Tugaloo Home Health Agency, An Amedisy Company

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on policy titled “Plan of Care (POC) /Care Planning Process,” review of clinical records and staff interviews, it was determined that the agency failed to follow the plan of care by not providing continuous oxygen at 3 liters per minute via nasal cannula and oxygen therapy interventions for one patient (P) (P#3) of five sampled patients. Findings include: Review of policy titled “AA-014 Plan of Care (POC) /Care Planning Process,” with last review date 1/31/25 revealed the following: Purpose: A plan of care will be developed through a care planning process, which is designed to provide care, treatment, and services that are appropriate to the patient’s individual needs. 7. The Clinical Manager is responsible for facilitating coordination among all disciplines. Review of document titled “Home Health Certification and Plan of Care” dated 9/13/24 revealed orders for oxygen 2 Liters per minute continuous via nasal cannula for P#3 and interventions that the Physical Therapist (PT) and the Physical Therapist Assistant (PTA) were to educate patient/caregiver on oxygen management. During an interview with the Executive Director of Operations on 9/30/25 at 12:30 p.m., the Executive Director of Operations acknowledged that the care plan for P#3 contained an order for oxygen. She stated that she was unaware P#3 was not receiving oxygen as ordered on the plan of care. She confirmed the Physical Therapist was assessing pulse oximetry (a measurement of the amount of oxygen that is in the blood, normal generally between 95% and 100%) on room air for P#3. The EDO confirmed that the agency failed to provide oxygen therapy and interventions as ordered on the plan of care. During an interview on 9/30/25 at 12:45 p.m. with the Physical Therapist (PT) PT AA states that he completed the recertification assessment for the period of 9/13/24 to 11/11/24 and was aware that oxygen 3 liters per minute continuous via nasal cannula had been ordered but failed to ensure that it was provided. During an interview with the Clinical Manager (CM) on 9/30/25 at 12:35 p.m. confirms that oxygen 3 Liters per nasal canula was ordered and listed on the plan of care for P#3. She was unaware that the oxygen was not available to P#3. She stated oxygen saturation levels were taken on room air. During an interview on 9/30/25 at 1:00 p.m. with Physical Therapist Assistant (PTA), PTA BB stated that there was no oxygen provided for P#3. She states that she looked for the oxygen but failed to report that the oxygen had not been provided to P#3. The PTA BB stated P#3 would have oxygen saturation levels below 90 while active and the levels would recover to the 90’s after she rested.”

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: Based on policy titled “AA-014 Plan of Care (POC) Care Planning Process,” record review, and family and staff interviews, it was determined the home health agency failed to provide services as ordered by the physician as indicated in the plan of care for one patient (P) (P#3) of five sampled patients. Findings include: Review of the policy titled “AA-014 Plan of Care (POC)/Care Planning Process,” revised January 2025 revealed the following: PURPOSE: To provide physician/allowed practitioner ordered care, treatment, and services through an organized process and plan Review of document titled “Home Health Certification and Plan of Care” dated 9/13/24 revealed orders for oxygen 2 Liters per minute via nasal cannula for P#3 and interventions that the Physical Therapist (PT) of Physical Therapist Assistant (PTA) were to educate patient/caregiver on Oxygen management. Review of PTA BB visit note report dated 10/23/24, PTA BB obtained oxygen saturation level on room air for P#3 with results of 65% saturation. (Normal oxygen saturation rates are typically between 95% and 100%.) PTA BB provided 10 minutes of rest time after exercises, and after recovery period of 10 minutes oxygen saturation returned to above 90% on room air. During an interview on 9/30/25 at 12:45 p.m. with the Physical Therapist (PT) PT AA states that he completed the recertification assessment for the period of 9/13/24 to 11/11/24 and was aware that Oxygen 3 liters per minute via nasal cannula had been ordered but failed to ensure that it was provided. During an interview on 9/30/25 at 1:00 p.m. with Physical Therapist Assistant (PTA) BB, PTA BB stated that there was no oxygen provided for P#3. She states that she looked for the oxygen but failed to report that the oxygen had not been provided to P#3. The PTA BB stated P#3 would have oxygen saturation levels below 90 while active and the levels would recover to the 90’s after she rested. During an interview with the Clinical Manager (CM) on 9/30/25 at 12:35 p.m. confirms that oxygen 3 Liters per nasal canula was ordered and listed on the plan of care for P#3. She was unaware that the Oxygen was not available to P#3. She stated oxygen saturation levels were taken on room air.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on policy titled “Coordination of Care,” record review and family and staff interviews, it was determined the agency failed to ensure communication to the physician involved in the plan of care. Specifically, the agency failed to notify the physician that P#3 was not receiving oxygen therapy and oxygen therapy interventions as ordered on the plan of care for one patient (P) (P#3) of five sampled patients. Findings include: Review of policy titled “TX-002 Coordination of Care,” last reviewed 7/10/25 revealed the following: Purpose: The patients’ care and services will be coordinated among staff and branches. To ensure consistent documentation, communication, retrieval of significant administrative and patient/family information. Procedure: 6. The overseeing physician is notified promptly of any changes in patient’s condition or needs that suggest that outcomes are not being achieved and /or the pan of care should be altered. 7. Agency staff involved in the patient’s plan of care provides patient related updates in a timely manner to the physician and includes as appropriate: Patient’s current condition Changes in patient’s condition Patient response to treatment, if negative will be reported to the physician immediately During an interview with the Clinical Manager (CM) on 9/30/25 at 12:35 p.m. confirms that oxygen 3 Liters per nasal canula was ordered and listed on the plan of care for P#3. She was unaware that the oxygen was not available to P#3. She stated oxygen saturation levels (a measurement of oxygen found in the blood) were taken on room air. CM denies notifying the physician that P#3 did not receive oxygen as ordered. The agency failed to notify the physician that P#3 was not receiving oxygen therapy and oxygen therapy interventions as ordered.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on record review and staff interviews, the agency failed to ensure that oxygen was initiated for one patient (P) (P#3) of five sampled patients (P) (P#3). Findings include: Review of visit note report dated 10/23/24, Physical Therapist Assistant (PTA) BB obtained pulse oximetry (a measurement of the amount of oxygen that is in the blood, normal generally between 95% and 100%) on room air for P#3 with results of 65% saturation. P#3 had ambulated to the bathroom. PTA BB waited 10 minutes of rest time, and the recovery time returned to above 90% on room air. During an interview on 9/30/25 at 12:45 p.m. with Physical Therapist (PT) PT AA confirmed that the care plan did contain orders for oxygen 3 liters per minute continuous via nasal cannula for P#3, but he failed to coordinate care with other disciplines to ensure that P#3 received the oxygen. He stated that he assessed P#3’s pulse oximetry on room air and did not provide interventions for oxygen therapy. During an interview on 9/30/25 at 1:00 p.m. with Physical Therapist Assistant (PTA), PTA BB stated that there was no oxygen provided for P#3. She states that she looked for the oxygen but failed to report that the oxygen had not been provided to P#3. The PTA BB stated P#3 would have oxygen saturation levels below 90 while active and the levels would recover to the 90’s after she rested. The agency failed to coordinate care delivery to meet patient’s needs.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on the policy titled “AA-014 Plan of Care (POC)/Care Planning Process,” record review and staff interviews, the agency failed to provide services ordered by the physician as indicated on the plan of care. Specifically, the agency did not follow the plan of care of one patient (P) P#3 to provide Oxygen 3 liters per minute via nasal cannula. Findings include: Review of the policy titled “AA-014 Plan of Care (POC)/Care Planning Process,” revised January 2025 revealed the following: PURPOSE: · To provide physician/allowed practitioner ordered care, treatment, and services through an organized process and plan Review of document titled “Home Health Certification and Plan of Care” dated 9/13/24 revealed orders for oxygen 3 Liters per minute continuously via nasal cannula for P#3 and interventions that the Physical Therapist (PT) of Physical Therapist Assistant (PTA) were to educate patient/caregiver on oxygen management. The plan of care also lacked oxygen saturation parameters to notify the physician of potential complications. Review of PTA BB visit note report dated 10/23/24, PTA BB obtained oxygen saturation level on room air for P#3 with results of 65% saturation. (Normal oxygen saturation rates are typically between 95% and 100%.) PTA BB provided 10 minutes of rest time after exercises, and after a recovery time of 10 minutes oxygen saturation returned to above 90% on room air. The agency staff failed to follow physician’s orders to oxygen administration as outlined in the plan of care. During an interview on 9/30/25 at 12:45 p.m. with Physical Therapist (PT), AA states that he completed the recertification assessment for the period of 9/13/24 to 11/11/24 and was aware that oxygen 3 liters per minute via nasal cannula had been ordered but failed to ensure that it was provided. During an interview on 9/30/25 at 1:00 p.m. with Physical Therapist Assistant (PTA), PTA BB stated that there was no oxygen provided for P#3. She states that she looked for the oxygen but failed to report that the oxygen had not been provided to P#3. The PTA BB stated P#3 would have oxygen saturation levels below 90 while active and the levels would recover to the 90’s after she rested. During an interview with the Clinical Manager (CM) on 9/30/25 at 12:35 p.m., CM confirms that oxygen 3 Liters per nasal canula was ordered and listed on the plan of care for P#3. She was unaware that the oxygen was not available to P#3. She stated oxygen saturation levels were taken on room air.”

“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 review of the policy “Discharge of Patients,” record reviews, and staff interview, it was determined the agency failed to provide the patient with written notice of discharge and send all necessary medical information to the receiving healthcare practitioner upon discharge for one patient (P) (P#5) of four sampled discharged patients. Findings include: A review of the policy titled, “Discharge of Patients”, Policy AA-016, reviewed 10/10/2024 reveals the following: Procedure: 7. The physician/allowed practitioner will be notified of the patient’s discharge from the home health agency. Documentation of physician/allowed practitioner communications/notification will be evident in the patient’s medical record. 11. A completed discharge summary is sent to the primary care physician/allowed practitioner, receiving facility or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge. 16. C. Verbal notification to non-institutionalized patients not in jeopardy will be followed by written notice- Notice of Medicare Non-Coverage (for traditional Medicare and Medicare Advantage patients.) A copy of this written notice shall be placed in the patient’s chart. A review of P#5’s clinical record revealed the patient was admitted on 8/13/2024 and discharged on 10/15/2024 due to no further skilled needs. A clinical chart review failed to reveal a signed Medicare Notice of Non-Coverage, documentation of physician notification of the discharge, or evidence the discharge summary was sent to the physician. The Executive Director of Operations (EDOO) provided the surveyor with a document titled “Event-Stages History Report”, which revealed that P#5’s discharge summary was faxed to an unnamed physician on 11/13/2024, 27 days after discharge. An interview on 1/28/2024 at approximately 10:45 a.m. was conducted with the EDOO, who agreed the clinical record lacked documentation of the discharge process.”

“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 a review of policies, record reviews, and staff interview, it was determined the hospice governing body failed to assume responsibility for the agency’s management and operation by failing to process and resolve complaints, failing to provide patients with written notice of discharge and send discharge summaries to the receiving healthcare practitioner upon discharge for one patient (P) (P#5). Findings include: A review of an unnumbered policy titled, “Complaint Documentation”, revised 7/2023 reveals the following: 7) The Administrator/DOO is responsible for reviewing every complaint, determining the necessary action, communicating the resolution with the person filing the complaint no later than 30 calendar days following receipt of the complaint. A review of the policy titled, “Discharge of Patients”, Policy AA-016, reviewed 10/10/2024 reveals the following: Procedure: 7. The physician/allowed practitioner will be notified of the patient’s discharge from the home health agency. Documentation of physician/allowed practitioner communications/notification will be evident in the patient’s medical record. 11. A completed discharge summary is sent to the primary care physician/allowed practitioner, receiving facility or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge. 16. C. Verbal notification to non-institutionalized patients not in jeopardy will be followed by written notice- Notice of Medicare Non-Coverage (for traditional Medicare and Medicare Advantage patients.) A copy of this written notice shall be placed in the patient’s chart. A review of complaint logs revealed a document titled, “Complaint Report”, dated 11/12/2024, which revealed complaints were received by P#5. The report failed to reveal documentation of a resolution to the complaint. A review of P#5’s clinical record revealed the patient was admitted on 8/13/2024 with a diagnosis of pneumonia and co-morbidities of cellulitis (a bacterial infection that affects the skin and underlying tissues) of both legs. The patient was discharged on 10/15/2024 due to no further skilled needs. The clinical record failed to reveal documentation of communication with the patient regarding the complaint. The Executive Director of Operations (EDOO) provided copies of several emails between upper-level agency management and revealed calls from P#5 were received on 11/9/2024 and twice on 11/11/2024. The Complaint Report and the clinical record failed to reveal documentation of the content of these calls or the resolution of the complaints. Further review of P#5’s clinical chart review failed to reveal a signed Medicare Notice of Non-Coverage, documentation of physician notification of the discharge, or evidence the discharge summary was sent to the physician. The Executive Director of Operations (EDOO) provided the surveyor with a document titled “Event-Stages History Report, which revealed discharge summary was faxed to an unnamed physician on 11/13/2024, 27 days after discharge. An interview on 1/28/2024 at approximately 10:45 a.m. was conducted with the EDOO, who confirmed that all documentation related to the discharge and the complaint had been provided, and agreed the clinical record lacked documentation of the discharge process.”

“Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This Element is not met as evidenced by: Based on review of policy “Complaint Documentation,” record reviews, and staff interview, it was determined the agency failed to process and resolve complaints for one patient (P) (P#5) of two patients sampled who submitted complaints to the agency. Findings include: A review of the policy titled “Complaint Documentation,” revised 7/2023 reveals the following: The Home Health Agency should be able to produce documentation for each complaint received that confirms an investigation was conducted and records the investigation findings as well as the ultimate resolution of the complaint. 7) The Administrator/DOO is responsible for reviewing every complaint, determining the necessary action, communicating the resolution with the person filing the complaint no later than 30 calendar days following receipt of the complaint. A review of P#5’s clinical record revealed the patient was admitted on 8/13/2024 with a diagnosis of pneumonia and co-morbidities of cellulitis (a bacterial infection that affects the skin and underlying tissues) of both legs. The patient was discharged on 10/15/2024 due to no further skilled needs. A review of complaint logs revealed a document titled, “Complaint Report”, dated 11/12/2024, which revealed complaints were received by P#5. The report failed to reveal documentation of a resolution to the complaint. The clinical record failed to reveal documentation of communication with the patient regarding the complaint. The Executive Director of Operations (EDOO) provided copies of several emails between upper-level agency management and revealed calls from P#5 were received on 11/9/2024 and twice on 11/11/2024. The Complaint Report and the clinical record failed to reveal documentation of the content of these calls or the resolution of the complaints. An interview on 1/28/2024 at approximately 10:45 a.m. was conducted with the EDOO, who confirmed that all documentation related to this complaint had been provided.”