Every finding on record at Amedisys Northwest, L. L. C.

An Abbreviated/Partial Extended Survey investigating complaint #114691 was conducted at Amedisys Home Health of Griffin on April 8, 2025, and concluded on April 9, 2025. At the time of the survey, the agency was not in compliance with Chapter 42 CFR Part 418, Rules and Requirements for Home Health and Hospice Agencies. Based on record reviews and staff interviews, the agency was not in compliance with complaint #114691. The census was 239. The following deficiency was cited:

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's 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). This ELEMENT is not met as evidenced by: Based on record reviews, staff interviews and review of policy titled "Initial referral/Admission Process," it was determined that agency failed to communicate plans with the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the agency, and failed to discuss discharge plans with one patient (P) (P#4) of three patients who were made non admit for the agency. Findings include: Review of the policy titled "Initial Referral /Admission Process," revised date 8/22/24, revealed the following: 11. If the patient is deemed in eligible for admission, the evaluation clinical will immediately contact the agency office and discuss the reasons for non-admission with the DOO/Clinical Manager or designee. If in agreement with the evaluating discipline's assessment, the DOO/Clinical Manager or designee will notify the physician /referral source of the reason for the patient's non acceptances and assist with any other arrangements as needed. 12. If the agency cannot provide services as ordered, the physician /allowed practitioner /referral source will be notified, and the patient will be referred to another agency of his/her choice with appropriate referral information forwarded to the receiving agency, Review of “Client Coordination Notes Report,” dated 10/16/24 for P#4, the nurse documents the following: Patient not admitted to home care after discussion with CM (Clinical Manager) due to unsanitary living conditions putting staff at risk. Review of clinical record failed to indicate that the physician was notified of the non-admit status and clinical record lack documentation that the patient /caregiver was notified of the non-admit status. Additional review of the clinical record failed to indicate coordination with other health care providers / health care personnel in providing care for P#4 after making the patient non-admit. On 4/8/25 at 2:00 p.m., an office interview was conducted with the Executive Director (ED) and the Clinical Manager (CM) who revealed that the clinical records lack documentation that the physician and patient was notified of the non-admit status. The ED and CM revealed that the agency did not follow the policy titled " Initial Referral /Admission Process.”

Amedisys Home Health, Griffin, Georgia, was in compliance with 42 CFR Part 418.113, Emergency Preparedness and Covid-19 infection control for Hospice as a result of an onsite survey conducted on 6/17/22.

A Recertification survey was conducted at Amedisys Home Health, Griffin, Georgia, on 6/17/22, by Surveyor. It was revealed that the agency is in compliance with Chapter 42 CFR Part 418, Rules and Requirements for Home Health and Hospice Agencies. The census was 249. The deficiencies were cited.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, it was determined that the agency staff failed to conduct an initial assessment within 48 hours of referral or on physician’s order for start of care date, for 4 (four) of 19 (nineteen) sampled patients (P#3, #13, #14 and #15). The Findings include: 1. Review of the plan of care for Patient (P#3) with a diagnosis of heart failure, hypertensive heart disease, atrial fibrillation, type 2 diabetes, revealed that the agency staff received home health referral for services on 5/5/22. However, services did not begin for the patient until 5/16/22. The clinical record lacked justification for the delay of the start of care and documentation: the physician was neither notified nor was authorization obtained concerning the start of care later than 48 hours from the referral. 2. Review of the plan of care for Patient (P#13) with a diagnosis of hypertension, chronic pain, anxiety, chronic obstructive pulmonary disease, depression, cirrhosis of liver and hyperlipidemia, revealed that the agency staff received home health referral for services on 4/22/22. However, services did not begin for the patient until 4/25/22. The clinical record lacked justification for the delay of the start of care and documentation: the physician was neither notified nor was authorization obtained concerning the start of care later than 48 hours from the referral. 3. Review of the plan of care for Patient (P#14) with a diagnosis of chronic ulcer to the right heel, chronic venous hypertension, and type 2 diabetes, revealed that the agency staff received home health referral for services on 1/25/22. However, services did not begin for the patient until 1/28/22. The clinical record lacked justification for the delay of the start of care and documentation: the physician was neither notified nor was authorization obtained concerning the start of care later than 48 hours from the referral. 4. Review of the plan of care for Patient (P#15) with a diagnosis of chronic kidney disease, and type 2 diabetes, revealed that the agency staff received home health referral for services on 2/8/22. However, services did not begin for the patient until 2/24/22. The clinical record lacked justification for the delay of the start of care and documentation: the physician was neither notified nor was authorization obtained concerning the start of care later than 48 hours from the referral. During an interview on 6/16/22 at 2:50 p.m., Registered Nurse (RN) BB, did not provide any additional information regarding the lack of documentation or if the physician was notified of the delay on start of care. In an interview on 6/16/22 at 11:45 a.m., the Administrator also confirmed that the surveyor has been provided with all available documentation for the patients’ record.

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 observation, clinical record review, and staff interviews, it was determined that the agency failed to ensure that patient medication profiles was updated to reflect current medications at the time of the comprehensive assessment for four (4) of nineteen (19) sampled patients. (P#1, P#3, P#5 and P#6). The Findings include: During a home visit observation conducted on 6/15/22 at approximately 10:20 a.m., with Registered Nurse (RN) AA, for (P#1), it was revealed that (P#1) was admitted on 4/13/22, with a diagnosis of congestive heart failure. The surveyor compared P#1's current medication list at home to the home health agency's medication profile. Discrepancies were found. The home health agency medication profile and plan of care revealed Milrinone 40 milligrams (MG)/200 milliliters (ML), in 5percent dextrose intravenous administer 5.4ml/hour continuously for heart failure. But the pharmacy label on intravenous bag revealed Milrinone 144 mg/D5W 288ml piggy bag administer 4ml/hour continuously for heart failure. Pharmacy label revealed Furosemide 40mg give one tablet oral daily for fluid overload. But the home health agency medication profile and care plan revealed 40mg give half tablet oral daily. The pharmacy label revealed potassium chloride extended release 10 milliequivalents (MEQ) give two tablets oral daily for electrolyte balance. But the home health agency medication profile and plan of care revealed 20MEQ give two tablets oral daily. Biotin 10,000micrograms (MCG), give one capsule oral daily for vitamin B supplement: this medication was not listed in home health agency medication profile and plan of care. On 6/16/22 at 1:40 p.m., an interview was conducted with Registered Nurse (RN) AA, who confirmed that she did not check the medications containers, IV bag, and did not update the medication profile and plan of care. A home visit was conducted at 12:38 p.m. on 6/15/22, at the residence of Patient (P#6) with Physical Therapist (PT)#FF. P# 6 was admitted to the home health agency on 5/24/22, with the diagnosis of Myopathy, unspecified. The clinical record was reviewed for certification period 5/24/22 to 7/22/22. During the home visit, the surveyor compared P#6 current medication list in the agency’s Electronic medical record (EMR) to the medications present in P#6 home. P#6 had the following medication listed in the home but not in the EMR: Pyridostigmine Bromide 60 mg x1 tab daily, 3/18/22 used to increase muscle strengthMeclizine 25 mg tab x1 tab daily, 12-29-15, a medication used to treat dizzinessNature Bounty Magnesium 500 mg x1 tab daily, a dietary supplementNaturalist Multi Source Potassium 99.0 mg x1 tab daily, a dietary supplement The following medication was listed incorrectly in the EMR: Gabapentin 30 mg, a medication used to treat neuropathic pain was listed in the EMR as taken x1 tab x3 times daily, but the home medication instructed P# to take 2 capsules x3 times daily.Oxygen 2 Liter continuous, a medication used to keep the blood adequately saturated, was discontinued based on P# caregiver interview but still listed in the agency’s EMR. While reviewing medications in the home with PT#FF, PT# FF verbalized understanding of the requirement to reconcile all medications in the home with medications listed in the agency EMR during every comprehensive visit. A home visit was conducted at 1:35 p.m. on 6/15/22, at the residence of Patient #3 with Physical Therapist (PT)#FF. P#3 was admitted to the home health agency on 5/16/22, with the diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed for certification period 5/16/22 to 7/14/22. During the home visit, the surveyor compared P#3 current medication list in the agency’s Electronic medical record (EMR) to the medications present in P# home. P#3 had the following medication listed in the home but not in the EMR: Amoxicillin, PRN, 4 tablets one hour prior to appointment 2-27-20, an antibioticAspirin 81mg, 1 tab daily, a medication used to thin bloodNature Made Super B complex vitamin x1 tab once daily, a dietary supplementQuality Plus Antidiarrheal x2 capsules daily, a medication used for diarrhea While reviewing medications in the home with PT#FF, PT# FF verbalized understanding of the requirement to reconcile all medications in the home with medications listed in the agency EMR during every comprehensive visit. A home visit was conducted at 4:00 p.m. on 6/15//22, at the residence of Patient #5 with Occupational Therapist (OT) #GG. P#5 was admitted to the home health agency on 5/19/22, with the diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed for certification period 5/19/22 to 7/17/22. During the home visit, the surveyor compared P#5 current medication list in the agency’s Electronic medical record (EMR) to the medications present in P#5 home. P#5 had the following medication listed in the home but not in the EMR: Nature Made Vitamin B6 100 mg x1 tab daily, a dietary supplementNature Made Vitamin B12 1000 mcg Soft gels x1 tab daily, a dietary supplementNature Made Vitamin D3 1000 IU x1 tab daily, a dietary supplement The following medication was listed incorrectly in the EMR: Jardiance, a medication used to lower blood sugar, was listed as 25 mg x1 tab daily in the EMR but the home medication was 10 mg x1 tab daily,Tamsulosin 0.4 mg capsule used to treat an enlarge prostate, was listed in the EMR to take once daily but the home medication instructed P #5 to take twice daily. While reviewing medications in the home with OT#GG, OT#GG verbalized understanding of the requirement to reconcile all medications in the home with medications listed in the agency EMR during every comprehensive visit.

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 observation, clinical record review, and staff interviews, it was determined that the agency failed to ensure that patient plan of care was updated to reflect current medications at the time of the comprehensive assessment for four (4) of nineteen (19) sampled patients (P#1, P#3, P#5 and P#6). A home visit was conducted at 12:38 p.m. on 6/15/22, at the residence of Patient (P#6) with Physical Therapist (PT)#FF. P# 6 was admitted to the home health agency on 5/24/22, with the diagnosis of Myopathy, unspecified. The clinical record was reviewed for certification period 5/24/22 to 7/22/22. During the home visit, the surveyor compared P#6 current medication list in the agency’s Electronic medical record (EMR) to the medications present in P#6 home. P#6 had the following medication listed in the home but not in the EMR: Pyridostigmine Bromide 60 mg x1 tab daily, 3/18/22 used to increase muscle strengthMeclizine 25 mg tab x1 tab daily, 12-29-15, a medication used to treat dizzinessNature Bounty Magnesium 500 mg x1 tab daily, a dietary supplementNaturalist Multi Source Potassium 99.0 mg x1 tab daily, a dietary supplement The following medication was listed incorrectly in the EMR: Gabapentin 30 mg, a medication used to treat neuropathic pain was listed in the EMR as taken x1 tab x3 times daily, but the home medication instructed P# to take 2 capsules x3 times daily.Oxygen 2 Liter continuous, a medication used to keep the blood adequately saturated, was discontinued based on P# caregiver interview but still listed in the agency’s EMR. While reviewing medications in the home with PT#FF, PT# FF verbalized understanding of the requirement to reconcile all medications in the home with medications listed in the agency EMR during every comprehensive visit. A home visit was conducted at 1:35 p.m. on 6/15/22, at the residence of Patient #3 with Physical Therapist (PT)#FF. P#3 was admitted to the home health agency on 5/16/22, with the diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed for certification period 5/16/22 to 7/14/22. During the home visit, the surveyor compared P#3 current medication list in the agency’s Electronic medical record (EMR) to the medications present in P# home. P#3 had the following medication listed in the home but not in the EMR: Amoxicillin, PRN, 4 tablets one hour prior to appointment 2-27-20, an antibioticAspirin 81mg, 1 tab daily, a medication used to thin bloodNature Made Super B complex vitamin x1 tab once daily, a dietary supplementQuality Plus Antidiarrheal x2 capsules daily, a medication used for diarrhea While reviewing medications in the home with PT#FF, PT# FF verbalized understanding of the requirement to reconcile all medications in the home with medications listed in the agency EMR during every comprehensive visit. A home visit was conducted at 4:00 p.m. on 6/15//22, at the residence of Patient #5 with Occupational Therapist (OT) #GG. P#5 was admitted to the home health agency on 5/19/22, with the diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed for certification period 5/19/22 to 7/17/22. During the home visit, the surveyor compared P#5 current medication list in the agency’s Electronic medical record (EMR) to the medications present in P#5 home. P#5 had the following medication listed in the home but not in the EMR: Nature Made Vitamin B6 100 mg x1 tab daily, a dietary supplementNature Made Vitamin B12 1000 mcg Soft gels x1 tab daily, a dietary supplementNature Made Vitamin D3 1000 IU x1 tab daily, a dietary supplement The following medication was listed incorrectly in the EMR: Jardiance, a medication used to lower blood sugar, was listed as 25 mg x1 tab daily in the EMR but the home medication was 10 mg x1 tab daily,Tamsulosin 0.4 mg capsule used to treat an enlarge prostate, was listed in the EMR to take once daily but the home medication instructed P #5 to take twice daily. While reviewing medications in the home with OT#GG, OT#GG verbalized understanding of the requirement to reconcile all medications in the home with medications listed in the agency EMR during every comprehensive visit. The Findings include: During a home visit observation conducted on 6/15/22 at approximately 10:20 a.m., with Registered Nurse (RN) AA, for (P#1), it was revealed that (P#1) was admitted on 4/13/22, with a diagnosis of congestive heart failure. The surveyor compared P#1's current medication list at home to the home health agency's medication profile. Discrepancies were found. The home health agency plan of care revealed Milrinone 40 milligrams (MG)/200 milliliters (ML), in 5percent dextrose intravenous administer 5.4ml/hour continuously for heart failure. But the pharmacy label on intravenous bag revealed Milrinone 144 mg/D5W 288ml piggy bag administer 4ml/hour continuously for heart failure. Pharmacy label revealed Furosemide 40mg give one tablet oral daily for fluid overload. But the home health agency medication profile and care plan revealed 40mg give half tablet oral daily. The pharmacy label revealed potassium chloride extended release 10 milliequivalents (MEQ) give two tablets oral daily for electrolyte balance. But the home health agency medication profile and plan of care revealed 20MEQ give two tablets oral daily. Biotin 10,000micrograms (MCG), give one capsule oral daily for vitamin B supplement: this medication was not listed in home health agency medication profile and plan of care. On 6/16/22 at 1:40 p.m., an interview was conducted with Registered Nurse (RN) AA, who confirmed that she did not check the medications containers, IV bag, and did not update the medication profile and plan of care.

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 clinical record reviews, observations, and staff interviews, it was determined that the agency failed to follow physician’s order to weigh Patients (P#1, #3, #9, and #12), daily; if unable to weigh patient, may measure abdominal girth and document, for four (4) of nineteen (19) sampled patients. The Findings include: 1. Patient #1 was admitted to agency on 4/13/22, with a diagnosis of congestive heart failure. Physician order dated 4/8/22: skilled nurse to assess, monitor and record daily weight, if unable to weigh patient, may measure abdominal girth and to notify physician if P#1 gained two pounds in one day or five pounds in one week. Registered Nurse (RN) BB did not weigh P#1 on 4/27/22 and 5/4/22. There was no record showing that (RN) BB notified physician for not obtaining the weight for two weeks. On 6/16/22, at 11:30 a.m., an interview was conducted with (RN) BB, who stated P#1’s scale was damaged, and she did not have a scale in her car to weigh P#1. Also (RN) BB confirmed that she did not measure abdominal girth or notify the physician. 2. Patient #3 was admitted to agency on 5/16/22, with a diagnosis of heart failure. Physician order dated 5/26/22: skilled nurse to assess, monitor and record daily weight, if unable to weigh patient, may measure abdominal girth and notify physician if P#3 gained two pounds in one day or five pounds in one week. Registered Nurse (RN) CC did not weigh P#3 on 6/1/22 and 6/8/22. There was no record showing that (RN) CC notified physician for not obtaining the weight for two weeks. On 6/16/22, at 1:08 p.m., an interview was conducted with (RN) CC, who stated that she did not weigh P#3’s. (RN) CC confirmed that she did not measure abdominal girth or notify the physician. 3. Patient #9 was admitted to agency on 11/30/21, with a diagnosis of heart failure. Physician order dated 11/30/22: skilled nurse to assess, monitor and record daily weight, if unable to weigh patient, may measure abdominal girth and notify physician if P#9 gained two pounds in one day or five pounds in one week. Registered Nurse (RN) CC did not weigh P#9 on 1/5/22, 1/12/22, and 1/19/22. There was no record showing that (RN) CC notified physician for not obtaining the weight for three weeks. On 6/16/22, at 1:08 p.m., an interview was conducted with (RN) CC, who stated that she did not weigh P#9’s. (RN) CC confirmed that she did not measure abdominal girth or notify the physician. 4. Patient #12 was admitted to agency on 1/6/22, with a diagnosis of congestive heart failure. Physician order dated 1/6/22: skilled nurse to assess, monitor and record daily weight, if unable to weigh patient, may measure abdominal girth and notify physician if P#12 gained two pounds in one day or five pounds in one week. Registered Nurse (RN) CC did not weigh P#12. There was no record showing that (RN) CC notified physician for not obtaining the weights. On 6/16/22, at 1:17 p.m., an interview was conducted with (RN) CC, who stated that she did not weigh P#12’s. (RN) BB confirmed that she did not measure abdominal girth or notified the physician.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, clinical record reviews and staff interviews, it was determined that the hospice agency failed to use standard precaution to prevent infection for Peripherally Inserted Central Catheter (PICC) wound care dressing by using dirty gloves to perform sterile wound dressing for one (1) of nineteen (19) sampled patients (P#1). The Findings include: On 6/15/22 at 10:40 a.m., surveyor observed Registered Nurse (RN) AA, perform sterile PICC wound care to P#1’s chest. (RN) AA used dirty gloves to touch sterile gauze and used it to wipe P#1’s chest PICC wound three times; then used the same dirty gloves to complete the sterile wound care dressing. Patient #1 was diagnosed with congestive heart failure, receiving Milrinone 144 mg/D5W 288ml piggy bag administered 4ml/hour continuously for heart failure. On 6/15/22 at 11:49 a.m., an interview was conducted with (RN) AA, stated she knew better however, was nervous; and would take the blame for using soiled gloves to touch the sterile gauze three times, she admitted to using the same dirty gloves to clean the PICC and complete the dressing.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, it was determined the agency failed to ensure the patients' clinical record contained complete, concise, and clear documentation of all services including evaluations, treatments, progress notes, and individualized plan of care; included all of the required elements to address the patients' needs for six (6) of nineteen (19) (#2, #5, #7, #8, #10, #11 and #19) sampled patients. The Findings include: 1. Review of the plan of care for Patient (P#2) with a certification of 6/1/22 to 7/30/22 required the skilled nurse (SN) to assess and instruct patient /caregiver on precautions to monitor and document patient’s weight daily for a diagnosis of heart failure. However, according to the plan of care, the patient was not weighed or measured for bilateral lower extremities for edema. The agency failed to ensure that the plan of care contained clear, accurate, and concise orders as per the needs of the patient. During an interview on 6/16/22 at 3:30 p.m., Registered Nurse (RN) BB confirmed that the agency failed to ensure the plan of care contained accurate and complete documentation regarding the assessment and needs of the patient. 2. Review of the plan of care for Patient (P#5) with a certification of 5/19/22 to 7/17/22 required the skilled nurse (SN) to assess and instruct patient /caregiver on precautions to monitor and document patient’s weight daily for a diagnosis of congestive heart failure. However, according to the plan of care the patient was not weighed or measured for bilateral lower extremities for edema. The agency failed to ensure that the plan of care contained clear, accurate, and concise orders as per the needs of the patient. During an interview on 6/16/22 at 4:12 p.m., Registered Nurse (RN) EE confirmed that the agency failed to ensure the plan of care contained accurate and complete documentation regarding the assessment and needs of the patient. 3.Review of the plan of care for (P#7) with a certification of 5/19/22 to 7/17/22 diagnosed with end stage renal disease and dialysis three time per week, required the skilled nurse (SN) to assess and instruct patient /caregiver on precautions to monitor and document patient’s dialysis assess site for bleeding and infection. However, according to the plan of care the patient dialysis assess site was not monitored nor documented for bleeding nor infection. The agency failed to ensure that the plan of care contained clear, accurate, and concise orders as per the needs of the patient. During an interview on 6/16/22 at 3:30 p.m., Registered Nurse (RN) BB confirmed that the agency failed to ensure the plan of care contained accurate and complete documentation regarding the assessment and needs of the patient. 4. Review of the plan of care for Patient (P#8) with a certification of 10/27/21 to 12/25/21 required the skilled nurse (SN) to assess and instruct patient /caregiver on precautions to monitor and document patient’s weight daily for a diagnosis of heart failure. However, according to the plan of care the patient was not weighed or measured for bilateral lower extremities for edema. The agency failed to ensure that the plan of care contained clear, accurate, and concise orders as per the needs of the patient. During an interview on 6/16/22 at 3:30 p.m., Registered Nurse (RN) BB confirmed that the agency failed to ensure the plan of care contained accurate and complete documentation regarding the assessment and needs of the patient. 5. Review of the plan of care for (P#10) with a certification of 11/9/21 to 1/7/21 required the skilled nurse (SN) to assess and instruct patient /caregiver on precautions to monitor and document patient’s weight daily for a diagnosis of heart failure. However, according to the plan of care, the patient was not weighed or measured for bilateral lower extremities or abdominal grith for edema. The agency failed to ensure that the plan of care contained clear, accurate, and concise orders as per the needs of the patient. During an interview on 6/16/22 at 3:27 p.m., Licensed Practical Nurse (LPN) DD confirmed that the agency failed to ensure the plan of care contained accurate and complete documentation regarding the assessment and needs of the patient. 6.Review of the plan of care for (P#11) with a certification of 4/30/21 to 6/28/21 required the skilled nurse (SN) to assess and instruct patient /caregiver on precautions to monitor and document patient’s weight daily for a diagnosis of heart failure. However, according to the plan of care, the patient was not weighed nor measured for bilateral lower extremities for edema. The agency failed to ensure that the plan of care contained clear, accurate, and concise orders as per the needs of the patient. During an interview on 6/16/22 at 3:30 p.m., Registered Nurse (RN) BB confirmed that the agency failed to ensure the plan of care contained accurate and complete documentation regarding the assessment and needs of the patient. 7. Review of the plan of care for (P#19) with a certification of 6/7/22 to 8/5/22 required the skilled nurse (SN) to assess and instruct patient /caregiver on precautions to monitor and document patient’s weight daily for a diagnosis of congestive heart failure. However, according to the plan of care the patient was not weighed nor measured for bilateral lower extremities for edema. The agency failed to ensure that the plan of care contained clear, accurate, and concise orders as per the needs of the patient. During an interview on 6/16/22 at 3:30 p.m., Registered Nurse (RN) BB confirmed that the agency failed to ensure the plan of care contained accurate and complete documentation regarding the assessment and needs of the patient.