Amedisys Home Health

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the clinical record failed to include all prescribed medications in the plan of care for 2 of 5 patients with record reviews conducted (patients #1 & 5). Findings included: A policy, Drug Regime Review (Home Health Only) (reviewed 1/16/26), received on 5/26/26 at 4:38 PM from the Vice President of Operations stated, “Conducting a drug regime review requires the Assessing RN [registered nurse] complete the following steps: … Recording a complete and accurate list of all medications…” 1. Patient #1 was admitted 4/2/26 with diagnoses of STEMI (heart attack), long term (current) use of anticoagulants (blood thinning medication), and long term (current) use of antithrombotic/antiplatelet (blood thinning medication). The plan of care (POC) for 4/2/26-5/31/26 included orders for skilled nurse visits 1 time a week for 4 weeks with 2 PRN (as needed). Review of the clinical record revealed that at the start of care registered nurse (RN) #4 discontinued the orders for Eliquis (anticoagulant, blood thinning medication) 2.5mg 1 tablet 2 times daily and Plavix (antiplatelet, blood thinning medication) 75mg 1 tablet daily due to the medications not being available in the home and contacted the physician. Further review revealed that on 4/8/26 RN #4 documented, “Cardiologist wanted patient to restart dual antiplatelet therapy at home.” Further review revealed that the dual antiplatelet medications were not included in the POC. An interview conducted on 5/26/26 at 3:42 PM with the clinical manager revealed that during a start of care, the medication orders should be documented clearly and precisely including the drug names, route of administration, frequency of administration, and dose.” An interview conducted on 5/26/26 at 4:46 PM with RN #4 revealed that they normally would add the medications to the POC. 2. Patient #5 was admitted on 9/12/25 with a diagnosis of multiple sclerosis (chronic disease of the central nervous system). The plan of care (POC) for 9/5/25-11/10/25 included orders for physical therapy visits 1 time a week for 9 weeks and occupation therapy visits 1 time a week for 5 weeks and 1 every other week for 2 weeks. Review of the clinical record revealed that a history and physical dated 9/19/25 provided by the primary care physician included the following medication orders: Doxycycline Monohydrate (antibiotic) 100mg 0.5 tablet by mouth every day in the morning and aspirin (blood thinning medication) 81mg 1 capsule(s) PO [by mouth] daily. Further review revealed that there were no medications included in the POC. During an interview conducted on 5/27/26 at 10:48 AM the clinical manager stated, “There should be a medication reconciliation at each visit, they [medications] should be added to the plan of care.””

“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, observations, clinical record review, and staff interviews, the Plan of Care failed to include all/current medications for 2 of 5 patients who received a home visit. (#11 and #16) The findings included: A policy, Drug Regimen Review, (revised 12/1/2023), received from the agency director on 6/17/2025 at 3:40 pm stated, “… the comprehensive list of medications are updated any time there is a medication change including dose change, new medications, and any medications discontinued. The clinician completing the OASIS (Outcome and Assessment Information Set-a group of standard data elements used to compare home health patient outcomes) assessment must complete a comprehensive drug regimen review of all medications the patient is currently taking at the time of admission, recertification, resumption of care, and with any major changes in condition.” 1.Patient #11 was admitted on 6/12/2025 with a diagnosis of peritoneal abscess (a localized collection of pus within the abdominal cavity). The plan of care for 6/12/2025- 8/10/2025 included orders for SN (skilled nurse) 1 time a week for 4 weeks, 1 time every other week for 4 weeks, 1 time a week for 1 week. During a home visit, conducted on 6/17/2025 at approximately 9:15 am with RN (registered nurse) #13, a medication review was conducted and the following discrepancies were noted: Not included in the Plan Of Care: Nexium (used to reduce the amount of acid in the stomach) 20 mg daily. The patient states they have taken it for years; Pregabalin (used to treat nerve and muscle pain) 15 mg 2 times a day. The patient stated that they have been taking it since last summer; Genfibrozil (used to treat cholesterol) 600 mg daily. The patient stated that they have taken it for years; Metronidazole (used to treat chronic facial rash) 0.75% cream 2 times a day to face. The patient stated that they have used it for years; Estrace (used to treat vaginal dryness) 0.01% 1 gram on Wednesday and Sundays. The patient stated that they have used it for 2 years; Magnesium (mineral supplement) 400 mg daily. The patient stated that they have taken it for years; Centrum Silver (multivitamin) daily. The patient stated they have taken it for years; Zinc (mineral supplement) 50 mg every other day. The patient stated they have taken it for 4 months; Tylenol (used to treat minor pain and fever) 325 mg 2 tabs every 4 hours as needed for pain. The patient stated that they have taken it for years. Cyclobenzaprine (used to treat muscle spasms) 5 mg was listed as 1 tablet 2 times a day on the Plan of Care. The patient stated they have been taking 1 tablet 3 times a day. Amoxicillin 875 mg/Potassium Clavulanate 125 mg (combination antibiotic) 1 tablet daily was listed on the Plan of Care as “discontinued effective 6/14/2025”. The patient stated that this medication was extended for another 21 days. During a phone interview on 6/19/2025 at 11:53 am, RN #13 stated “I typically compare discharge instructions and patient’s (pill) bottles in the home. I’m not sure how I missed those” and confirmed that the medications on the plan of care were incorrect. During an interview conducted on 6/19/2025 at 11:54 am, The director stated, “Do a complete med rec [medication reconciliation] between discharge instructions and med bottles” and confirmed that the medications on the plan of care were incorrect. 2.Patient #16 was admitted on 4/7/2025 with a diagnosis of non-displaced fracture of olecranon process (elbow fracture). The plan of care for 6/6/2025- 8/4/2025 included orders for PT (physical therapy) 1 time a week for 4 weeks, 1 time every other week for 4 weeks. During a home visit on 6/17/2025 at approximately 3:50 pm with PTA (physical therapy assistant) #6, a medication review was conducted, and the following discrepancies were noted: Not listed on the Plan of Care: Vitamin B12 (used to support energy production and nerve and blood cell health) 1000 mcg daily and Vitamin B complex (a group of B vitamins used to support energy production, brain function, and cell health) 1 tablet daily. The patient stated that they have taken both of these medications since January, 2025. Aranesp (used to treat low red blood cell count) 150mcg injection every 6 weeks, Heparin (used to help prevent blood clots) 5,000 units injection every 8 hours, and Thiamin (Vitamin B1 used for healthy blood cell development) 100 mg daily. The patient stated that these were all discontinued in April, 2025. During an interview on 6/19/2025 at 11:05 am, PTA #6 stated, “I do it [medication review] every visit” and confirmed that the medications on the Plan of Care were incorrect.”

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient 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 an infection requiring the use of contact precautions (increased personal protective equipment, PPE) for 1 of 1 patient with a diagnosis of Methicillin-resistant Staphylococcus aureus (antibiotic resistant infection) in the plan of care. Patient #8 Findings included: A policy, Plan of Care (POC)/Care (reviewed 01/31/2025) received on 06/17/2025 at 3:40 PM from the agency director stated, “The individualized plan of care must include the following: … All pertinent diagnoses.” Patient #8 was admitted on 05/19/2025 with a diagnosis of unspecified wound. The plan of care (POC) for 05/18/2025-07/16/2025 included orders for skilled nurse (SN) visits 2 times a week for 4 weeks and 1 time a week for 5 weeks, “RN/LPN/LVN [registered nurse, licensed practical nurse, or licensed vocational nurse] to perform/teach patient/caregiver wound care to right elbow abrasion: cleanse with wound cleanser and gauze. Pat dry with gauzeapply [sic] calcium alginate AG/equivalent [silver antimicrobial dressing], apply skin barrier to periwoundcover [sic] with roll gauze, secure with tape. Change dressing twice a week and PRN [as needed] for soilage or dressing replacement.”, and “Diagnostic culture/LPN/LPN to collect wound specimen for culture via swab week of 05.18.25.” Review of the clinical record revealed that the culture was collected on 05/23/2025 by LPN #13 and the results reported on 05/28/2025 stated, “Heavy growth of Methicillin resistant Staphylococcus aures (MRSA).” Further review revealed that there was no update to the POC to include MRSA or the need for increased PPE. An interview conducted on 06/18/2025 at 11:18 AM with LPN #13 revealed that they are new to home health and unaware of agency protocols for updates to the POC, orders for increased PPE use, and documentation related to PPE use. An interview conducted on 06/18/2025 at 11:20 AM with the agency director revealed that there was no expectation of updating the POC to include MRSA or orders for increased precautions.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (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 notify the physician of the patient and caregiver’s non-compliance with blood sugar monitoring, wound care, and medications as ordered in the Plan of Care for 1 out of 7 patients with diabetes. (#1) The findings included: A policy, Coordination of Care (revised 5/22/2024), received from the agency director on 6/18/2025 at 12:47 pm stated “Agency staff involved in the patient’s plan of care (clinicians, clinical managers) provide patient related updates in a timely manner to the physician/allowed practitioner…” Patient #1 was admitted on 6/13/2024 with a diagnosis of infection and inflammatory reaction due to indwelling urethral catheter subsequent encounter (infection and inflammation caused by a urinary catheter on more than one episode of care, type 2 Diabetes (condition in which the body has trouble controlling blood sugar) with hyperglycemia (high blood sugar), abscess of corpus cavernosum and penis (a rare and potentially serious infection of the erectile tissue of the penis). The plan of care for 8/12/2024-10/10/2024 included orders for SN (skilled nursing) 1 time a week for 5 weeks, 1 time every other week for 4 weeks. Review of the clinical record revealed that on the 8/14/2024, 8/28/2024, 9/5/2024, 9/11/2024, and 9/26/2024 SN visits, the nurse documented the patient’s ongoing non-compliance with checking blood sugar levels, taking insulin, and performing wound care on non-skilled nurse visit days. Further review revealed that there was no documentation that the physician had been notified. During an interview with the clinical manager on 6/17/2025 at approximately 8:28 am, the clinical manager revealed that there was no documentation in the clinical record of physician being notified and stated “It [physician notification] should be documented within the visit.””