Amedisys Home Health

“Release of patient identifiable OASIS info. CFR(s): 484.40 Condition of participation: Release of patient identifiable OASIS information. The HHA and agent acting on behalf of the HHA in accordance with a written contract must ensure the confidentiality of all patient identifiable information contained in the clinical record, including OASIS data, and may not release patient identifiable OASIS information to the public. This Condition is not met as evidenced by: . Based on document review, record review and interview, the agency failed to accurately completed the Outcome and Assessment Information Set (OASIS) data for M0102 and M014 (repeated non-compliance from previous survey). Failure to accurately complete the OASIS data places patients at risk for physical harm due to not receiving services in a timely manner. Findings Included: 1. Failure to accurately complete the OASIS data places patients at risk for physical harm due to not receiving services in a timely manner for 2 of 10 patients. 2. Repeated non-compliance identified in recertification survey conducted on 08/31/23. The agency was previously cited under Tag G0374, Accuracy of encoded OASIS data, 42.CFR 484.45 (b), Failure to accurately complete the OASIS data. Based on the scope and severity of deficiencies identified under 42 CFR 484.40 Condition of Participation: Release of patient identifiable OASIS information is NOT MET. Cross Reference: G0374 .”

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: . Based on document review, record review and interview, the agency failed to conduct the initial assessment visit within 48 hours of completing the referral (repeated non-compliance from previous survey). Failure to conduct initial assessments within 48 hours of completing the referral puts patients at risk of physical harm due to not receiving services in a timely manner. . Findings Included: 1. Failure to conduct the initial assessment visit within 48 hours of completing the referral and notifying patients or their legal representative of the delayed services for 3 of 10 patients. 2. Repeated non-compliance identified in recertification survey conducted on 08/31/23. The agency was previously cited under Tag G0514, Initial Assessment Visit, 42.CFR 484.55(a)(1), for failure to do the initial assessment within forty-eight hours of referral, or forty-eight hours of the patient’s return home, or on the physician-ordered start of care date. Based on the scope and severity of deficiencies identified under 42 CFR 484.55 Condition of Participation: Comprehensive assessment of patients is NOT MET. Cross Reference: G0514 .”

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: . Based on document review, record reviews, and interviews, the agency failed to accurately complete the Outcome and Assessment Information Set (OASIS) datas for M0102 and M0104 for 3 of 10 patients (Patient #101, Patient #106, and Patient #109). Failure to accurately complete the OASIS data places patients at risk for physical harm due to not receiving services in a timely manner. . Findings included: 1. Document review of agency’s policy titled, “Oasis Outcome and Information Set,” (Last Review Date: 06/09/25) showed that as part of the condition of participation reporting OASIS in accordance with §484.55 encoded Oasis data must accurately reflect the patient’s status at the time of assessment. 2. Record review of patient’s records for Patient #101, Patient #106, and Patient #109 showed: a. Patient #101 was admitted on 09/18/24 with the primary diagnosis of Left Knee Infection. Documentation showed the OASIS M0102 Start of Care (SOC) date of 09/18/24 rather than the accurate data of M0104 and the date of 09/10/24. In addition, documentation in the Intake Care Coordination note showed referral date of 09/10/24, and that there was no documentation of a physician order’s for M0102. b. Patient #106 was admitted on 03/17/26 with the primary diagnosis of Dementia. Documentation showed the OASIS M0102 SOC date of 03/17/26 rather than the accurate data of M0104 and the date of 03/16/26. In addition, documentation in the Intake Care Coordination note showed referral date of 03/16/26, and that there was no documentation of a physician order’s for M0102. c. Patient #109 was admitted on 12/28/24 with a primary diagnosis of Right Lower Extremity Amputation. Documentation showed the OASIS M0102 SOC date of 12/27/24 rather than the accurate data of M0104 and the date of 12/20/24. In addition, documentation in the Intake Care Coordination note showed referral date of 12/22/24, and that there was no documentation of a physician order’s for M0102. 3. On 05/06/26 at 2:00 PM, the Surveyor interviewed the agency’s Area Administrator (Staff #112) about lack of accuracy in OASIS Data entry for M0102 and M0104. Staff #112 acknowledged the OASIS data error findings and stated that the agency reviews the OASIS data for accuracy prior to submission but stated that they were not able to provide documentation as to why the OASIS M0102 and M0104 were inaccurate. This is a REPEAT CITATION, previously cited under Tag G0374 on the last CMS survey completed on 08/31/23. .”

“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 document review, record reviews, and interview, the agency failed to conduct the initial assessment visit within the 48 hours of completing the referral for 2 of 10 patients (Patient #101 and Patient #109). Failure to meet this requirement places patients at risk for physical harm due to not receiving services in a timely manner. Findings included: 1. Document review of agency’s policy titled, “Initial Referral/Admission Process,” (Policy AA-002, Last Review date: 06/09/25) indicated that the admitting discipline will perform the admission assessment within 48 hours of both the facility discharge and receipt of referral. 2. Record review of patient’s records for Patient #101 and Patient #109 showed: a. Patient #101’s Start of Care (SOC) date was 09/18/24. The patient was admitted for primary diagnosis of Left Knee Infection. The agency completed the referral on 09/10/24 for the Skilled Nursing (SN) initial assessment, but the SOC for the SN services did not occur until 09/18/24. There was no documentation of why SN services did not occur within 48 hours of the referral, and no documentation that the patient and the patient’s physician was notified of the delayed admission. b. Patient #109’s SOC date was 12/28/24. The patient was admitted for primary diagnosis of Right Lower Extremity Amputation. The agency completed the referral on 12/22/24 for the Physical Therapy (PT) initial assessment, but the SOC for the PT services did not occur until 12/28/24. There was no documentation of why the PT services did not occur within 48 hours of the referral, and no documentation that the patient and the patient’s physician was notified of the delayed admission. 3. On 05/06/26 at 11:00 AM, the Surveyor interviewed the agency’s Office Manager (Staff #111) regarding the lack of documentation that explains why the services did not occur within 48 hours of the referral and the notification of the patient and their physician of the delayed SOC. Staff #111 acknowledged the findings and stated that referrals go through the agency’s centralized intake, but stated that they were not able to provide documentation as to why the services were delayed. This is a REPEAT CITATION, previously cited under Tag G0514 on the last CMS survey completed on 08/31/23.”