Every finding on record at Amedisys New Jersey, L.L.C.

Upon patient record review, 4 of 19 (Patient #1, #2, #4, #10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #1- The patient record contains orders on 03/25/24 for Heparin and Saline Flushes for port- a-cath maintenance. Heparin and Saline dosages are not listed on the medication profile. (corrected on site) Patient #2-On 02/22/24 the nurse documents Oxygen was ordered. The medication profile does not include Oxygen. (corrected on site) Patient #4-On 02/06/24 Tylenol 1000mg is ordered every eight hours as needed for pain. The medication profile lists Tylenol 1000mg every eight hours scheduled for pain(inaccurate). (corrected on site) Patient #10-On 02/09/24 the nurse documents the MD prescribed Prednisone. The medication profile was not updated with Prednisone. On 04/05/24 the nurse documents Lidocaine patches on the knees and ankles provide adequate pain relief. The medication profile does not include Lidocaine patches. On 04/11/24 the nurse documents Senna was refilled. The medication profile does not include Senna.

Upon patient record review, 3 of 19 (Patient #1, #2, #10) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including specific orders for all medications. Patient #1-The 03/25/24 plan of care includes orders to flush the patients port-a-cath which read: Flush port with NS _ml(amount is blank) followed by Heparin _u/ml (5ml). (Dosage units/ml is left blank). (corrected on site) Patient #2-On 02/22/23 the nurse documented Oxygen was ordered. The plan of care does not include Oxygen orders. (corrected on site) Patient #10-On 02/09/24 the nurse documented the MD prescribed Prednisone. The plan of care does not include Prednisone. On 04/05/24 the nurse documented Lidocaine patches to the knees and ankles provided adequate pain relief. The plan of care does not include Lidocaine patches. On 04/11/24 the nurse documented Senna was refilled and the plan of care does not include Senna. (corrected on site)

Upon patient record review, 2 of 19 (Patient #2, #12) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #2-On 02/22/24 the nurse documented an overbed table, Oxygen Concentrator and Oxygen tank were ordered. On 02/23/24 triage documented a bed with half rails, BSC, and walker had also been ordered. The plan of care does not include the ordered equipment. (corrected on site) Patient #12-The nurse documents on 03/18/24 the patient is on Oxygen. The DME section of the plan of care does not include Oxygen.(corrected on site)

Upon patient record review, 2 of 19 (Patient #8, #10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #8-On 04/09/24 the nurse documents increasing the patient's Oxygen to 8/lpm. The orders on record are for 5/lpm continuous. Patient #10- On 03/08/24 the nurse documents performing a venipuncture for lab work (CBC and CMP). The record does not include orders for a CBC and CMP.

Upon patient record review, 1 of 19 (Patient #2) did not have evidence that each patient record contains Advance Directives. Patient 2-The 03/13/24 IDG documentation indicates the patient is a DNR. A copy of the DNR is not on record. (corrected on site)

Upon patient record review, 1 of 19 (Patient # 1) did not have evidence that all entries are clear and complete. Patient #1-On 03/27, 03/28, 03/31 and 04/01/24 the nurse documents the patients port-a-cath was flushed. The documentation is not specific for the flush type(s) and amount(s) administered. (late entry documentation correction on site)

Upon patient record review, 2 of 19 (Patient #18, #19) did not have evidence that the discharge summary includes all required information. Patient #18-The patient revoked the election 01/17/24. The discharge summary only states the patient revoked and was hospitalized due to the terminal illness. The discharge summary does not include a summary of the patient's stay, including treatments, symptoms and pain management. Patient #19-The discharge summary on record only states the patient was discharged to no longer meeting hospice criteria. The discharge summary does not include a summary of the patient's stay, including treatments, symptoms and pain management.