Amedisys Home Care

“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 review, medical record review, Assisted Living Facility (ACLF) record review, and interview the agency failed to reconcile the medication profile for 3 patients (#2, #3 and #4) of 7 patients reviewed with home visits. The findings include: Review of the agency’s policy titled, “Monitoring Medications,” revised 11/21/2017, revealed “...To provide a process to ensure continuous monitoring of medications in patient’s home...A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments...all nurses will participate in medication review and reconciliation...” Medical record review revealed Patient #2 was admitted to the agency on 4/24/2025 with diagnoses including Osteoporosis, Multiple Rib fractures, and Wedge Compression Fracture T5-T-6. Review of Patient #2’s ACLF Order Summary Report dated 5/14/2025, revealed “...Acetaminophen Tab 325mg (medication for pain or fever) 2 tabs as needed every 6 hours...Docusate Sodium Cap 100mg (medication for constipation) 1 cap every 4-6 hours as needed...Lidocaine 4% topical patch (medication for pain) 1 patch to be applied topically to lower back once daily as needed for pain...” Review of Patient #2’s agency Physician Orders revealed no documentation for the ordered medications. Medical record review revealed Patient #3 was admitted to the agency on 3/10/2025 with diagnoses including Hypertensive Chronic Kidney Disease Stage 3, Weakness, and Age Related Osteoporosis. Review of Patient #3’s ACLF Order Summary Report dated 5/14/2025, revealed “...Acetaminophen Tab 325mg 2 tabs as needed every 6 hours...Docusate Sodium Cap 100mg 1 cap every 4-6 hours as needed...Geri-Lanta (medication for heartburn or indigestion) 30ml every 6 hours as needed...” Review of Patient #3’s agency Physician Orders revealed no documentation for the ordered medications. Medical record review revealed Patient #4 was admitted to the agency on 4/30/2025 with diagnoses including Displaced Fracture of the Base of Neck of Left Femur, Essential Hypertension, and Unspecified Severe Protein-Calorie Malnutrition. Review of Patient #4’s ACLF Order Summary Report dated 5/14/2025, revealed “...Acetaminophen Tab 325mg 2 tabs as needed every 6 hours... Docusate Sodium Cap 100mg 1 cap every 4-6 hours as needed... Hydrocortisone Cream 1% (topical medication for itching) to be applied as needed for itching. Review of Patient #4’s agency Physician Orders revealed no documentation for the ordered medications. During an interview on 5/14/2025 at 1;15PM, the Director of Operations confirmed Patients #2, #3, and #4’s medication profile had not been reconciled with the ACLF medication profile.”

“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 medical record review and interview, the agency failed to follow physician’s orders for 1 patient (#13) of 17 patients reviewed. The findings include: Review of the agency’s policy titled, “Physician Orders and Medical Supervision of the Plan of Care,” revised 11/4/2024, revealed “...Each patient receives the home health services that are written in an individualized plan of care...” Review of the agency’s policy titled, “Management of Diabetic,” revised 3/5/2024, revealed “...Perform blood glucose monitoring according to Physician orders...instruct the patient/caregiver to: follow ordered diet, medication, and activity plans...” Medical record review revealed Patient #13 was admitted to the agency on 1/24/2025 with diagnoses including Type 2 Diabetes Mellitus, Chronic Kidney Disease, and Congestive Heart Failure. Medical record review of the Home Health Certification and Plan of Care dated 1/24/2025-3/24/2025 revealed the physician had ordered the skilled nurse to provide instructions and reinforcement for diabetic care to include monitor blood sugar logs for blood sugar readings that are being checked by the patient daily. Blood sugar parameters are 60-350 and should be reported to the physician when out of range. Nurse to perform finger stick blood glucose as needed. Medical record review of skilled nurse’s notes dated 1/24/2025, 1/27/2025, 1/31/2025 revealed the skilled nurse had not assessed, provided instruction/reinforcement to Patient #13 regarding blood glucose monitoring. During an interview on 5/15/2025 at 1:15 PM, the Director of Operations confirmed the skilled nurse had not monitored Patient #13’s blood glucose 1/24/2025, 1/27/2025, 1/31/2025 as ordered by the physician. Further interview confirmed the agency failed to follow physician orders.”