Every finding on record at Audubon Home Health South, Inc

Emergency Preparedness Survey.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to conduct an exercise at least annually to test the emergency plan. Findings: A review of the agency’s emergency preparedness binder revealed no evidence that an annual exercise to test the emergency plan had been conducted since 09/09/2024. On 12/17/2025 at 9:11 a.m., an interview was conducted with S2RN (Registered Nurse). S2RN reviewed the emergency preparedness binder and confirmed she could not provide evidence that an annual exercise to test the emergency plan was conducted in 2025. S2RN confirmed the last exercise to test the emergency plan was conducted on 09/09/2024, which was over a year ago. On 12/17/2025 at 11:15 a.m., an interview was conducted with S1ADM (Administrator). S1ADM confirmed that an annual exercise to test the emergency plan was not conducted since 09/09/2024, which was over a year ago.

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 record review, observation, and interview, the agency failed to ensure a patient’s comprehensive assessment accurately reflect the patient’s current drug regimen as evidenced by the SN failing to conduct a thorough review of all the patient’s (#4) current medications, including OTC (over-the-counter) for 1 (#4) out 10 sampled patients. Findings: Patient #4: Review of the patient’s electronic clinical records revealed the start of care date was 07/01/2025. The patient’s diagnoses included in part, Alzheimer’s disease with late onset, age-related osteoporosis without current pathological fracture, and abnormal weight loss. Review of the patient’s POC (Plan of Care) for certification period 10/20/2025 to 12/28/2025 revealed an order for “SN (effective 11/02/2025) 1wk8 (skilled nurse visit one time a week for eight weeks).” Further review of the POC revealed an order “Skilled nurse to review patient medication profile and reconcile medications as needed.” On 12/15/2025 at 11:37 a.m., a review of Patient#4’s medications was conducted with S5RN during a home visit. The following OTC medications were identified and not on the patient’s medication list: Zyrtec 10mg (milligrams) tablet, Cranberry + D-(Vitamin D) Mannose tablet, and Melatonin gummies. S5RN confirmed the 3 OTC medications were not on Patient #4’s medication list. S5RN stated that she knew the patient was taking Cranberry + D-Mannose for her digestive issues. She stated the patient must have just started the Melatonin and Zyrtec. S5RN asked Patient #4 how long she had been taking the Zyrtec and Melatonin. Patient’s son replied, “She has been taking them for a long time.” S5RN confirmed that a patient’s medications should be reconciled with each SN visit. She confirmed that she had overlooked Patient #4’s OTC medications and they should have been added to her medication list. On 12/17/2025 at 12:02 p.m., an interview was conducted with S2RN. She confirmed that S5RN informed her that she had overlooked OTC medications for Patient #4 and had not added them to the patient’s medication list. S2RN confirmed that Patient #4’s medication list was not accurate.

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 ensure the patient's written individualized POC (Plan of Care) was followed as evidenced by the SN (Skilled Nurse) failing to record daily weights for 1 (#2) out of 10 sampled patients. Findings: Patient #2. Review of the patient's electronic clinical record revealed the start of care date was 11/10/2025. The patient's diagnosis included acute diastolic congestive heart failure. The certification period reviewed was 11/10/2025 to 01/08/2026. Review of the patient's POC for certification period 11/10/2025 to 01/08/2026 revealed an order for skilled nurse 2wk2, 1wk7 (skilled nurse visit two times a week for two weeks, skill nurse visit one time a week for seven weeks). Further review of the patient's POC revealed an order for “Skilled nurse to instruct patient to obtain daily weighs at the same time each day and enter weights into provided log.” Review of the patient's SN visit note dated 11/10/2025 revealed there was no evidence the SN recorded the patient’s weight. On 12/16/2025 at 9:19 a.m., an interview was conducted with S2RN (Registered Nurse). S2RN reviewed the patient’s electronic clinical record and confirmed there was no evidence the SN recorded the patient’s weight and that she should have recorded the weight. On 12/17/2025 at 11:15 a.m., an interview was conducted with S1ADM (Administrator). S1ADM stated she reviewed the patient’s clinical record and confirmed there was no evidence the SN recorded the patient’s weight for the SN visit made on 11/10/2025 and that she should have recorded the weight.

Audubon Home Health of Lafayette is in compliance with federal emergency preparedness requirements.

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, interview and record review, the agency failed to ensure a review of all medications was conducted each SN (skilled nurse) visit in order to identify any potential adverse effects and drug reactions, and noncompliance with drug therapy. The agency failed to ensure an accurate Drug Regimen was obtained upon admission and reviewed for medication changes for 1 (#1) out of 4 (#1, #2, #3, #4) sampled patients with home visits made. Findings: Review of Patient #1's Home Health Certification and Plan of Care dated 11/11/2022 to 01/09/2023 revealed diagnoses included: Cellulitis of Left Lower Limb, Blister Left Foot, Blister Left Great Toe, Blister Left Lesser Toes, Type II Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, and Hyperlipidemia. Review of the Medication Profile revealed the orders for medications included: Budesonide-Formoterol Hydrofluoroalkane 160 microgram inhaler 1 puff daily; Ezetimibe 10 milligrams by mouth at bedtime; Ferate 240mg 1 tablet po twice a day; Metoprolol Succinate Extended Release 100mg 1 po daily; Tamsulosin 0.4mg capsule 2 capsules by mouth twice a day; Tizanidine 2mg 1 tablet every 8 hours as needed; On 11/28/2022 at 12:00 p.m., S2RN was observed reviewing patient #1’s medications during the home visit. Patient #1 presented medication bottles from a Ziploc bag as well as 2 bottles on her nightstand. Patient #1 was interviewed and medications were checked by S2RN on 11/28/2022 at 12:20 p.m. Patient #1 reported she had not used the Budesonide inhaler in over a month and did not have an inhaler in the home. Patient #1 stated she was not taking Tamsulosin. Patient #1 also stated she had not taken Tizanidine in several months and did not have any of this medication in the home. S2 RN continued to review Patient #1’s medications and found Patient #1 did not have Metoprolol, Ezetimibe, or Ferate 240mg tablets in the home. S2 RN also noted Patient #1 had a bottle of Nitroglycerin 0.4mg tabs indicated for prn use. Observation on 11/28/2022 at 12:43 p.m. revealed S2 RN called Patient #1’s pharmacy to clarify medication orders. S2 RN stated she had been informed by the pharmacy that Patient #1’s Ezetimbe had been changed to Crestor, Metoprolol had been discontinued on 11/10/2022, and there was no record Patient #1 had ever been on Tamsulosin, and Tizanidine had not been filled for Patient #1 since 06/2022. Interview on 11/28/2022 at 1:00 p.m. with S2 RN confirmed Patient #1’s medication list was not accurate. Interview on 11/28/2022 at 2:45 p.m. with S1Administrator confirmed Patient #1’s medication record was not accurate. S1Administrator confirmed Patient #1 had six Skilled Nurse visits prior to 11/28/2022 and the medication record had not been updated to reflect current/accurate medication orders on either of those visits and should have been.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure the Governing Body implemented performance improvement efforts to address priorities for improved quality of care and patient safety by failing to conduct QA/QAPI meetings at least quarterly. Findings: Review of the agency’s QAPI meeting minutes provided by S1 Administrator revealed the 1st quarter 2022 QAPI meeting was dated 05/25/2022. Interview on 11/29/2022 at 1:47 p.m. with S1 Administrator revealed the agency was behind on data collection when she assumed the position of Administrator in 11/2021. S1 Administrator stated she started collecting data for the first quarter of 2022 in 02/2022. Further interview confirmed the agency did not have a 1st quarter 2022 QAPI meeting where the data collected from the 1st quarter was presented to the QA committee and Governing Body until the second month of the 2nd quarter of 2022.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure that skilled professionals assume responsibilities appropriately as evidenced by the SN (Skilled Nurse) failing to follow the agency’s policy and procedure for communicating a change in a patients’ condition with the RN (Registered Nurse) for 1 (#6) out of 10 (#1-10) sampled patients. Review of the agency’s policy titled “Care/Service Coordination” revealed that timely and ongoing communication was the responsibility of each team member of the interdisciplinary group and would be appropriate to the needs and abilities of the patient, and relevant to the care/service provided. Further review of the policy revealed in part, Procedure: 4. Care coordination will include, but not limited to: C. timely documentation or coordination of care activities… 6. Organizational personnel will communicate changes in a timely manner via telephone, one-on-one meetings, case conferences, and home visits. Documentation of all communications will be included in the clinical record on a communication note, case conference summary, or clinical note. Documentation will include: the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication. Patient # 6: A review of the patient’s electronic clinical record revealed a start of care date of 11/11/2022. The patient’s diagnoses included Type 2 Diabetes, Hypertension, Weakness, and Urinary Tract Infection. The certification period reviewed was 11/11/2022 to 1/9/2023. A review of the patient’s POC (Plan of Care) for the certification period 11/11/2022 to 1/9/2023, revealed an order for “SN 1wk9” (skilled nurse visit one time a week for nine weeks). A review of the patient’s skilled nurse visit notes dated 11/21/2022 revealed that the patient complained of back pain, lower abdominal pain, and frequent urination. Further review revealed that S7LPN spoke with the nurse at the patient’s physician’s office and an order was given to collect a urine sample and that antibiotics would be called in by the physician for a UTI (Urinary Tract Infection). Further review of the patient’s clinical record failed to reveal a clinical note or other communication with S6RN, that a urine sample had been collected or that the physician had ordered antibiotics for the patient. On 11/29/2022 at 2:45 p.m., an interview was conducted with S1Administrator. She stated that she was also the DON for the agency. S1Administrator conducted a review of Patient #6’s electronic records was conducted with S1Administrator. She reviewed the SN visit note dated 11/21/2022 and confirmed that the nurse had documented that the patient complained of back pain, lower abdominal pain, and frequent urination, and that an order was given to collect a urine sample and that antibiotics would be called in by the physician for a UTI. She further confirmed that there was no evidence in the patient’s medical record that the nurse had followed the agency’s policy and communicated with the RN regarding the change in the patient’s condition or the new orders. Concurrently, a telephone interview was conducted with S7LPN, who stated that when there was a change in a patients’ condition and/or medication(s), the nurse was responsible for communicating the changes with the RN and/or the DON (Director of Nursing). She stated that on 11/22/2022, she collected the urine sample for Patient #6 and she informed the RN and/or the DON by text that the urine was collected. S7LPN further stated that she was unable to remember if she had informed the RN that the patient’s physician had ordered antibiotics or if she had documented the notification in the patient’s clinical record.