Every finding on record at Amedisys Oregon, LLC

An unannounced Federal recertification survey was completed at this agency on 2/16/2022. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484. The Director of Operations was notified of the survey via phone on 2/7/2022 at 10:50 AM. An entrance conference was held with the Business Office Manager and a Clinical Manager on 2/7/2022 at 11:04 AM. The purpose of the survey and the survey needs were explained. An opportunity was provided for questions, answers and comments. Definitions and abbreviations: CFR - Code of Federal Regulations COPD - Chronic obstructive pulmonary disease HFA - hydrofluoroalkane, a propellant used in metered dose inhalers mcg - microgram mg - milligram PRN/prn - as needed tx - treatment

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 clinical record review and interview, it was determined the agency failed to ensure the individualized plan of care included complete medication orders for 5 of 10 active patient clinical records reviewed (Patients #1, 2, 6, 8 and 10). Findings: Patient #1: Review of the "Home Health Certification and Plan of Care" for the certification period from 12/29/2021 to 2/26/2022 revealed the order "Oxycodone 5 mg tablet, 1 tablet, as needed/prn, Reason: severe pain." The order failed to include the frequency the medication could be taken. Further review of the "Home Health Certification and Plan of Care" revealed the order "Prochlorperazine maleate 10 mg tablet, 1 tablet, as needed/prn, Reason: Nausea tx." The order failed to include the frequency the medication could be taken. Patient #8: Review of the "Home Health Certification and Plan of Care" for the certification period from 1/20/2022 to 3/20/2022 revealed the order "Ondansetron 4 mg disintegrating tablet, 1 tablet, as needed/prn, Reason: nausea management." The order failed to include the frequency the medication could be taken. Further review of the "Home Health Certification and Plan of Care" revealed the order "Proair HFA 90 mcg/actuation aerosol inhaler, 2 puff, as needed/prn, Reason: COPD management." The order failed to include the frequency the medication could be taken. Patient #10: Review of the "Home Health Certification and Plan of Care" for the certification period from 1/7/2022 to 3/7/2022 revealed the order "Tramadol 50 mg tablet, 1 tablet, as needed/prn, Reason: severe pain." The order failed to include the frequency the medication could be taken. During an interview with Employees #1, 3, 4, 5, 6, 12 and 13 on 2/15/2022 beginning at 12:30 PM, the above findings were presented. Employee #1 acknowledged the findings that the orders were incomplete and stated "Without the parameters, I do agree with you." Patient #2: Review of the "Home Health Certification and Plan of Care" for the certification period from 12/21/2021 to 2/18/2022 revealed the order "Diphenhydramine 25 mg capsule, 1 capsule, every 6 hours, Reason: allergies tx." The order indicated the medication was to be taken routinely. Patient #6: Review of the "Home Health Certification and Plan of Care" for the certification period from 1/18/2022 to 3/18/2022 revealed the order "Diphenhydramine 25 mg tablet, 1 tablet, every 6 hours, Reason: allergies/itching." The order indicated the medication was to be taken routinely. During an interview with Employees #1, 3, 4, 5, 6, 12 and 13 on 2/15/2022 beginning at 12:30 PM, the above findings were presented. It was discussed that diphenhydramine is typically used as needed and routine use would be rare. Employee #1 was asked to review the original medication orders for Patients #2 and 6 and provide supporting documentation that the medication was ordered routinely. Employee #1 provided additional information regarding Patient #2 at 3:01 PM on 2/15/2022. Employee #1 confirmed that according to the medication list from hospital paperwork "Diphenhydramine is listed as a PRN medication." Employee #1 provided additional information regarding Patient #6 at 2:55 PM on 2/15/2022. Employee #1 confirmed that according to the medication list from the referring provider "You are correct - the diphenhydramine should have been labeled a PRN medication."