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 review, medical record review, and interviews, the agency failed to update the medication profile with new medications for 1 Patient (#7) of 17 patients medications reviewed. The findings include: Review of the agency policy titled, “Monitoring Medications,” revised 7/1/2024 revealed “...a drug regimen review will be performed on all patients...the skilled nurse is responsible for medication review and reconciliation throughout the episode...Compare medication list...to actual medications patient is taking...Review all medications including over the counter (OTC) medications, vitamins...creams and topical ointments...” Review of the agency policy titled, “Drug Regimen Review,” revised 1/15/2026 revealed “...Update the medication profile in the clinical records...when change was verified by reviewing a written prescription or prescription bottle... Medical record review revealed Patient #7 was admitted to the agency on 6/22/2026 with diagnoses including Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, and Hypertension. Review of the Physician Medication List for Patient #7 dated 7/9/2026 revealed Vitamin B-12 1,000 mcg (microgram) oral route (vitamin supplement), metoprolol tartrate 25 mg (milligram) oral route (medication used for blood pressure), sertraline 25 mg oral route (medication used for mood), and Thermotabs 287 mg-180 mg-15 mg oral route (vitamin supplement). Review of the agency Client Medication Report for Patient #7 dated 6/22/2026 revealed Vitamin B-12 1,000 mcg, metoprolol tartrate 25 mg sertraline 25 mg and Thermotabs 287 mg-180 mg-15 mg had not been added to the list of current medications. During an observation and interview on 7/14/2026 at 2:15 PM, Speech Therapist (A) medication reconciliation in the home revealed Patient #7’s Vitamin B-12 1,000 mcg, metoprolol tartrate 25 mg sertraline 25 mg and Thermotabs 287 mg-180 mg-15 mg had been added by the patient’s Primary Care Physician on 7/9/2026. Speech Therapist A confirmed the medications in the home did not match Patient #7’s current medications. During an interview on 5/14/2026 at 3:30 PM, the Director of Operations stated the medication reconciliation are to be completed on each skilled nurse visit and confirmed the medication reconciliation had not been updated to reflect Patient #7’s current medication orders.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on agency policy review, medical record review, and interviews, the agency failed to physician order for visit frequency and laboratory test for 1 Patient (#6) of 17 patients reviewed. The findings include: Review of the agency policy titled, “Plan of Care,” revealed 2/9/2026 revealed “...A 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...initiated by a physician...The frequency of visits...orders for home health...frequency and duration...” Review of the agency policy titled, “Physician Orders and Medical Supervision of the Plan of Care,” revised 1/15/26 revealed “...Verbal orders are put in writing, signed, dated, and timed with the date/time of receipt by the registered nurse or qualified therapist responsible for furnishing or supervising the ordered services...must be recorded/integrated in the plan of care to assure coordination of all services and interventions provided...” Medical record review revealed Patient #6 was admitted to the agency on 3/30/2026 with diagnoses including Chronic Kidney Disease, Anemia, and Anxiety Disorder. Review of the Plan of Care for Patient #6 dated 5/29/2026 to 7/27/2026 revealed a physician’s order for SN (Skilled Nurse) weekly for 1 week dated 6/14/2026. Review of the HHA (Home Health Agency) Survey Investigation Worksheet: Calendar and Coordination Notes for Patient #6 showed the SN had not completed a visit as ordered for the week of 6/14/2026-6/20/2026. Review of a Physician Order for Patient #6 dated 6/19/2026 revealed “...Skilled Nurse to draw BMP [Basic Metabolic Panel] lab [laboratory] scheduled for 6/20/26 [6/20/2026]...” Continued review revealed a laboratory test had not been obtained on 6/20/2026. During an interview on 7/13/2026 at 11:44 AM, the Director of Operations confirmed a skilled nurse had not made a scheduled visit for 6/14/2026-6/20/2026 and had not obtained an ordered lab scheduled for 6/20/2026.”