Amedisys Home Health of Winston Salem

Staff interviews the agency failed to provide care in accordance with The Condition Skilled Professional Service for 3 of 18 patient [5, 1 and 14]. Cross refer to §484.75(b) G0704 §484.75(b)(6) G0716

The agency failed to ensure accuracy of the OASIS [Outcome and Assessment Information Set-a group of standard date elements included in comprehensive assessments] for 6 of 18 records reviewed [#1, 5, 11,12, 14 and 16]. The findings included: The policy, Oasis Outcome and Information Set [6/23/23]…

The agency failed to follow the POC related to obtaining vital signs for 1 of 18 records reviewed (#13), failed to follow the POC related to suprapubic catheter (tube used to drain urine from the bladder through a cut in the abdomen) changes for 1 of 1 patients with a suprapubic catheter (#13).

Direct observation and staff interviews clinicians failed to follow proper infection control guidelines for 2 of 6 home visits [#10 and 11]. The findings included: The policy, Bag Technique [6/20/23], was provided by the agency director on 10/24/23 at 3:30 pm.

The Registered Nurse [RN] failed to follow up with the physician for wound care orders for 1 of 1 patient who underwent partial amputation of left great toe [#5]. Immediate Jeopardy was identified beginning 5/16/23 and abated at 3:34 pm on 10/25/23. The findings included: Patient # 5 had a Start of…

Staff interviews the Plan of Care [POC] failed to include all current/correct medications the patient was using for 5 of 6 home visits observed (#6, #9, #10, #11, and #12), failed to include all DME (durable medical equipment) for 1 of 5 home visits (#6), failed to include all diagnoses for 1 of 18…

Interview with Employee #5 on 10/25/23 at 9:40 a.m. “I did not call the doctor”.

Staff interview the agency failed to coordinate care with the physician regarding a suprapubic catheter for 1 of 1 records reviewed with a suprapubic catheter (#13).

Staff interviews the OT [occupational therapist] and PT [physical therapy] failed to document accurately related to skin breakdown/presence of nonremovable dressing for 3 of 18 patients [#1, 5 and 14]. The findings included The policy, Clinical Record Contents [9/1/23], was provided by the agency…

Staff interviews the agency failed to complete/provide physician with a transfer summary for 3 of 4 patients who were transferred/admitted to the hospital [#1, 5 and 8]. The findings included: The policy, Transfer of Patients [1/23/23], was provided by the area vice president on 10/25/23 at 12:33…

The agency failed to follow the Plan of Care related to wound care orders for 2 of 13 records reviewed [#1 and 6]; failed to follow the POC related to suprapubic catheter changes for 1 of 1 patient with a suprapubic catheter [#9]; failed to obtain a full set of vital signs for 2 of 24 charts [#15…

Staff interviews the agency failed to document the existence of a complaint for 1 of 5 discharged charts reviewed [#22]. The findings included: The policy, Patient/Caregiver Grievance/Complaint Policy [review date of 6/24/21], was presented by RN # 16 on 8/19/21. The policy stated, “…The agency is…

Staff interviews the Plan of Care [POC] failed to include all current/correct medications the patient is using for 2 of 24 charts reviewed [#6 and 18]; failed to include blood sugar parameters on the Plan of Care [POC] for 7 of 24 charts [#6, 1, 2, 5, 9, 19, 23]. The findings included: The policy…

The agency failed to obtain orders for wound care for 1 of 13 charts [#1]; failed to obtain an order to flush a Foley catheter for 1 of 1 patient with a Foley catheter [#9]. The findings included: 1. Patient # 1 had a Start of Care [SOC] date of 6/29/21 and admitting diagnoses of disruption of…

Staff interviews the agency failed to notify the MD of the deterioration of a wound for 1 of 2 patients with NPWT [negative pressure wound therapy] [#1]. The findings included: The policy, Coordination of Care [revised date of 4/2019], was provided by RN # 16 on 8/19/21. The policy stated…

The agency failed to coordinate care with the MD related to medications and dressing orders for 2 of 24 charts [#5 and 20]. The findings included: 1. Patient # 5 had a Start of Care [SOC] date of 7/22/21 and admitting diagnoses of hypertensive heart disease without heart failure and type 2 diabetes…

The agency failed to give the patient correct information related to frequency of dressing changes for 1 of 24 charts [#9]. The findings included: Patient # 9 had a Start of Care [SOC] date of 7/8/21 and an admitting diagnosis of type 2 diabetes mellitus with foot ulcer.

Staff interviews the agency failed to document wound measurements in accordance with agency policy for 2 of 13 patients [#19 and 23]. the findings included: The policy, The Provision of Wound and Skin Care [revised date of 2/25/21] was provided by RN # 16 on 8/19/21. The policy stated, "...In…