Amedisys Home Health of Pa

“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 review of Clinical Records (CR), home visit observations (HV), and interview with agency staff, the agency failed to ensure the Plan of Care (POC) included all medications the patient is currently using for seven (7) of seventeen (17) CR reviewed (CR# 6, 8, 12-13, 15, &17), supplies and equipment required for five (5) of seventeen (17) CR reviewed (CR# 6, 11, 12, 14, & 15), and patient-specific interventions for three (3) of seventeen (17) CR reviewed (CR# 9, 12, & 17). Findings included: Review of CR#6 on 2/4/26 at approximately 12:00pm revealed start of care (SOC) date 1/2/26, dates reviewed 1/2/26-2/4/26. Plan of Care (POC) included diagnosis of Type II Diabetes Mellitus with other skin ulcer and interventions for diabetic teaching and monitoring. Medication list included Novolog Flexpen U-100 insulin Aspart 100 unit/ml (3ml) subcutaneous 3 times a day per sliding scale (methos of managing blood sugar where the dose of fast acting insulin is determined by current blood glucose level). POC and medication list failed to include the sliding scale. POC failed to include diabetic supplies. Review of CR#8 on 2/4/26 at approximately 1:00pm revealed SOC date 10/21/25, dates reviewed 12/20/25-2/4/26. POC and med list included Ipratropium 0.5mg Albuterol 3mg (2.5mg base)/3ml Nebulization solution inhalation every 4 hours pro re nata (PRN) as needed). POC and medication list failed to include indications/symptoms for as needed use. Review of CR#9 on 2/4/26 at approximately 1:30pm revealed SOC date 1/12/26, dates reviewed 1/12/26-2/4/26. POC included orders to draw labs every Monday. Labs ceased being drawn when PICC line (peripherally inserted central catheter-flexible tube inserted into an upper arm vein and threaded to a large vein near the heart for long term IV therapy) was removed. No order from doctor to discontinue lab draws. Review of CR#11 2/4/26 at approximately 2:30pm revealed SOC date 12/26/25, dates reviewed 12/26/25-2/4/26. POC included liquid oxygen base unit, liquid oxygen portable unit, and oxygen concentrator on equipment/supply list. POC and medication list failed to include oxygen. POC and medication list included ipratropium 0.5mg-albuterol 3mg (2.5mg base)/3ml nebulization solution inhalation 2 times a day PRN. POC and medication list failed to include indications/symptoms for as needed use. POC failed to include nebulizer on equipment list. Review of CR#12 on 2/9/26 at approximately 10:00am revealed SOC date 1/2/26, dates reviewed 1/2/26-2/9/26. HV conducted 2/5/26 at approximately 9:00am revealed patient has a bedside commode in the home and a bi-pap (bilevel positive airway pressure) machine (a non-invasive ventilator that helps people breathe by delivering pressurized air through a mask, with higher pressure during inhalation and lower pressure during exhalation). POC equipment list failed to include bedside commode. POC failed to include order for bi-pap use and settings to be programmed. POC and medication list included Narcan 4 mg/actuation nasal spray as directed. POC and medication list fail to include directions for use. Review of CR#13 on 2/9/26 at approximately 10:30am revealed SOC date 1/29/26, dates reviewed 1/29/26-2/9/26. HV conducted 2/5/26 at approximately 10:30am revealed through interview with patient wife that patient receives chemotherapy. POC and medication list failed to include chemotherapy. Review of CR#14 on 2/9/26 at approximately 11:00am revealed SOC date 1/6/26, dates reviewed 1/6/26-2/9/26. HV conducted 2/6/26 at approximately 9:30am revealed patient has a home INR (international normalized ratio-standardized laboratory measurement used to determine how quickly blood clots) machine. POC includes order to obtain INR via fingerstick machine. POC equipment list failed to include home INR monitoring machine. Review of CR#15 on 2/9/26 at approximately 11:30am revealed SOC date 1/23/26, dates reviewed 1/23/26-2/9/26. HV conducted 2/6/26 at approximately 10:45am revealed patient uses home blood glucose monitoring by continuous monitoring device and also blood glucose machine via fingerstick and meter. POC included order for blood glucose testing before meals and at bedtime. POC and medication list included insulin lispro (u-100) 100 unit/ml subcutaneous pen 3 times a day per sliding scale. POC and medication list failed to include the sliding scale. POC failed to include diabetic supplies. POC and medication list failed to include the sliding scale. POC failed to include diabetic supplies. Review of CR#17 on 2/9/26 at approximately 12:30pm revealed SOC date 12/18/25, dates reviewed 12/18/25-2/9/26. POC included diagnosis of type II diabetes mellitus with diabetic polyneuropathy and intervention for “...blood glucose testing as ordered and report abnormal findings to physician...” POC failed to include clear orders for frequency of blood glucose testing and normal parameters for results. POC and medication list included Novolog flexpen u-100 insulin aspart 100 unit/ml (3ml) subcutaneous 3 times per day per sliding scale. POC and medication list failed to include the sliding scale. Interview with agency Administrator and 2 branch Directors of Operations on February 9, 2026, at approximately 3:00pm confirmed findings.”