Every finding on record at A-1 Bayou Health 2000, Inc.

The entity is in compliance with the federal emergency preparedness requirements

Recertification Survey

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on interview and record reviews the agency failed to ensure the Outcome and Assessment Information Sets (OASIS) were successfully completed and transmitted within 30 days of completion for 5 (Patient #1, Patient #3, Patient #R9, Patient #R10, Patient #R11) of 13 OASIS Assessments reviewed for timely submission. Findings: Patient #1 Review of Patient #1’s OASIS Agency Final Validation report revealed, in part, OASIS completion date of 01/02/2025. Review of Patient #1’s Task Details Log for OASIS dated 01/02/2025 revealed, in part, Patient #1’s 01/02/2025 OASIS was not exported till 02/07/2025, which was 36 days after the assessment. Patient #3 Review of Patient #3’s OASIS Agency Final Validation report revealed, in part, OASIS completion date of 10/22/2025. Review of Patient #3’s Task Details Log for OASIS dated 10/22/2025 revealed, in part, Patient #3’s 10/22/2025 OASIS was not exported till 11/24/2025, which was 33 days after the assessment. Patient #R9 Review of Patient #R9’s OASIS Agency Final Validation report revealed, in part, OASIS completion date of 05/25/2025. Review of Patient #R9’s Task Details Log for OASIS dated 05/25/2025 revealed, in part, Patient #R9’s 05/25/2025 OASIS was not exported till 06/29/2025, which was 35 days after the assessment. Patient #R10 Review of Patient #R10’s OASIS Agency Final Validation report revealed, in part, OASIS completion date of 01/02/2025. Review of Patient #R10’s Task Details Log for OASIS dated 01/02/2025 revealed, in part, Patient #R10’s 01/02/2025 OASIS was not exported till 02/07/2025, which was 36 days after the assessment. Patient #R11 Review of Patient #R11’s OASIS Agency Final Validation report revealed, in part, OASIS completion date of 02/10/2025. Review of Patient #R11’s Task Details Log for OASIS dated 02/10/2025 revealed, in part, Patient #R11’s 02/10/2025 OASIS was not exported till 03/19/2025, which was 37 days after the assessment. In an interview on 12/03/2025 at 3:45p.m. S4Regional Director (RD), confirmed Patient #1, Patient #3, Patient #R9, Patient #R10 and Patient #R11’s OASIS were not transmitted within 30 days of completion of the OASIS as required.

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 interview and record reviews, the agency failed to ensure occupational therapy services were provided per physician orders for 1(Patient #3) of 1 patient reviewed for occupational therapy services as ordered. Findings: Review of Patient #3’s physician order dated 11/24/2025 revealed, in part, occupational therapy was to evaluate and treat Patient #3 the week of 11/24/2025. Review of Patient #3’s Occupational Services Initial Evaluation dated 12/03/2025 revealed Patient #3 received an initial evaluation for services with a request to the physician for continued services. Review of Patient #3’s record did not reveal any evidence Patient #3 received occupational services the week of 11/24/2025 as ordered. In an interview on 12/03/2025 at 1:42p.m., S2Director of Nursing (DON) indicated Patient #3 did not receive the occupational therapy evaluation the week of 11/24/2025 as per physician order.

Emergency Preparedness Survey

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to have a plan and policy in place related to integration of volunteers during activation of the agency’s Emergency Plan. Findings: Review of the agency’s emergency preparedness plan did not reveal any documented evidence of a policy or plan for the use of volunteers in an emergency or other emergency staffing strategies for the agency to address surge needs nor did the agency present any documented evidence. In an interview on 12/08/2022 at 3:00 p.m., S1Administrator/DON confirmed the agency did not have a policy for the use of volunteers in an emergency to address surge needs.

Recertification Survey

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, record review, and interview the agency failed to ensure an accurate medication reconciliation was completed for 1 of 3 sampled patients (Patient #1) observed during home visits in a total sample of 7 patients. Findings: Review of Patient #1’s Home Health Certification and Plan of Care for certification period of 11/11/2022 to 01/09/2023 revealed Patient #1 was to receive nursing services twice a month for two months. Review of Patient #1’s record revealed Patient #1 was provided nursing services on 11/16//2022 and 11/24/2022. Review of Patient #1’s Medication Profile, provided by S1Administrator/DON (Director of Nursing) as a current medication Profile, revealed the following medications were listed as current medications, Neurontin (medication used to treat nerve pain) 300mg (milligrams) one capsule by mouth twice a day; Modafinil (medication used to treat attention deficit disorder) 200mg one tablet every morning; and Linagliptin (medication used to treat diabetes) 5mg one tablet by mouth daily. Further review revealed no documented evidence of Potassium CL (chloride) ER (extended release) 10meq (milliequillivants). Observation on 12/07/2022 at 3:30 p.m. revealed during home visit the following medications were not present as a current prescription: Neurontin 300mg one capsule by mouth twice a day; Modafinil 200mg one tablet every morning; and Linagliptin 5mg one tablet by mouth daily. Further observation revealed a prescription for Potassium CL ER 10meq with a filled date of 11/02/2022. In an interview on 12/07/2022 at 3:30 p.m., S4RN (Registered Nurse) stated Neurontin was discontinued about one month ago, Modafinil was discontinued about one month ago, and Linagliptin had been discontinued for a while, but S4RN was unsure of the actual date. S4RN stated he was aware of a current order for Potassium CL ER. S4RN further stated he was aware of the above medication discrepancies with the Medication Profile, and he had failed to update the Medication Profile and the medical record. In an interview on 12/08/2022 at 9:40 a.m., S1Administrator/DON stated Patient #1’s medications should be reconciled at every visit which includes a review of the actual prescriptions. S1Administrator/DON further stated S4RN failed to ensure Patient #1’s medication profile was accurate and updated per regulation.

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 record review and interview, the agency failed to follow a patient’s plan of care by failing to initiate a Physical Therapy (PT) evaluation as ordered. This deficient practice was identified for 1 (Patient #6) of 6 patients sampled for PT services in a total sample of 7. Findings: Review of Patient #6’s Home Health Certification and Plan of Care with a certification period of 08/07/2021 through 10/05/2022 revealed, in part, PT to evaluate and treat the week of 08/09/2022. Review of Patient #6’s record revealed no documented evidence and the provider did not present any documented evidence of a PT evaluation and/or order to change the start PT services for the week of 08/09/2022. Review of Patient #6’s medical record revealed, in part, a Patient Communication dated 08/24/2022 that stated patient/family requested to stat PT on 08/25/2022. In an interview on 12/07/2022 at 3:23p.m., S2Coorporate Nurse confirmed the physician should have been notified, a clinical note should have been entered, and an order to change the evaluation date should have been entered in Patient #6’s medical record due to PT not completing the evaluation within the ordered time frame prior to the note completed on 08/24/2022.

Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to coordinate with a patient’s physician regarding a referral for MSW (Medical Social Worker) services when the agency did not have MSW services available for 1 (Patient #4) of 2 patients sampled with MSW referral orders. Findings: Review of Patient #4’s Referral dated 11/04/2022 revealed, in part, social work for resources. Review of Patient #4’s medical record revealed a Communication Note dated 11/07/2022 completed by S1Administrator/DON (Director of Nursing) that stated no MSW available to do visit at this time, Medical Doctor notified by phone. In an interview on 12/07/2022 at 10:18 a.m., S1Administrator/DON confirmed neither the doctor nor patient #4 were notified of the agency not being able to provide a social worker as ordered prior to admission and both should have been notified.

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, record review, and interview the agency failed to ensure the Registered Nurse (RN): 1. Changed her gloves and used hand hygiene between dirty and clean procedures; 2. Did not clean multiple wounds and intact skin with the same gauze; 3. Did not place a soiled dressing on the patient’s floor of the home; and 4. Properly cleaned soiled equipment prior to being placed with clean equipment. This deficient practice was identified for 1 of 1 sampled patients (Patient #3) and for 1 of 1 staff members (S3RN) observed during wound care in a total sample of 7 patients. Findings: Review of Patient #3’s Physician Order dated 11/23/2022 revealed wound care to Patient #3’s left lower extremity was to cleanse the wound with normal saline and gauze, pat the wound dry with gauze, then apply calcium alginate with silver (wound dressing used to absorb drainage and suppress bacterial growth) to the open wounds, apply unna boot (compression bandaged used ti treat slow healing lower leg ulcers) wrap followed by kerlix, and secure with coban from base of the toes to approximately 2-3 inches below the knee. 1. Observation on 12/05/2022 at 1:56 p.m., revealed S3RN used hand sanitizer and then applied two pairs of gloves on each hand. S3RN removed scissors from the supply bag and then used the scissors to cut off Patient #3’s left lower extremity soiled dressing. S3RN then removed the outer layer of gloves and did not remove the second layer of gloves and did not use hand hygiene. S3RN then cleaned the two open wound areas under Patient #3’s left knee, then using the same gauze cleaned Patient #3’s entire left lower extremity. Further observation revealed S3RN then took the same gauze and proceed to clean the open area to Patient #3’s medial ankle area with the same gloved hands without completing hand hygiene. S3RN then discarded the gauze and used a new dry gauze to dry the left lower extremity without having changed gloves or performed hand hygiene. S3RN proceeded to without changing gloves or performing hand hygiene apply skin barrier to the intact skin of the left lower extremity. S3RN then removed both sets of dirty gloves and performed hand hygiene using alcohol gel. S3RN was further observed then apply two sets of clean gloves to redress wounds. Observation revealed from the start of wound care until skin barrier applied S3RN never removed both pairs of gloves and performed hand hygiene. 2. Observation on 12/05/2022 at 1:56 p.m., revealed S3RN cleaned the two open wound areas under Patient #3’s left knee, then using the same gauze cleaned Patient #3’s entire left lower extremity, then with the same gauze cleaned the open area to Patient #3’s medial ankle area. 3. Observation on 12/05/2022 at 1:56pm revealed S3RN used hand sanitizer and then she applied two pairs of gloves on each hand. S3RN removed scissors from the supply bag and then used the scissors to cut off Patient #3’s left lower extremity soiled dressing and placed the soiled dressing directly on Patient #3’s floor with no barrier placed under the soiled dressing. 4. Observation on 12/05/2022 at 1:56pm revealed S3RN used hand sanitizer and then applied two pairs of gloves on each hand. S3RN removed scissors from the supply bag and then used the scissors to cut off Patient #3’s left lower extremity soiled dressing. S3RN then placed the scissors used to cut off the soiled dressing back in the supply bag with the clean supplies without cleaning the scissors prior to placing them in the bag. In an interview on 12/06/2022 at 3:13 p.m., S3RN stated she should have removed gloves and performed hand hygiene per infection control guidelines. S3RN stated she should not have placed the soiled dressing on Patient #3’s floor, and should not have placed the soiled scissors in the bag with the clean supplies. S3RN further stated she should have changed gloves, performed hand hygiene, and used new gauze when cleaning each wound and leg so there would be no cross contamination. In an interview on 12/06/0222 at 3:45 p.m., S1Administrator/DON (Director of Nursing) was notified of the above findings, and stated the observations were a breach of infection control standards of practice.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observation, record review, and interview the agency failed to ensure there was coordinated system for the collection of infection control data which included all infections for the Quality Assessment Performance Improvement (QAPI) committee to review. This deficient practice was identified for 2 of 7 sampled patients (Patient #2 and Patient #3) reviewed for infection control. Findings: Review of Patient #2’s Patient Medication Record revealed Levofloxacin (medication used to treat infection) 500mg (milligrams) one tablet by mouth daily for 5 days with start date of 09/02/2022. Review of Patient #2’s OASIS (Outcome and Assessment Information Set) Addendum Page dated 09/02/2022 revealed Patient #2 was admitted with a urinary tract infection (bladder infection). Review of Patient #3’s Patient Medication Record revealed the following, in part: -04/26/2022 Bactrim DS (Double Strength) (medication used to treat infections) 800/160mg (milligrams) one tablet by mouth every 12 hours; -05/27/2022 Vancomycin HCL (hydrochloride) (medication used to treat infections) intravenous (in the vein) one gram every 12 hours; -06/21/2022 Bactrim DS 800/160mg one tablet by mouth twice a day; -06/30/2022 Doxycycline Hyclate (medication used to treat infections) 100mg one capsule by mouth twice a day; -08/02/2022 Cipro (medication used to treat infections) 250mg one tablet by mouth twice a day; -10/12/2022 Clindamycin HCL (medication used to treat infections) 150mg two capsules by mouth three times a day; and Bactrim DS 800/160mg one tablet by mouth every 12 hours; -11/22/2022 Doxycycline Hyclate 100mg one capsule by mouth in the morning and night; and -11/30/2022. Zyvox (medication used to treat infections) 600mg one tablet by mouth twice daily. Review of Patient #3’s Skilled Nursing Visit Note dated 04/27/2022 revealed Patient #3 was prescribed Bactrim DS 800/160mg by mouth twice a day and Cleocin 150mg two capsules by mouth three times a day for redness to the left lower extremity. Review of Patient #3’s Skilled Nursing Visit Note dated 05/28/2022 revealed Patient #3 was receiving Vancomycin HCL intravenous for cellulitis to the left lower extremity. Review of Patient #3’s Skilled Nursing Visit Note dated 06/22/2022 revealed Patient #3 was receiving Bactrim DS for cellulitis to the left lower extremity. Review of Patient #3’s Skilled Nursing Visit Note dated 06/29/2022 revealed no indication for Patient #3’s use of Doxycycline. Review of Patient #3’s Skilled Nursing Visit Note dated 08/01/2022 revealed Cipro was prescribed for urinary tract infection. Review of Patient #3’s OASIS-D Addendum Page dated 10/13/2022 revealed Clindamycin and Bactrim DS was prescribed for cellulitis. Review of Patient #3’s OASIS Addendum Page dated 12/01/2022 revealed, in part, Patient #3 was treated on 11/22/2022 with Doxycycline for a wound infection and then admitted to the hospital after culture results on 11/25/2022 and discharged on Zyvox. Review of the agency’s List of Infections for 12/05/2021 to 12/04/2022 revealed only three infections were recorded. Further review revealed no documented evidence and the agency presented no documented evidence of Patient #2’s urinary tract infection, nor Patient #3’s infections dated 04/26/2022, 05/27/2022, 06/21/2022, 06/30/2022, 08/02/2022, 10/12/2022, 11/22/2022, and 11/30/2022 having been captured on the agency’s List of Infections used for QAPI and tracking and trending purposes. In an interview on 12/08/2022 at 2:01 p.m., S1Administrator/DON (Director of Nursing) stated the List of Infections with only three infections was accurate as the agency only had three infections in the last year. S1Administrator/DON stated the process for infections was when the nursing staff identifies signs and symptoms of infection or a new antibiotic (medications used to treat infections), the nurse was to document in the note and complete an infection control log which would generate notification to her for follow-up and tracking and trending purposes. Surveyor reviewed the above findings with S1Administrator/DON and S1Administrator stated the agency could not explain why no infections were captured from April 2022 to July 2022, and no further infections were captured on the report after the July 2022 infections. S2Corporate Nurse stated the nurses were not filling out the infection reports properly inside the skilled nursing notes and therefore not triggering appropriately to be included on the reports. S2Corporate Nurse further stated infections were not being captured, and tracked and trended appropriately, and therefore accurate information was not shared for QAPI purposes.