Amedisys Home Health Care

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to follow physician’s orders on the Plan of care for 4 of 7 patients with diabetes [#1, 7, 16 and 20]; and failed to follow physician’s orders on the Plan of Care related to wound care for 1 of 6 patients with a wound [#7]; and failed to follow physician’s orders on the Plan of Care to monitor weights for 2 of 4 patients [#1 and 16]. The findings included: The policy, Plan of Care [10/31/23], was provided by the agency director on 2/21/24 at approximately 3 pm. The policy stated, “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...To provide physician ordered care, treatment and services...” 1A. Patient # 1 had a Start of Care [SOC] date of 1/9/23 and an admitting diagnosis of type 1 diabetes mellitus with ketoacidosis [body can’t make enough insulin and acid builds up in the body]. Review of the Plan of Care [POC] for the certification period 1/9/23-3/9/23 included orders for PT [physical therapy] 1 time a week for 5 weeks, 1 time every 2 weeks for 4 weeks and “Diabetes management [PT] blood sugar parameters 70-300…stick frequency of patient/caregiver daily…” The POC included a goal of “Patient’s blood sugar will remain well controlled throughout the episode of care…” Review of the clinical record revealed PT # 1 completed the SOC visit on 1/9/23 and no blood glucose readings were documented. PTA [physical therapy assistant] # 2 conducted routine visits on 1/18/23 and 1/23/23 and no blood glucose readings were documented. The clinical record revealed the patient was transferred to the hospital on 1/27/23 for elevated blood sugar readings. Review of the hospital ED [emergency department] report revealed the patient had a blood glucose reading of 1197 at the time he was admitted to the hospital. Resumption of Care [ROC-assessment completed after in-patient stay] orders were written on 2/2/23 by PT # 3. The ROC orders included a PT frequency of 1 time a week for 6 weeks and “Diabetes Management”. The patient received 5 PT visits from 2/2/23-3/2/23. Review of the PT visit documentation revealed no blood glucose readings were documented. During an interview with the agency director on 2/21/24 at approximately 9:30 am, the director confirmed physician’s orders were not followed. 1B. Patient # 1 had a Start of Care [SOC] date of 1/9/23 and an admitting diagnosis of type 1 diabetes mellitus with ketoacidosis [body can’t make enough insulin and acid builds up in the body]. Review of the Plan of Care [POC] for the certification period 1/9/23-3/9/23 included orders for PT [physical therapy] 1 time a week for 5 weeks, 1 time every 2 weeks for 4 weeks. A supplemental order was written on 2/2/23 for SN [skilled nursing] to evaluate diabetes management. Review of the clinical record revealed an order dated 2/9/23 for SN visits 1 time a week for 5 weeks and “Report increased edema or weight gain of greater than 2 pounds in 1 day or 5 pounds in 1 week. May measure abdominal girth if unable to weight…SN for instructions on diabetic care to include…signs and symptoms of hypo/hyperglycemia…blood glucose testing 3 x frequency [sic]…Skilled nurse may perform blood glucose test as needed…Skilled nurse to report to physician blood glucose readings greater than 300 or less than 70…” There were 4 SN visits made from 2/9/23-2/27/23. Review of the documentation revealed there were no blood glucose readings obtained for 3 of those SN visits and no weights or abdominal girths obtained for 3 of those visits. During an interview with the agency director on 2/21/24 at approximately 9:30 am, the director confirmed the SN failed to follow physician’s orders. 2. Patient # 7 had a Start of Care [SOC] date of 12/20/23 and an admitting diagnosis of type 2 diabetes mellitus with foot ulcer, other streptococcal [type of bacteria] arthritis, left shoulder, bacteremia [bacteria in the blood], type 2 diabetes with hyperglycemia [high blood glucose], unspecified systolic [congestive] heart failure and encounter for adjustment and management of VAD [vascular access device- thin flexible tube that provides access to blood vessels without the need for repeated needle sticks]. Review of the Plan of Care [POC] for the certification period 12/20/23-2/17/24 included orders for PT [physical therapy] 2 times a week for 1 week, 1 time a week for 3 weeks, 1 time every 2 weeks for 4 weeks and “Physical therapy to observe wound/incisions and/or intact dressing on right foot and left shoulder…” Review of the clinical record revealed 3 PT visits were made from 12/24/23-12/31/23 [patient transferred to hospital]. There is no evidence the wounds were observed for 3 of the 3 PT visits. During an interview with the agency director on 2/21/24 at approximately 10 am, the director confirmed the PT failed to follow the physician’s order related to observing the wounds. 3A. Patient # 16 had a Start of Care [SOC] date of 1/11/24 with admitting diagnoses of acute and chronic respiratory failure with hypoxia [low oxygen level in the blood] and hypertensive heart and chronic kidney disease with heart failure and type 2 diabetes with hyperglycemia [high blood sugars]. Review of the Plan of Care [POC] for the certification period 1/11/24-3/10/24 included orders for SN [skilled nursing] 2 times a week for 1 week, 2 times a week for 8 weeks and “report blood glucose readings greater than 350 and less than 70…Report increased edema or weight gain greater than 2 pounds in 1 day or 5 pounds in 1 week or more than target weight…Target weight 370 pounds with maximum weight of 375 pounds…” Review of the clinical record revealed 10 SN visits were made from 1/11/24-2/12/24. There was a weight of 356 pounds documented at the SOC. The record revealed no blood glucose readings for any of the SN visits. During an interview with the administrator on 2/21/24, the administrator confirmed the SN did not follow the physician’s orders on the POC. 3B. Patient # 16 had a Start of Care [SOC] date of 1/11/24 with admitting diagnoses of acute and chronic respiratory failure with hypoxia [low oxygen level in the blood] and hypertensive heart and chronic kidney disease with heart failure and type 2 diabetes with hyperglycemia [high blood sugar]. Review of the Plan of Care [POC] for the certification period 1/11/24-3/10/24 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 4 weeks and “…PT for diabetes management…blood sugar parameters 70-300…Physical therapy to assess and record patient reported weight and notify CM [case manager/RN case manager for MD notification for signs and symptoms of exacerbation (2 pounds weight gain in 1 day or 5 pounds in 1 week over the baseline…” Review of the clinical record revealed 3 PT visits were made from 1/16/24-2/12/24 and there were no blood sugar readings or weights documented for 3 of 3 visits. During an interview with the administrator on 2/21/24 at approximately 9:15 am, the director confirmed PT did not follow the physician’s orders on the POC. 3C. Patient # 16 had a Start of Care [SOC] date of 1/11/24 with admitting diagnoses of acute and chronic respiratory failure with hypoxia [low oxygen level in the blood] and hypertensive heart and chronic kidney disease with heart failure and type 2 diabetes with hyperglycemia [high blood sugars]. Review of the Plan of Care [POC] for the certification period 1/11/24-3/10/24 included orders for OT [occupational therapy] 2 times a week for 2 weeks, 1 time a week for 6 weeks and “…OT to assess and record patient reported weight…OT for diabetes management-Blood sugar parameters 70-300 finger stick frequency of patient/caregiver 1 x a day…”Review of the clinical record revealed OT visits were made on 1/15/24, 1/19/24, 1/23/24 and 2/9/24. Further review of the clinical record revealed no evidence of blood sugar readings or weights in accordance with the physician’s order on the POC. During an interview with the agency director on 2/21/24 at approximately 9:15 am, the director confirmed OT failed to follow the physician’s orders on the POC. 4. Patient # 20 had a Start of Care [SOC] date of 11/8/23 with admitting diagnoses of type 2 diabetes with foot ulcer, type 2 diabetes mellitus with diabetic neuropathic arthropathy [serious complication of diabetes, causing destruction of bones and joints of the foot], and type 2 diabetes with diabetic peripheral angiopathy without gangrene [narrowing of the arteries]. Review of the Plan of Care [POC] for the certification period 1/7/24-3/6/24 included orders for SN [skilled nursing] 3 times a week for 8 weeks then 2 times a week for 1 week and “Diabetes management: RN to assess and teach LPN to observe and teach…blood glucose testing daily…observe and teach to perform and record blood glucose testing as ordered and to report abnormal findings to physician…Nurse to report to physician blood glucose readings greater than 350 and less than 70…” Review of the clinical record revealed the SN made 14 routine visits from 1/8/24-2/16/24. There were 5 visits which had no blood glucose readings documented. During an interview with the agency director on 2/21/24 at approximately 9:30 am, the director confirmed the SN failed to follow the POC.”

“Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This Standard is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the registered nurse failed to conduct an evaluation visit for 7 days after the completion of the resumption of care visit for 1 of 1 patients [#1]; and failed to identify a wound for 1 of 6 patients with a wound [#7]. The findings included: The policy, The provision of Wound and Skin Care [3/8/23], was provided by the agency director on 2/21/24 at approximately 3 pm. The policy stated, “…Assessment of the integumentary system is part of the comprehensive total body assessment…Documentation of the skin and any wounds will take place in the EMR [electronic medical record] 4in the areas provided each time wound or skin care is provided…”. 1. Patient # 1 had a Start of Care [SOC] date of 1/9/23 and an admitting diagnosis of type 1 diabetes mellitus with ketoacidosis [body can’t make enough insulin and acid builds up in the body]. Review of the Plan of Care [POC] for the certification period 1/9/23-3/9/23 included orders for PT [physical therapy] 1 time a week for 5 weeks, 1 time every 2 weeks for 4 weeks. Review of the clinical record revealed supplemental orders [ROC-resumption of care orders] were obtained on 2/2/23 for “SN [skilled nursing] to evaluate for diabetes management” after the patient was admitted to the hospital with a blood glucose level of 1197. Further review of the clinical record revealed RN # 4 did not complete the evaluation visit until 2/9/23. There was no evidence in the clinical record that RN # 4 notified the physician to obtain an order to complete the evaluation visit. RN # 4 was not available for interview. During an interview with the agency director on 2/21/24 at approximately 9:30 am, the director confirmed the evaluation visit was delayed. 2. Patient # 7 had a Start of Care [SOC] date of 12/20/23 and an admitting diagnosis of type 2 diabetes mellitus with foot ulcer, other streptococcal [type of bacteria] arthritis, left shoulder, bacteremia [bacteria in the blood], type 2 diabetes with hyperglycemia [high blood glucose], unspecified systolic [congestive] heart failure and encounter for adjustment and management of VAD [vascular access device- thin flexible tube that provides access to blood vessels without the need for repeated needle sticks]. Review of the Plan of Care [POC] for the certification period 12/20/23-2/17/24 included orders for SN [skilled nursing] 2 times a week for 9 weeks. Review of the hospital discharge orders from _____ [name of hospital] dated 12/18/23 revealed the following orders “Patient with diabetic ulcer on his right, lateral, plantar foot…Patient also has a left shoulder incision. Cover with large gauze and tape to secure it. Ensure incision is clean and dry. Daily dressing changes…” Review of the clinical record revealed RN # 5 completed the SOC admission visit on 12/20/23. The RN identified the wound to the right foot [completed wound assessment at the SOC] and the POC included orders for wound care. The RN did not identify the wound [incision noted on the left shoulder] and the POC did not include any orders. The wound to the shoulder was not identified until 12/24/23 when the PT identified the wound. RN # 5 was not available for interview. During an interview with the agency director on 2/21/24 at approximately 10 am, the director confirmed the RN should have identified the wound.”

“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, direct observation, clinical record review, and interviews with patient/caregivers and staff, the Plan of Care [POC] failed to include all medications the patient was taking for 2 of 4 home visits [# 3 and 14]. The findings included: The policy, Plan of Care [POC] [10/31/23], was provided by the agency director on 2/21/24 at 3 pm. The policy stated, “…The individualized plan of must [sic] include the following…all medications and treatments…” 1. Patient # 3 had a Start of Care [SOC] of 11/27/23 and an admitting diagnosis of chronic obstructive pulmonary disease [COPD-lung condition]. Review of the Plan of Care [POC] for the certification period 11/27/23-1/25/24 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 3 weeks, 1 time every 2 weeks for 2 weeks. A joint visit was made with PT # 9 on 2/19/24 at approximately 2 pm. During the visit, a medication review was conducted using a medication profile provided by the agency. The following discrepancy was noted: The medication profile listed Hydrocodone [pain medication] 7.5 mg – Acetaminophen 325 mg. Take 1 tablet twice a day as needed. The caregiver presented a bottle of Hydrocodone 10 mg – Acetaminophen 325 mg and advised this was the correct strength of the medication. During an interview with the agency director on 2/21/24 at approximately 9:15 am, the director confirmed the POC did not include the correct strength of the medication. 2. Patient # 14 had a Start of Care [SOC] date of 1/4/24 and an admission diagnosis of sever persistent asthma with acute exacerbation. Review of the Plan of Care [POC] for the certification period 1/4/24-3/3/24 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 6 weeks. On 2/20/24 at approximately 1 pm a joint visit was conducted with PT # 8. During the visit, a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The patient provided a bottle of Amlodipine [blood pressure] 5 mg. Take 1 every day with a start date of 1/2/24. The Amlodipine was not included on the medication profile. During an interview with the patient, the patient confirmed she was taking this medication before admission to home health. The patient provided a bottle of Vitamin D 3 [supplement]. Take 50 mcg each day. The medication profile did not list Vitamin D. During the interview the patient confirmed she had been using Vitamin D since before admission to the agency. During an interview with the agency director on 2/21/24 at approximately 9:30 am, the director confirmed the POC did not include all the correct/current medications.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to include orders related to a VAD [vascular access device- thin flexible tube that provides access to blood vessels without the need for repeated needle sticks] on the Plan of Care for 1 of 2 patients with a VAD [# 7]. The findings included: The policy, Plan of Care [10/31/23], was provided by the agency director on 2/21/24 at approximately 3 pm. The policy stated, “...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 disciplines(s), and 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...” Patient # 7 had a Start of Care [SOC] date of 12/20/23 and an admitting diagnosis of type 2 diabetes mellitus with foot ulcer, other streptococcal [type of bacteria] arthritis, left shoulder, bacteremia [bacteria in the blood], type 2 diabetes with hyperglycemia [high blood glucose], unspecified systolic [congestive] heart failure and encounter for adjustment and management of VAD [vascular access device- thin flexible tube that provides access to blood vessels without the need for repeated needle sticks]. Review of the Plan of Care [POC] for the certification period 12/20/23-2/17/24 included orders for SN [skilled nursing] 2 times a week for 9 weeks. Review of the hospital discharge orders from _____ [name of hospital] dated 12/18/23 revealed the following orders “IV catheter care instructions: Inspect and clean site and apply a clear dressing …weekly…Flush with 10 ml normal saline before and after administration of medication. Flush with 5 ml heparin [prevent clotting of line] following last normal saline flush …administer Ceftriaxone [antibiotic] 2 gram every 24 hours. Review of the POC did not include the information related to the PICC line flushes or the antibiotic. RN # 5 was not available for interview. During an interview with the agency director on 2/21/24 at approximately 10 am, the director confirmed the POC did not include orders related to the PICC line.”

“Communication with all physicians CFR(s): 484.60(d)(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 agency policy, clinical record review and staff interviews the agency failed to coordinate care with the physician for 1 of 2 patients with VAD [vascular access device] [#7]; and failed to coordinate care for 1 of 1 patients receiving MSW [social work] services which required an APS [adult protective services] report [#9]. The findings included: The policy, Coordination of Care [5/4/23], was provided by the agency director on 2/21/24 at approximately 3 pm. The policy stated, “...Relevant physicians are notified promptly of any changes in the patient’s condition or needs that suggest that outcomes are not being achieved...” 1. Patient # 7 had a Start of Care [SOC] date of 12/20/23 and an admitting diagnosis of type 2 diabetes mellitus with foot ulcer, other streptococcal [type of bacteria] arthritis, left shoulder, bacteremia [bacteria in the blood], type 2 diabetes with hyperglycemia [high blood glucose], unspecified systolic [congestive] heart failure and encounter for adjustment and management of VAD [vascular access device- thin flexible tube that provides access to blood vessels without the need for repeated needle sticks]. Review of the Plan of Care [POC] for the certification period 12/20/23-2/17/24 included orders for SN [skilled nursing] 2 times a week for 9 weeks [the POC did not include any orders related the VAD]. Review of the clinical record revealed RN # 5 completed the SOC visit on 12/20/23 and documented the following PICC [peripheral inserted central catheter-type of VAD device] line assessment: “Power PICC, RUE [right upper extremity], 17 cm exposed PICC catheter length, 29 cm arm circumference”. LPN # 6 conducted a routine visit on 12/26/23 and documented the following assessment “12 cm exposed catheter length and an arm circumference of 30.5 cm.” There was no evidence the LPN notified the physician of the measurements she had obtained. LPN # 6 was not available for interview. During an interview with the agency director on 2/21/24 at approximately 10 am, the director confirmed the physician should have been notified of the possible migration of the PICC line. 2. Patient # 9 had a Start of Care [SOC] date of 1/9/24 and admitting diagnoses of unspecified open wound to left lower leg, diffuse large B-cell lymphoma [cancer] and malignant pleural effusion [cancer extending into the pleural space]. Review of the Plan of Care [POC] for the certification period 1/9/24-3/8/24 included orders for MSW [social work] 1 time a week for 1 week, 1 time every 3 weeks for 3 weeks and 1 time every 2 weeks for 2 weeks. Review of the clinical record revealed MSW # 7 made a routine visit on 1/15/24 and documented the following information, “MSW met with patient and caregiver, MSW observed marks on the patient from his spouse. MSW discussed concerns and made APS [adult protective services] report to _________ [name of county] …” The MSW conducted a visit on 2/7/24 and documented, “MSW met with patient to complete discharge…MSW followed up with APS to report holes in the wall. Patient reports holes are from his wife throwing a water glass at him. MSW noted DSS [department of social services/APS worker response. Case is under review at this time…” Further review of the clinical record revealed no evidence the MSW notified the physician of the allegations related to abuse. During an interview with the agency director on 2/21/24 at approximately 9:30 am, the director confirmed there was no evidence the physician was notified.”