Every finding on record at Board of Commissioners-Hospital Service District #2 of Lasalle Parish

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

Recertification Survey Abbreviations: POC-Plan of Care RN-Registered Nurse

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 record review, observation, and interview, the agency failed to ensure the individualized plan of care included all pertinent diagnoses, all types of services and treatments required, and patient and caregiver education and training for 2 (#1 and #6)) of 7 sampled patients reviewed. Findings: Patient #1 Review of Patient #1’s POC (Plan of Care) revealed a start of care date of 12/18/2024 and a certification period of 10/14/2025 through 12/12/2025. Further review revealed Client #1 diagnoses were Cerebrovascular disease, Hypothyroidism, Age-related Osteoporosis without current pathological fracture, Other specified nutritional anemias, Dermatitis, and Slow transit constipation. Review of the POC revealed no diagnoses of wounds or orders for wound care. In an interview on 12/15/2025 at 11:41 a.m., S1 Director confirmed Patient #1 was receiving wound care and the wound diagnoses and wound care orders were not listed on the POC, but should have been. S1 Director stated the orders did not get carried over to the new POC from the last episode but should have been. During a home visit on 12/15/2025 at 3:15 p.m., wound care was performed by S3 RN to Patient #1’s right shoulder area. At this time, S3 RN confirmed Patient #1 also had wounds to her left hip and sacrum/coccyx area that were being treated weekly by the wound care clinic. In an interview on 12/16/2025 at 2:50 p.m., S3 RN confirmed she recertified Patient #1 and completed the POC but failed to enter the diagnoses and wound care orders for her wounds, but should have. Patient #6 Review of #6’s Home Health Care Certification and Plan of Care (485) for the certification period 04/24/2025 – 06/22/2025 reflected no care interventions, measureable outcomes listed, and no specific patient and caregiver education and training. Staff interview with S1 Director on 12/15/2025 at 3:50 p.m. revealed Patient #6’s nursing interventions were entered into the computer for the nurses’ visits while creating the Plan of Care, but they did not carry over to the 485/doctor’s orders and they should have. Interview on 12/16/2025 at 9:00 a.m. with S1 Director revealed when the assessing nurse generates a Plan of Care/485, the goals, care interventions, and outcomes have to be clicked on to carry over to the 485. S1 Director confirmed Patient #6’s 485/Plan of Care did not have goals, interventions, patient and caregiver education and training, or outcomes, and it should have. She revealed they had failed to click the button to carry them over to the 485. Interview on 05/16/2025 at 2:00 p.m. with S2 RN, revealed she was Patient #6’s home health nurse and that she was the nurse that performed the initial assessment, created the plan of care, and made all the skilled nurse visits, including the discharge visit. She revealed that she had created interventions, goals, outcomes, and patient/caregiver education and training, but must have not clicked to have them added to the 485 and she should have. S2 RN confirmed the interventions, goals, outcomes, and patient/caregiver education and training were on the Plan of Care that she followed in the home, and that the doctor did sign the 485, but she did not realize that the interventions, goals, outcome, and patient/caregiver education and training were not on the signed 485 and they should have been.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the revised POC (Plan of Care) reflected current information from the patient’s updated comprehensive assessment for 1 (#1) of 7 sampled patients reviewed. Findings: Review of Patient #1’s POC (Plan of Care) revealed a start of care date of 12/18/2024 and a certification period of 10/14/2025 through 12/12/2025. Further review revealed Client #1 diagnoses were Cerebrovascular disease, Hypothyroidism, Age-related Osteoporosis without current pathological fracture, Other specified nutritional anemias, Dermatitis, and Slow transit constipation. Further review of Patient #1’s POC revealed interventions that included physical therapy and speech language pathology therapy. Review of the visit notes revealed no visits made by physical therapy or speech therapy. In an interview on 12/15/2025 at 11:41 a.m., S1 Director stated Patient #1 last received speech therapy in 05/2025 and physical therapy in 01/2025. S1 Director confirmed the speech and physical therapy orders were carried over from a previous episode by the nurse writing the POC. S1 Director confirmed the nurse should have removed the speech and physical therapy interventions, but had not. In an interview on 12/16/2025 at 2:50 p.m., S3 RN confirmed Patient #1 was no longer receiving physical or speech therapy services. S3 RN stated those were old orders that she should have removed when recertifying the patient, but did not.

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

Recertification Survey Abbreviations: LPN - Licensed Practical Nurse DON - Director of Nurses w - week mg - milligram POC - Plan of Care CNA - Certified Nursing Assistant PT - Physical Therapist RN - Registered Nurse

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 the nurse reviewed all the patient medications in use during a skilled nurse home visits for 1 (Patient #1) of 3 (Patient #1, #2, and #3) home visits conducted. Findings: Review of the clinical record revealed Patient #1 was admitted to the agency on 11/25/2022, with a principal diagnosis of Hypertension and Fracture of left shoulder. Review of the Home Health Certification and Plan of Care for certification period of 11/25/2022 to 01/23/2023 revealed orders for Skilled Nurse Visits to be conducted 1w8 beginning 11/28/2022. Observation during the home visit conducted on 01/04/2023 at 9:00 a.m. revealed S4 LPN did not request or observe Patient #1’s medications. Interview with S4 LPN on 01/04/2023 at 9:50 a.m. confirmed she had not observed the patient’s medications and reconciled the medications with the Medication Profile. S4 LPN stated she normally will go down the list of medications with the patient and ask if she is still taking that dosage and if there had been any changes. Interview S1 DON on 01/04/2023 confirmed the skilled nurses should physically observe the patients medication bottles and reconcile them with the Medication Profile each visit to ensure the patients are receiving the correct medications. S1 DON confirmed if staff had observed the medication bottles each visit.

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: Patient #1 Review of Patient #1’s Home Health Care Certification and Plan of Care for Certification Period 11/25/2022 through 01/23/2023 revealed an order for home health aide treatments twice per week for 8 weeks beginning during week of 11/28/2022 and ending on 01/21/2023. Further review revealed Patient #1 was admitted with diagnoses that included, in part, Fracture of left shoulder, Atherosclerotic Heart Disease, and Iron Deficiency Anemia. Review of Patient #1’s medical record revealed an order for Physical Therapy twice per week for 4 weeks beginning 12/01/2022 through 12/24/2022. Review of Patient #1’s visit records revealed the patient only received one home health aide visit the week of 12/18/2022 through 12/24/2022 and revealed a missed home health aide visit on 12/23/2022. Further review of the missed visit note revealed S2 CNA documented the reason for the missed visit as “Holiday.” Further review of Patient #1’s visit records revealed the patient only received one physical therapy visit the week of 12/18/2022 through 12/24/2022. Review of a missed physical therapy visit dated 12/21/2022 revealed S3 PT documented a telephone note that stated, “Patient today contacted prior to treatment session. Patient was not home, gone with granddaughter. Patient was informed due to holiday would be next week till next treatment session…” Further review of visit records revealed Patient #1 was not seen again by physical therapy until 12/28/2022, at which time the patient was discharged. During an interview on 01/04/2023 at 12:40 p.m., S3 PT acknowledged Patient #1 was only seen once during the week of 12/18/2022 through 12/24/2022. S3 PT reported he could not complete the PT visit on 12/22/2022 because he was booked that day, 12/23/2022 was a holiday and they were closed. S3 PT confirmed he did not see Patient #1 until 12/28/2022 and stated the agency was also closed on 12/26/2022. S3 PT confirmed the agency does have a back-up physical therapist but she did not see Patient #1 in his absence. During an interview on 01/04/2023 at 11:49 a.m., S1 DON acknowledged Patient #1 did not receive the home health aide visits or physical therapy visits as ordered by the physician for the week of 12/18/2022 through 12/24/2022. S1 DON confirmed the agency was closed on 12/23/2022.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a registered nurse (RN) conducted an onsite visit to the patient’s home no less than every 14 days for an aide supervisory visit for 2 (Patient #1 and #5) of 7 sampled patients out of total of census of 55 patients. Findings: 1. Review of the clinical record revealed Patient #5 was admitted to the agency on 11/29/2022, with a principal diagnosis of Urinary Tract Infection and Primary Generalized Osteoarthritis. Review of the Home Health Certification and Plan of Care for certification period of 11/29/2022 to 01/27/2023 revealed orders that included the following: Home Health Aides 1w1, 2w8. Review of the Home Health Aide visit notes revealed documentation that an Aide Supervisory visit was conducted by the RN on 12/06/2022, however there was no documentation that reflected that Patient #5 had received an Aide Supervisory Visit from 12/13/2022 thru 01/03/2023. 2. Review of the clinical record revealed Patient #1 was admitted to the agency on 11/29/2022, with a principal diagnosis of Hypertension and Fracture of left shoulder. Review of the Home Health Certification and Plan of Care for certification period of 11/25/2022 to 01/23/2023 revealed orders that included the following: Home Health Aides 2w8. Review of the Home Health Aide visit notes revealed documentation that an Aide Supervisory visit was conducted by the RN on 12/07/2022, however there was no documentation that reflected that Patient #1 had received an Aide Supervisory Visit from 12/14/2022 thru 01/03/2023. Interview with S1 DON on 01/04/2023 at 11:44 a.m. confirmed that the RN had not documented an Aide Supervisory visit every 14 days for Patients #1 and #5 as she should have.