Amedisys Home Health of Maryland LLC

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on review of employee record review and interview with agency Administrator, the agency failed to provide and maintain documentation of training (initial and continued) in emergency preparedness policies and procedures for staff #2. Failure to provide training to all staff in policies and procedures places patients and staff at risk for adverse outcomes during an emergency. Employee: #2 During review of personnel EPP training records, there was no documentation of EPP policies and procedures training for employees. Employee #2 hire date 2/12/2024, there was no documentation of initial EPP training and there was no documentation of continued EPP training as of the date of this review. During the interview on 2/27/2025, the Administrator was unable to provide documentation of the training for the employee.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on record review and interview with Director of Operations (DOO), in a 12-month period the agency did not transmit eighty OASIS assessments to the CMS system within 30 days of completing initial assessments, as required by regulation 484.45(a). This failure to adhere to the required time frame for Oasis transmission has the potential to compromise the accuracy and timeliness of data reporting and impact compliance with federal regulations. On 2/25/2025 review of the agency’s Error Summary Report for the period of 2/24/2024 through 2/24/2205 noted error #3330 with eighty records being transmitted beyond the 30-day requirement time frame. The DOO provided a copy of the agency’s OASIS workflow job aid.”

“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 observation during a home visit with agency clinical staff, the clinical supervisor and the Registered Nurse (RN) clinician, adequate infection control prevention was not implemented during the provision of wound care. The RN failed to demonstrate adequate infection control practices. Failure to adhere to infection control standards placed patients at risk for infection. Patient: #14 Employee: #1 Findings included: Infection prevention practices require the separation between dirty (contaminated: covered with disease-causing organisms) and clean (reduced level of contamination) tasks and areas during a dressing change an invasive procedure to prevent the transmission (cross-contamination) of bacteria/viruses, which can lead to infection. It means that hands must be washed or sanitized in addition to glove changes between dirty procedures (for example, removing a soiled dressing, cleansing a wound, removing used clinical supplies, cleansing before an invasive procedure and touching a cellular telephone) and clean procedures (for example, inserting a urinary catheter applying new dressing materials or handling new clinical supplies, including medications). Additionally, every attempt should be made to avoid the contamination of sterile (free of bacteria) or clean items. The regulation for standard infection prevention states that the home health agency must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This did not occur. 1.During observation of the start of care visit, on 2/25/2025, with patient #14, the RN (Employee #1) performed the initial nursing assessment and admission to agency. After completing the nursing assessment, the RN failed to disinfect the used equipment before placing the equipment back into the main compartment of the supply bag. After exiting the home, the Director of Operations acknowledged the breaches in universal precautions.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on review of patient records and interview with agency staff, the agency staff did not communicate delays in the start of care (SOC) for 4 out 18 patients reviewed. Placing the patients at risk for adverse or negative health care outcomes. Patient: #5, #8, #9, and #13 Findings included: The home health agency furnishing services must maintain communication to ensure that their efforts are coordinated effectively and support the objectives outlined in the patients plan of care. 1. All clinical staff members have the responsibility to communicate or refer patient care related issues to other professional disciplines to ensure the provision of optimal health care services and to prevent adverse outcomes. This did not occur, as evidenced by the review of patient records on 2/27/2025, and 3/3/2025. a) On 2/27/2025, during the review of patient #5 medical record, it is documented that on 9/16/2024 the agency received and accepted a referral to provide skilled nursing and physical therapy services for the patient. It was documented on 9/17/2024 that the patient’s physician was contacted and a SOC date of 9/24/2025 was requested. A client coordination note dated 10/4/2024 requesting a 10/4/2024 SOC was approved by the physician. No documentation communicating the reason for the nine-day delay in communicating with the patient or to the referring physician was in the record. During the interview, the agency staff did not provide any further information or documentation for the delay in care. b) On 3/3/2025, during the review of patient #8 medical record, it is documented that on 1/17/2025 the agency received and accepted a referral to provide physical therapy services for the patient. The start of care date is documented as 1/24/2025. A client coordination note dated 1/20/2025 requesting a 1/24/2024 SOC was approved by the physician. There was no documentation explaining the delay in contacting the physician for approval to delay the SOC. During the interview, the agency staff did not provide any further information or documentation for the delay. c) On 3/3/2025, during the review of patient #9 medical record, it is documented that on 2/5/2025 the agency received and accepted a referral to provide skilled nursing and physical therapy services for the patient. The start of care date is documented as 2/12/2025. A client coordination note dated 2/7/2025 requesting a 2/12/2025 SOC was approved by the physician. There was no documentation explaining the reason for delay in the start of care request. During the interview, the agency staff did not provide any further information or documentation for the delay in care. d) On 3/3/2025, during the review of patient #13 medical record, it is documented that on 1/21/2025 the agency received and accepted a referral to provide skilled nursing, home health aide, occupational and physical therapy services for the patient. The patient was discharged from the hospital on 1/23/2025. The start of care date is documented as 1/31/2025. No documentation communicating the eight-day delay in the start of care to the referring physician was in the record. During the interview, the agency staff did not provide any further information or documentation for the delay in care.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on the review of patient records and interview with agency staff, the agency did not obtain or clarify physician orders for 1 out of 18 patients reviewed. Failure to obtain and clarify all physician orders has the potential to cause negative health care outcomes. Patient: #18 Findings included: 1. The Physical Therapist has an obligation to make sure that a physician’s order is present for patient care. This did not occur, as evidenced by the record review on 3/3/2025. On 3/3/2025, during the medical record review, a referral dated 11/21/2024 for falls was noted. There was no agency admission documentation for the referral. A hospital stay from 12/11/2024 through 12/14/2024, the discharge summary page 6 of 6 noted a recommendation for home health physical therapy. A face-to-face encounter was performed and documented on 1/10/2025 with findings of the patient needing home health skilled nursing services. The agency’s clinical coordination note dated 2/5/2025 indicates a physician referral was received for skilled nursing services; however, no evidence of the referral was found. The agency’s clinical coordination note dated 2/6/2025, documented that the agency’s request for a delayed start of care was approved for 2/10/2025; however, no evidence of an original order was found. The home health certification and plan of care reflect a start of care date of 2/10/2025, with an order date of 2/10/2025 at 10:49 a.m. The plan included an order for physical therapy twice weekly for four weeks; however skilled nursing was not indicated. There was no documentation of clarification being requested for an order. When asked, the DOO was unable to provide any additional information.”