Every finding on record at Amedisys Illinois, LLC

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 03/21/25. The Agency was in compliance with 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements, on 03/21/25. Standard level deficiencies cited. Abbreviations: Pt./Pts. = Patient/Patients Wk = week SOC = Start of Care POC / PsOC = Plan of Care / Plans of Care lbs = pounds PRN = As needed SN = Skilled Nurse PT = Physical Therapy OT = Occupational Therapy RN = Registered Nurse LPN = Licensed Practical Nurse LVN = Licensed Vocational Nurse

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on the clinical records reviewed and staff interviews, it was determined that in 3 of 17 (Pts. #7, 10 and 9) clinical records reviewed, the Agency failed to ensure that the staff provided service as ordered in the POC. 3. Pt. #9 was admitted to Home Health Services on 02/16/25 with diagnosis of Cellulitis of Right Lower Limb and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The clinical record was reviewed on 03/19/25. The clinical record contained a POC for certification period 02/16/25 to 04/16/25 that required to report to physician blood glucose readings greater than 200 or less than 70. The SN visit notes for week 1 to week 4 lacked blood sugar assessments. 4. The findings of the Agency Staff not provided services as ordered in the PsOC were confirmed during interviews with the Administrator and Clinical Manager on 03/19/25 between 11:00 AM and 1:30 PM and on 03/20/25 between 9:50 AM and 10:45 AM. 2. Pt. #10 was admitted to the Home Health Services on 02/20/25 with the diagnoses of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The clinical record was reviewed on 03/18/25. The clinical record contained a POC dated 02/20/25, that required the PT to assess the patient 2 times a week for 2 weeks and 1 time a week for 3 weeks. The PT failed to visit the week of 03/12/25 (week #4). Findings include: 1. Pt. #7 was admitted to Home Health Services on 02/15/25 with the diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 03/18/25. The clinical record contained a POC for the certification period of 02/15/25 to 04/15/25, that required: “….Heart Failure….Record Patient reported weight, or weigh Patient as needed. Report increased edema or weight gain of > 2 lbs in 1 day or > 5 lbs in 1 week….” The following SN notes dated 02/19/25, documented weight of 192 lbs. and SN note dated 02/28/25, documented a weight of 198 lbs. (6 lbs weight gain). There was no documentation that the weight gain was reported as ordered in the POC. The same POC, required: “….Skin integrity….RN to assess and teach….LPN/LVN to observe and teach integumentary status….” The following SN notes dated 02/19/25, 02/28/25 and 03/14/25, lack a complete assessment of integumentary status (including wound status/measurements) as ordered in the POC.

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 the clinical records reviewed, home visit observations and staff interview, it was determined in 4 of 17 (Pts. #5, 6, 10 and 11) clinical records reviewed, the patient plan of care was not complete. 4. Pt. #11 was admitted to Home Health Services on 01/23/25 with diagnoses of Encephalopathy, Unspecified, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The clinical record was reviewed on 03/19/25, the record contained a POC for certification period 01/23/25 to 03/23/25 that lacked patient specific blood sugar parameters to be assessed. 5. The findings of the PsOC lacking patient specific interventions were confirmed during interviews with the Administrator and Clinical Manager on 03/19/25 between 11:00 AM and 1:30 PM and on 03/20/25 at 10:45 AM and 11:30 AM. Findings include: 1. Pt. #5 was admitted to the Home Health Services on 03/12/25 with the diagnosis of Chronic Diastolic (Congested) Heart Failure. The clinical record was reviewed on 03/18/25. The clinical record contained a POC dated 03/13/25, that required the SN to assess the patient 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 1 week and 2 PRN visits. A home visit was conducted 03/18/25 at 11:30 AM, with the LPN. The LPN was observed removing and appling a compression stocking to the right lower leg. The POC lacked the orders/care for the compression stocking. 2. Pt. #6 was admitted to the Home Health Services on 03/12/25 with the diagnoses of COVID-19, Metabolic Encephalopathy and Personal History of Urinary Tract Infections. The clinical record was reviewed on 03/18/25. The clinical record contained a POC dated 03/12/25, that required the SN to assess the patient 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 1 week and 2 PRN visits. A home visit was conducted on 03/18/25 at 12:30 PM, with the RN. During the home visit the patient reported having a buttock sore. Desitin ointment was observed in the home for the patient's use. The POC lacked the diagnosis for the use of Desitin ointment. 3. Pt. #10 was admitted to the Home Health Services on 02/20/25 with the diagnosis of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The clinical record was reviewed on 03/18/25. The clinical record contained a POC dated 02/20/25, that required the SN to assess the patient 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 3 weeks and 2 PRN visits. The LPN visit note dated 03/12/25, included the "rash, was diagnosed as Shingles by the physician". The POC lacked the Shingles-diagnosis and care instructions for the patient.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on review of clinical records and staff interviews, it was determined that in 10 of 17 (Pts. #1, 2, 17, 9, 11, 12, 7, 8, 14, and 16) clinical records reviewed, the Agency failed to assess the need for Pneumonia and/or Influenza vaccines of Pts. Pt. #7. SOC 02/15/25 lacked a complete Pneumonia / Flu vaccine assessment. Pt. #8. SOC 03/04/25 lacked a complete Pneumonia / Flu vaccine assessment. Pt. #14. SOC 04/20/24 lacked a complete Pneumonia / Flu vaccine assessment. Pt. #16. SOC 09/19/24 lacked a complete Pneumonia / Flu vaccine assessment. Pt. #9. SOC 02/16/25 lacked Pneumonia / Flu vaccine assessment. Pt. #11 SOC 01/23/25 lacked a complete Pneumonia / Flu vaccine assessment. Pt.#12 SOC 02/06/25 lacked a complete Pneumonia / Flu vaccine assessment. Findings include: 1. The following clinical records were reviewed on 03/18/25 and 03/19/25: Pt. #1. SOC 03/04/25. Lacked inquiry for Pneumonia and Influenza vaccines. Pt. #2. SOC 03/03/25. Lacked inquiry for Pneumonia vaccine. Pt. #17. SOC 10/08/24. Lacked inquiry for Pneumonia vaccine. 2. During interview with the Administrator and the Clinical Manager, on 03/19/25 at 11:45 AM and 03/20/25 at 11:30 AM, the above findings were confirmed.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on the clinical records reviewed and staff interview, it was determined in 4 of 5 (Pts. #14, 15, 16 and 17) discharged records reviewed, the completed discharge summary was not sent to the physician. 4. Pt. #17 was admitted to Home Care Services on 10/08/24 with diagnosis of Encounter for other Orthopedic Aftercare. The clinical record was reviewed on 03/19/25. The discharge date was 11/26/24 and discharge summary/episode summary report was sent to the physician on 12/16/24. 5. During interview with the Administrator and the Clinical Manager, on 03/19/25 at 11:45 AM and 03/20/25 at 9:50 AM, the above findings were confirmed. Findings include: 1. Pt. #14 was admitted to Home Health Services on 04/20/24 with the Diagnosis of Hypertensive Chronic Kidney Disease with Stage 1-4 Unspecified Chronic Kidney. The clinical record was reviewed on 03/19/25. The clinical record indicated that Pt. #14 was discharged from the Agency on 06/04/24. The discharge summary/episode summary report was sent to the Physician on 07/05/24 (more than the required 5-day timeframe). 2. Pt. #15 was admitted to Home Health Services on 03/13/24 with the Diagnosis of Anoxic Brain Damage, Not Elsewhere Classified. The clinical record was reviewed on 03/13/24. The clinical record indicated that Pt. #15 was discharged from the Agency on 04/04/24. The discharge summary/episode summary report was sent to the Physician on 04/10/24 (more than the 5-day timeframe). 3. Pt. #16 was admitted to Home Health Services on 09/19/24 with the Diagnosis of Displaced Intertrochanteric Fracture of Left Femur. The clinical record was reviewed on 03/19/25. The clinical record indicated that Pt. #16 was discharged from the Agency on 01/03/25. The discharge summary/episode summary report was sent to the Physician on 01/17/25 (more than the 5-day timeframe).