Amedisys Home Health of Chapel Hill

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on agency policy, clinical record review, direct observations, and staff interviews the Plan of Care [POC] failed to include all/correct medications the patient was taking for 5 of 6 patients receiving home visits [# 6, 8, 11, 7 and 9]. The findings included: 4. Patient #7 had a Start of Care date of 5/5/25 with admitting diagnoses of acute pancreatitis without necrosis or infection, unspecified (inflammation of the pancreas without pancreatic tissue death or infection). Review of the Plan of Care (POC) for the certification period 5/5/25-7/3/25 included orders for PT (physical therapy) 1 time a week for 9 weeks. On 7/8/25 at approximately 11 am, a joint visit was made with PTA (physical therapy assistant) # 5. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Lidocaine pain relief 4% topical patch (over the counter topical patch for pain) 2 adhesive patches every pm and Maalox maximum strength 400 mg/5ml oral suspension (over the counter liquid antacid) 30 ml every 6 hours as needed for heartburn. During an interview with the patient on 7/8/25 at approximately 11:20 am, the patient stated, “I don’t take those anymore.” The medication profile did not include magnesium 250 mg daily, which the patient revealed that he has taken for “a couple months.” During an interview with the agency director on 7/10/25 at approximately 12:30 pm, the director confirmed the POC did not include all/correct medications. 5. Patient #9 had a Start of Care date of 6/7/25 with an admitting diagnosis of Ankylosing hyperostosis, thoracolumbar region (type of arthritis that causes soft tissue around the spine to stiffen and calcify). Review of the Plan of Care (POC) for the certification period 6/7/25-8/5/25 included orders for ST (speech therapy) 1 time a week for 1 week for evaluation. On 7/8/25 at approximately 1:30 pm a joint visit was made with ST #6 . During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Acetaminophen (over the counter pain medication) 325mg every 6 hours as needed, Cyclobenzaprine (used to treat muscle spasms)10mg every 8 hours as needed, Entresto (used to treat heart failure) 24mg-26mg tablet, and Hydrocodone 5mg/Acetaminophen 325 mg (narcotic pain medication) every 4 hours as needed. During an interview with the patient on 7/8/25 the patient stated, “I don’t take those anymore.” The medication profile listed Olanzapine (used to treat schizophrenia, bipolar disorder, and agitation) 5mg at bedtime. During an interview with the patient on 7/8/25 at approximately 1:45 am, the patient stated “I only take it when I need it.” During an interview with the agency director on 7/10/25 at approximately 12:35 pm, the director confirmed the POC did not include all/correct medications. The policy, Drug Regimen Review [12/1/23], was provided by the agency director on 7/9/25 at 1:51 pm. The policy stated, “...The clinician will question the patient/and or caregiver periodically regarding changes in medications...Medications will be visualized minimally at...and upon any medication change...” 1. Patient # 6 had a Start of Care date of 5/13/25 with admitting diagnoses of aftercare following joint replacement surgery and presence of left artificial hip joint. Review of the Plan of Care [POC] for the certification period 5/13/25-7/11/25 included orders for PT [physical therapy] 2 times a week for 1 week, 3 times a week for 1 week, 1 time a week for 7 weeks. On 7/8/25 at approximately 9 am a joint visit was made with PT # 1. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Acetaminophen [over the counter pain medication] 500 mg. Take 2 tablets 3 times per day. During an interview with the patient on 7/8/25 the patient stated, “I don’t take that.” The mediation profile listed Gabapentin [nerve pain] 100 mg. Take 2 capsules 3 times a day. During the visit the patient reported, “I don’t take that anymore.” The medication profile did not include the following medications the patient reported she is taking: Vasotec [blood pressure] 5 mg each day Iron blood builder [supplement] each day Vitamin E [supplement] 800 mg each day Fish Oil [supplement] 1 tablet 2 times per day Vitamin D 3 [supplement] 5,000 IU [international units] 2 times per week Vitamin B Complex [supplement] 1 tablet each day During an interview with the agency director on 7/10/25 at approximately 2 pm, the director confirmed the POC did not include all/correct medications. 2. Patient # 8 had a Start of Care date of 7/1/25 with an admitting diagnosis of Hypertension. Review of the Plan of Care [POC] for the certification period 7/1/25-8/29/25 included orders for PT [physical therapy] 1 time a week for 4 weeks. On 7/8/25 at approximately 2 pm a joint visit was made with PT # 3. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancy was noted: The patient presented a bottle of Zofran [anti-nausea] 4 mg. Take 1 tablet every 8 hours as needed for nausea and vomiting. The patient reported he had been using the medication before he was admitted to home health. The medication profile provided by the agency did not include Zofran. PT # 3 confirmed the POC did not include all the medications the patient was taking. 3. Patient # 11 had a Start of Care date of 6/28/24 with an admitting diagnosis of infection following a procedure, deep incisional surgical site. Review of the Plan of Care [POC] for the certification period 6/23/25-8/21/25 included orders for SN [skilled nursing] 1 time a week for 9 weeks. On 7/8/25 at approximately 12 pm a joint visit was made with LPN # 2. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Imipenem-Cilastatin [dehydropeptidase inhibitor-used to prevent the breakdown of certain antibiotics] 500 mg 2 times per day. During an interview with the patient the patient reported she no longer is taking the IV medication. During an interview with the agency director on 7/10/25 at approximately 1 pm, the director confirmed the POC did not include the correct/current medications the patient was taking.”

“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 clinical record review, direct observation, and staff interviews the agency failed to follow the Plan of Care/Physician’s for wound care for 1 of 2 patients who had wound care ordered during a home visit [#11]; failed to follow the Plan of Care/Physician’s order related to wound care for 1 of 2 discharged patients who had orders for wound care [#4]. The findings included: 2. Patient #4 had a Start of Care date of 6/29/2024 with admitting diagnoses of pressure ulcer of left buttock stage 4 (full thickness tissue loss, exposing muscle, tendon, or bone). Review of the Plan of care for the certification period 6/29/2024 to 8/27/2024 included orders for SN (skilled nursing) 1 time a week for 1 week, 2 times a week for 8 weeks, 1 time a week for 1 week. Further review of the plan of care revealed the following orders: “Registered nurse/licensed practical nurse to perform/teach patient/caregiver wound care pressure injury to left hip area: irrigate/cleanse with wound cleanser or normal saline and pat dry. Alternate Dakins moistened gauze and collagen to wound bed…cover with bordered foam dressing. Change dressing every day and prn [as needed] for wound complications or dressing dislodgement.” Review of the clinical record revealed on the 7/9/24 and 7/16/24 SN visits, LPN #2 applied silvercel to the wound bed. During an interview with the agency director on 7/10/2025 at approximately 12:40 pm, the director confirmed that there was not an order for silvercel in the clinical record and that the skilled nurse failed to follow the physician’s order on the plan of care related to wound care. 1. Patient # 11 had a Start of Care date of 6/28/24 with an admitting diagnosis of infection following a procedure, deep incisional surgical site. Review of the Plan of Care [POC] for the certification period 6/23/25-8/21/25 included orders for SN [skilled nursing] 1 time a week for 9 weeks and “RN/LPN/LVN to perform/teach wound care to left out breast area; Daily wound care cleanse with wound cleaner [sic] apply medihoney to wound bed, cover with ABD pad...”. On 7/8/25 at approximately 12 pm a joint visit was made with LPN # 2. During the visit LPN # 2 assessed and measured the wound. The LPN did not complete the wound care in accordance with the POC/physician’s order. The LPN stated, “she is getting ready to be discharged and she does her own wound care.” During an interview with the agency director on 7/10/25 at approximately 2 pm, the director confirmed the LPN failed to follow the POC/physician’s order.”