Every finding on record at Bluebonnet Healthcare, Inc

The entity is in compliance with federal emergency preparedness requirements.

Recertification Survey

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 interviews and record reviews, the agency failed to ensure each patient’s plan of care included nutritional requirements, patient-specific interventions, and/or measurable outcomes and goals for 2 (#1 and #2) of 2 patients reviewed. The agency failed to ensure the plan of care included: Patient #1’s occupational therapy goals and interventions; andPatient #2’s enteral feeding order and skilled nursing goals and interventions. Findings: Review of the agency’s undated policy titled, “Physician’s Plan of Care/Change Orders” revealed the following, in part: The physician’s plan of care (CMS-485) is an individualized plan for care and treatment prepared by the client’s physician with the assistance from the nurse and/or therapist who establishes the plan based upon the current assessment of the client. The plan of care shall be developed within five days of the assessment… The agency will provide care/services consistent with the plan of care. The plan of care shall include but not limited to: Nutritional requirements Specific procedures for treatments, treatments performed by therapies include the amount, frequency and duration of the modalities… Goals and outcomes to be achieved Review of the agency’s policy titled, “Professional/Ancillary Care Plans” revealed the following, in part: An individualized plan of care may be developed and implemented by each professional discipline providing service. Each plan will include: Identified problems and needs Specific, individualized, measurable goals and interventions Specific services to be provided including frequency and duration 1. Patient #1 Review of Patient #1’s Clinical Record revealed she began receiving services from the agency on 02/20/2026, had a current certification period of 02/20/2026 through 04/20/2026, and diagnoses, which included Spinal Stenosis – Lumbar Region. Further review revealed Patient #1 received skilled nursing visits once weekly for nine weeks and occupational therapy visits once weekly for one week beginning the week of 02/22/2026 then twice weekly for two weeks. Review of Patient #1’s plan of care for certification period of 02/20/2026 through 04/20/2026 revealed no documented occupational therapy goals or interventions. Patient #2 Review of Patient #2’s Clinical Record revealed she began receiving services from the agency on 02/21/2026, had a current certification period of 02/21/2026 through 04/21/2026, and diagnoses, which included Traumatic Cerebral Hemorrhage, Pressure Ulcer of Sacral Region – Stage 3, Type II Diabetes Mellitus, Quadriplegia, Aphasia, Tracheostomy Status, Dependence on Supplemental Oxygen, and Gastrostomy Status. Further review revealed Patient #2 received skilled nursing visits once weekly for nine weeks. Review of Patient #2’s plan of care for certification period of 02/21/2026 through 04/21/2026 revealed no documented enteral feeding order and no documented nursing goals or interventions. An interview was conducted with S1ADM and S2CD on 03/04/2026 at 2:41 p.m. S1ADM stated the agency’s process for developing a plan of care was S2CD and/or the therapy discipline performed an initial assessment, and based on the assessment, a plan of care was established. S1ADM stated he was responsible to ensure therapy goals and interventions were placed on the plan of care. S1ADM confirmed Patient #1 received occupational therapy services. S1ADM reviewed Patient #1’s plan of care. S1ADM confirmed there were no occupational therapy goals or interventions on Patient #1’s plan of care. S2CD reviewed Patient #2’s plan of care and confirmed there were no nursing goals or interventions on the plan of care. S2CD confirmed Patient #2’s only source of nutrition was through enteral feedings. S2CD confirmed Patient #2’s enteral feeding order was not on the plan of care and should have been. S1ADM and S2CD confirmed each patient’s plan of care should have reflected the therapy and nursing goals and interventions to ensure care and services were provided adequately and accurately.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure wound care orders were recorded on the plan of care for 1 (#2) of 2 patients reviewed with wounds. Findings: Review of the agency’s undated policy titled, “Physician’s Plan of Care/Change Orders” revealed the following, in part: The physician’s plan of care (CMS-485) is an individualized plan for care and treatment prepared by the client’s physician with the assistance from the nurse and/or therapist who establishes the plan based upon the current assessment of the client. The plan of care shall include but not limited to: Specific procedures for treatments Review of Patient #2’s Clinical Record revealed she began receiving services from the agency on 02/21/2026, had a current certification period of 02/21/2026 through 04/21/2026, and diagnoses, which included Pressure Ulcer of Sacral Region – Stage 3. Further review revealed Patient #2 received skilled nursing visits once weekly for nine weeks. Review of Patient #2’s electronic Medical Record revealed an attachment with the following wound care order dated 02/23/2026: Sacrum: Cleanse with Vashe, apply Iodosorb Gel and Hydrofera Blue, and cover with silicone bordered gauze. Change dressing daily. Review of Patient #2’s plan of care for certification period of 02/21/2026 through 04/21/2026 revealed no documented treatment for her Sacral Pressure Ulcer. An interview was conducted with S2CD on 03/04/2026 at 10:28 a.m. She confirmed Patient #2 had received wound care since the start of care. She confirmed Patient #2’s wound care order was not recorded on the plan of care. An interview was conducted with S1ADM on 03/04/2025 at 11:08 a.m. He confirmed Patient #2’s current wound care order should have been recorded on the 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 observation, interview, and record review, the agency failed to ensure wound care was provided as ordered by the physician for 1 (#2) of 1 resident observed for wound care. Findings: Review of the agency’s undated policy titled, “Physician’s Plan of Care/Change Orders” revealed the following, in part: The physician’s plan of care (CMS-485) is an individualized plan for care and treatment prepared by the client’s physician with the assistance from the nurse and/or therapist who establishes the plan based upon the current assessment of the client. The agency will provide care/services consistent with the plan of care. Review of Patient #2’s Clinical Record revealed she began receiving services from the agency on 02/21/2026, had a current certification period of 02/21/2026 through 04/21/2026, and diagnoses, which included Pressure Ulcer of Sacral Region – Stage 3. Further review revealed Patient #2 received skilled nursing visits once weekly for nine weeks. Review of Patient #2’s Sacral Pressure Ulcer wound care order dated 03/02/2026 revealed to Cleanse with Vashe, apply Iodosorb Gel and Hydrofera Blue, and cover with a silicone bordered gauze. A home visit was conducted with Patient #2 on 03/03/2026 at 3:00 p.m. with S2CD. S2CD performed wound care during the home visit to Patient #2’s Sacral Pressure Ulcer. S2CD cleansed the wound with Vashe soaked gauze and applied Solosite wound gel, hydrofera blue, and a dry, adhesive dressing. S2CD did not apply Iodosorb to the wound bed. An interview was conducted with S2CD on 03/04/2026 at 10:28 a.m. S2CD confirmed Patient #2’s current sacral wound care order was to apply Iodosorb to the wound bed. She confirmed she should have applied Iodosorb to the wound bed and not Solosite wound gel. An interview was conducted with S1ADM on 03/04/2025 at 11:08 a.m. He confirmed Patient #2’s wound care should have been performed as ordered by the physician.

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 interview and record review, the agency failed to ensure a physician’s order for Physical Therapy was integrated into the patient’s plan of care for 1 (#1) of 2 patients reviewed. Findings: Review of Patient #1’s Clinical Record revealed she was referred to the agency on 02/18/2026 with a physician order for Physical Therapy Services. Further review revealed Patient #1 began receiving services from the agency on 02/20/2026, had a current certification period of 02/20/2026 through 04/20/2026, and diagnoses, which included Spinal Stenosis – Lumbar Region. Review of Patient #1’s Plan of Care for certification period of 02/20/2026 through 04/20/2026 revealed no documentation pertaining to physical therapy services or refusal of physical therapy services. Review of Patient #1’s Physician Orders and Coordination Notes for the certification period of 02/20/2026 through 04/20/2026 revealed no documented evidence the physician was contacted for clarification of the physical therapy services, to discontinue the order, or that physical therapy services would not be provided. An interview was conducted with S2CD on 03/04/2026 at 10:28 a.m. She confirmed Patient #1’s referral included an order for physical therapy. She confirmed physical therapy was not provided for Patient #1 and should have been. An interview was conducted with S1ADM on 03/04/2026 at 10:54 a.m. He confirmed physical therapy services were not provided for Patient #1. He reviewed Patient #1’s clinical record. He confirmed there was no documentation Patient #1 refused physical therapy. He confirmed there was no order to discontinue physical therapy services.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Registered Nurse provided Skilled Professional Services in accordance with current clinical practice guidelines as set forth by the Louisiana State Board of Nursing Declaratory Statement for Scope of Practice for Registered Nurses - Wound Care Management and accepted professional standards as set forth by the National Pressure Ulcer Advisory Panel for Prevention and Treatment of Pressure Ulcers for 1 (#2) of 1 patient reviewed with Pressure Ulcers. The agency failed to ensure the RN assessed Patient #2’s Pressure Ulcer weekly. Findings: Review of the Louisiana State Board of Nursing, Declaratory Statement Scope of Practice for Registered Nurses - Wound Care Management revealed, in part, the following: Registered nurses render care that is directed towards the prevention and the treatment of wounds. Scope of Practice - The Louisiana State Board of Nursing recognizes that assessment, planning, intervention, teaching, evaluation, and supervision are the major responsibilities of the registered nurse in the practice setting. The Registered Nurse initiates appropriate wound prevention measures, stages wounds and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by the authorized prescriber. The Registered Nurse initiates appropriate wound preventative measures, stages wounds and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by an authorized prescriber. Delegation - In accord with the Law Governing the Practice of Nursing (RS 37:913(14) the Registered Nurse may delegate select nursing interventions to qualified nursing personnel as set forth in the Board's rules on delegation (LAC 46:XLVII.3703.). The Registered Nurse retains the accountability for the total nursing care of the individual. The Registered Nurse may delegate to a Licensed Practical Nurse wound care interventions in any situation when the Registered Nurse has deemed the patients status is stable, the intervention is based on a relatively fixed and limited body of scientific knowledge, can be performed by following a defined nursing procedure with minimal alteration, responses of the individual to the nursing care are predictable and changes in the patient's clinical condition are predictable. Furthermore, the patient's medical and nursing orders are not subject to continuous change or complex modification, and appropriate RN supervision is available. Review of the National Pressure Ulcer Advisory Panel Prevention and Treatment of Pressure Ulcers: Quick Reference Guide revealed, in part, the following: Pressure Ulcer Assessment 1. Assess the Pressure Ulcers initially and re-assess it at least weekly. 1.1. Document the results of all wound assessments. Assess and document physical characteristics including: location, category/stage, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. Review of Patient #2’s Clinical Record revealed she began receiving services from the agency on 02/21/2026, had a current certification period of 02/21/2026 through 04/21/2026, and diagnoses, which included Pressure Ulcer of Sacral Region – Stage 3. Further review revealed Patient #2 received skilled nursing visits once weekly for nine weeks. Review of Patient #2’s electronic Medical Record revealed an attachment with the following wound care order dated 02/23/2026: Sacrum: Cleanse with Vashe, apply Iodosorb Gel and Hydrofera Blue, and cover with silicone bordered gauze. Change dressing daily. Review of Patient #2’s Sacral Pressure Ulcer wound care order dated 03/02/2026 revealed to Cleanse with Vashe, apply Iodosorb Gel and Hydrofera Blue, and cover with a silicone bordered gauze. Review of Patient #2’s Visit Notes for certification period of 02/21/2026 through 04/21/2026 revealed nursing visits were conducted on 02/21/2026 and 02/26/2026. Further review revealed Patient #2’s Sacral Pressure Ulcer assessment dated 02/21/2026 did not include tissue type(s), color, peri-wound condition, and wound edges condition. There was no documentation Patient #2’s Sacral Pressure Ulcer was assessed by the RN on 02/26/2026. An interview was conducted with S2CD on 03/04/2026 at 12:15 p.m. She confirmed there was no documentation of the tissue type(s), color, peri-wound condition, and wound edges condition for Patient #2’s Sacral Pressure Ulcer assessment on 02/21/2026, which was not a full assessment. She confirmed she did not perform or document a full Pressure Ulcer assessment for Patient #2 on 02/26/2026. She confirmed Pressure Ulcer assessments should have been conducted and documented weekly.

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey Abbreviations: DON-Director of Nursing G-tube- Gastrostomy tube LPN-Licensed Practical Nurse mg-milligram mL-milliliter

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 during a home visit, interviews, and record review, the agency failed to ensure the patient’s comprehensive assessment included a review of all medications the patient was currently using. The agency failed to ensure skilled nursing staff reconciled a patient’s medications for 1 (#2) of 3 (#1, #2, and #3) patients reviewed with home visits. Findings: Review of the Agency’s Policy titled, “Medication Reconciliation” revealed the following, in part: Objectives: To ensure consistency and awareness of medication reconciliation and best practices. To reduce medication discrepancies that have the potential to result in adverse drug events by ensuring the accurate and complete transfer of medication at care transitions. Elements: 2. Process: 2.3 Step 3: Document and communicate the medication information. (i) any changes to the patient’s medications that have been made or new medications that have been added. Review of the Clinical Record for Patient #2 revealed she began receiving services from the Home Health Agency on 08/15/2019 and had a current Certification Period of 01/26/2023 to 03/26/2023. Patient #2 had diagnoses, which included Lennox-Gastaut Syndrome, Generalized Idiopathic Epilepsy, Cerebral Palsy, Chronic Respiratory Failure, and Encounter for Attention to Tracheostomy. Further review revealed Patient #2 was ordered to receive Skilled Nursing Visits 24 hours a day/7 days a week for Certification period of 01/26/2023 to 03/26/2023. A home visit was conducted with Patient #2 on 03/01/2023 at 10:00 a.m. with S2LPN present in the home. Patient #2’s medications were reviewed during the home visit. The following medication discrepancy was identified when compared to the Current Medication Profile for Patient #2 provided by the Home Health Agency: Lacosamide Oral Solution 10mg/mL administer 5mL daily via G-tube – instructions on medication bottle revealed administer 10mL daily An interview was conducted with S2LPN on 03/01/2023 at 10:15 a.m. She stated in January 2023, Patient #2’s physician increased the dose of Lacosamide 10mg/mL from 5 mL to 10 mL daily. She reviewed the Locasamide medication box and stated the Lacosamide Oral Solution 10mg/mL administer 10mL daily via G-tube was filled on 02/12/2023. She confirmed the current Medication Profile and the prescribed Locasamide dosage did not match. She confirmed the medication profile should have reflected the current prescribed dose of Locasamide. An interview was conducted with S1DON on 03/01/2023 at 11:15 a.m. She stated medications should have been reconciled during each visit by the Home Health Agency. She confirmed Patient #2’s Medication Profile should have reflected the current prescribed dose of Lacosamide.

Recertification Survey. A COVID-19 Focused Infection Control Survey was conducted on 03/11/2021 per QSO-20-20-ALL. No deficiencies were cited as a result of this survey. Abbreviations: HHA- Home Health Agency MD- Medical Doctor QA- Quality Assurance

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interviews and record reviews, the agency failed to ensure the plan of care was signed and dated by the patient's physician in a timely manner for 3 (#2, #3, #4) of 7 (#1-#7) sampled patients. Cross-referenced with State Regulations 9123. Patient Care Standards: C. Plan of Care. The plan of care for each patient must be individualized to address the patient's problems, goals, and required services. 1. The Plan of Care, telephone and/or verbal orders must be signed by the physician within a timely manner, not to exceed 30 days. Findings: Patient #2 Review of the clinical record for Patient # 2 revealed a start of care date of 08/15/2019. Review of the plan of care for the certification period 02/05/2021 - 04/05/2021 for the patient revealed a principal diagnosis of Lennox-Gastaut Syndrome. Further review of the plan of care for this certification period revealed it was not signed by the physician. Patient #3 Review of the clinical record for Patient # 3 revealed a start of care date of 04/11/2018. Review of the plan of care for the certification period 01/25/2021 - 03/25/2021 for the patient revealed a principal diagnosis of Infantile Spinal Muscular Atrophy. Further review of the plan of care for this certification period revealed it was not signed by the physician. Patient #4 Review of the clinical record for Patient #4 revealed a start of care date of 08/03/2018. Review of the plan of care for the certification period 01/19/2021 - 03/19/2021 for the patient revealed a principal diagnosis of Chronic Obstructive Pulmonary Disease. Further review of the plan of care for this certification period revealed it was not signed by the physician. An interview was conducted on 03/11/2021 at 2:00 p.m. with S3OfficeMgr. She verified she was responsible for submitting the plan of care to the physician to be signed for all patients that received services. She stated she was unaware the plan of care was to be signed by the physician within 30 days. She confirmed she was not submitting them to the physician in time to ensure the 30-day requirement was met.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record reviews and interview, the agency failed to measure, analyze and track quality indicators, including adverse patient events, and other aspects of performance that enable the home health agency to assess processes of care, agency services and operations. Findings: A request was made to review the HHA Quality Indicator program documentation on 03/11/2021 at 1:00 p.m. Several binders were provided for review by S4Scheduler, one of which included a QA binder. In the QA binder revealed documentation of QA Committee meetings that occurred September 2020 and December 2020. Review of the Quality Improvement Meeting documentation revealed the following: 09/14/2020-6 open charts and 2 closed charts were reviewed that revealed the following in part: MD orders not signed timely in 2 of 8 records reviewed Orders not followed in 2 of 8 records audited Medication Profile not updated in 3 of 8 records Monthly Validation reports reviewed 50% Wound Care charts audited 50% Hospitalization charts audited Following COVID Policy and Procedure- Blank Variances completed timely 4 of 4 records audited. Action to correct deficiencies: Resubmit MD orders every 14 days, Reprimand for continued errors, In-services, Continue Monthly Validation Report reviews and Audit Adverse Events. 12/08/2020- 5 open charts and 2 closed charts were reviewed that revealed the following in part: MD orders not signed timely in 1 of 7 records reviewed Orders not followed in 2 of 7 records audited Medication Profile not updated in 1 of 7 records Monthly Validation reports reviewed 50% Wound Care charts audited 50% Hospitalization charts audited Following COVID Policy and Procedure- 1 of 7 records audited Notes completed in a timely manner- 3 of 7 records audited Variances completed timely 2 of 7 records audited. Action to correct deficiencies: Resubmit MD orders every 14 days, Reprimand for continued errors, In-services, Continue Monthly Validation report reviews and Audit Adverse Events. A request was made to review the results of the information that was obtained during the Quality Improvement Meetings on 09/14/2020 and 12/08/2020. The agency was unable to provide documentation showing concerns that were identified in the QA meetings were analyzed and tracked. On 03/11/2021 at 1:30 p.m., other binders were reviewed that included Incident Accident Reports, Policy and Procedure Manuals, Administrative documentation and Infection Control documentation. A review was conducted of all of the information provided. There was no documentation to show the agency was analyzing and tracking any data that was located in the binders for QA purposes. An interview was held with S4Scheduler on 03/11/2021 at 2:00 p.m. She stated she assisted the agency with scheduling the patients and ensuring the nurses were providing services as needed. She also stated she was a consultant for the agency as needed. She confirmed she was involved in the agency's quality improvement program. When asked about a particular concern they identified in their QA meetings, she stated they would discuss it and address it during the meeting. She verified she was unable to show documentation showing the quality committee was tracking and analyzing the data they obtained when they met in September and December.

Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to take action aimed at performance improvement, measure the success of the actions taken and ensure the improvements were sustained. Findings: Review of the Quality Improvement Meeting documentation revealed the following: 09/14/2020-6 open charts and 2 closed charts were reviewed that revealed the following in part: MD orders not signed timely in 2 of 8 records reviewed Orders not followed in 2 of 8 records audited Medication Profile not updated in 3 of 8 records Monthly Validation reports reviewed 50% Wound Care charts audited 50% Hospitalization charts audited Following COVID Policy and Procedure- Blank Variances completed timely 4 of 4 records audited. Action to correct deficiencies: Resubmit MD orders every 14 days, Reprimand for continued errors, In-services, Continue Monthly Validation report reviews and Audit Adverse Events. 12/08/2020- 5 open charts and 2 closed charts were reviewed that revealed the following in part: MD orders not signed timely in 1 of 7 records reviewed Orders not followed in 2 of 7 records audited Medication Profile not updated in 1 of 7 records Monthly Validation reports reviewed 50% Wound Care charts audited 50% Hospitalization charts audited Following COVID Policy and Procedure- 1 of 7 records audited Notes completed in a timely manner- 3 of 7 records audited Variances completed timely 2 of 7 records audited. Action to correct deficiencies: Resubmit MD orders every 14 days, Reprimand for continued errors, In-services, Continue Monthly Validation report reviews and Audit Adverse Events. A request was made on 03/11/2021 at 1:30 p.m. to provide information regarding corrective actions taken to correct concerns that were identified in the meetings that were held on 09/14/2020 and 12/08/2020. There was no documentation available for review to show actions taken by the agency to fix the concerns identified in the meetings. An interview was held with S4Scheduler on 03/11/2021 at 2:00 p.m. A request was made to review documentation of the actions taken to correct deficiencies that were identified in the QA meetings on 09/14/2020 and 12/08/2020. She stated when they identified a concern such as physician orders not being followed for a patient, a staff member would look at the patient record to investigate it to see why the order was not followed. She stated most of the time it was due to the nurse documenting in error. She stated they would have this concern fixed at that time. When asked to provide all of the documentation to show they had taken action to correct the concerns identified in the meeting, she was unable to show the agency had implemented anything to correct the issue. She also verified she was unable to show documentation they had monitored to ensure the action taken had corrected the concern identified and no further issues were occurring.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record reviews and interviews, the Home Health Agency failed to annually conduct and document a minimum of one performance improvement project undertaken, the reasons for conducting the project, and measurable progress achieved on that project. Findings: A request was made to review the Performance Improvement project the agency was conducting or in development on 03/11/2021 at 1:00 p.m. S4Scheduler provided all of the identified Quality Assurance information the agency had for review. A review was made at that time and there was no documentation of any performance improvement projects at the time of the request. An interview was held with S4Scheduler on 03/11/2021 at 2:00 p.m. When asked if they had conducted a performance improvement project for the agency, she was unable to verbalize or provide any documentation a performance project had been completed.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to provide services ordered by the physician for 1 (#6) of 7 (#1 - #7) sampled patients. The agency failed to ensure Patient #6 received 35 hours/week of skilled nursing as indicated in the plan of care. Findings Review of the 485/Home Health Certification and Plan of Care for 12/27/2020 to 02/24/2021 revealed the following: Patient #6 had a principal diagnosis of Anoxic Brain Damage and was ordered to receive private duty nursing 35 hours a week/7 days a week. Review of Oasis Assessment Details for Patient #6 dated 02/05/2021 revealed the following: This assessment is currently being completed for the following reason: 6. Transferred to inpatient facility- patient not discharged from agency. Review of the Skilled Nurse visit notes for Patient #6 revealed the following: Patient #6 received services on 02/04/20. Further review revealed Patient #6 did not receive services again until 03/03/2021. Review of Patient Communication Log report provided by the agency for Patient #6 revealed the following: in part; 02/08/2021 Patient discharged from local hospital. Patient will quarantine for COVID-19. Quarantine to be completed on the 02/18/2021. Informed mom that he had to be retested prior to skilled nurse returning. An interview was conducted on 03/11/2021 at 11:30 a.m. with Patient #6's mother. She said Patient #6 was admitted to the hospital on 02/05/2021 and was discharged on 02/09/2021. She said he tested positive for COVID-19 while in the hospital. She said Patient #6 quarantined for 14 days according to the home health agency policy. She said he tested negative for COVID -19 on 02/19/2021 and qualified to resume services with the home health agency. She said Patient #6's nurse had been assigned to another patient while he was in the hospital so she and her mother provided care to Patient #6 until the agency could provide another staff member. An interview was conducted on 03/11/2021 at 12:00 p.m. with S2DON. She said patients who test positive for COVID-19 are required to quarantine for 14 days and obtain a COVID -19 negative test result before a skilled nurse could resume care in the home. She reviewed Patient #6's medical record and confirmed he quarantined for 14 days after testing positive for COVID-19 and tested negative on 02/19/2021. She said Patient #6 should have had skilled nurse services resumed on 02/22/2021. She reviewed the nurse's notes for Patient #6 and verified Patient #6 received skilled nurse services on 02/04/2021 prior to hospitalization and did not receive services again until 03/03/2021. She said she was unsure why staff had not resumed care for Patient #6 on 02/22/2021 after obtaining a negative COVID-19 test. She said the agency failed to provide services according to Patient #6's plan of care.