified during the record review. Review of the personnel file for ST AA with a hire date of 1/4/24 revealed a document labeled “Code of Conduct Workforce Conflict of Interest & Relationship Disclosure Form,” signed and dated by ST AA on 1/4/25. During a telephone interview with the complainant on 2/4/25 at 1:00 pm, the complainant related the same concerns as stated in the complaint submitted to the state and did not have anything to add. The complainant reported that (complainant) did not notify the agency of the concerns as she could not find a working number for the agency to report the incident. An in-office interview with the Director of Operations (DOO) on 2/4/25 at approximately 12:00 p.m., it was confirmed that agency staff are not allowed to accept gifts from patients and staff are educated on conflicts of interest and all staff are required to sign forms to ensure they understand their work roles and responsibilities. The DOO denied any identified disciplinary issues with ST AA and was not aware of any incident concerning this allegation of staff misconduct. During a telephone interview with P#2 on 2/4/25 at approximately 1:30 p.m., P#2 did admit that ST AA traveled to Superbowl 2025 with him, and he provided hotel accommodations for her. He adamantly denied any inappropriate behavior from ST AA during the trip, stating ST AA accompanied him as his caregiver to provide medical assistance as needed. He did acknowledge purchasing the Superbowl ticket and hotel accommodations for ST AA however, he stated this was necessary to ensure she was close by incase he needed medical attention. An in-office interview with ST AA on 2/5/25 at 10:30 a.m., revealed ST AA did admit to going to Superbowl 2025 to provide caregiving duties for P#2. ST AA acknowledged criteria for home bound status and was able to state the criteria for home bound status. ST AA stated she and a friend followed behind P#2 in another car as they traveled to the Superbowl, and she did not actually ride in the van with P#2. ST AA denied using P#2 credit cards for personal gain and stated P#2 did not buy her Superbowl ticket. ST AA stated a friend brought the ticket. When asked if P#2 provided hotel accommodations for her, ST AA stated a friend of hers brought the room from P#2 so he did not actually provide a hotel room for her. ST AA adamantly denied lying in bed with P#2 and denied any inappropriate behaviors between herself and the patient. ST AA did acknowledge that she did not notify her supervisor of the trip to the Superbowl with P#2 outside of business hours. ST AA failed to maintain a professional code of conduct to not receive gifts from active patients in which services were being provided.”