Every finding on record at Central Home Health of Metairie, LLC

Complaint Survey #LA2709186 Abbreviations: POC- Plan of Care PRN- As needed RN- Registered Nurse SN- Skilled Nurse SNV- Skilled Nurse Visit

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 reviews and interviews, the agency failed to ensure the Registered Nurse (RN) provided home health agency services in accordance with current clinical practice guidelines as set forth by the Louisiana State Board of Nursing (LSBN) 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 3 sampled patients reviewed for Pressure Ulcers. This deficient practice was evidenced by failure of the agency to ensure the RN performed weekly assessments and measurements for Patient #2’s Stage 2 Pressure Ulcer. Findings: Review of the agency’s undated policy titled “Skin Assessment, Wound Care, Pressure Ulcer Prevention” revealed, in part: Procedure: When a skin condition, wound, pressure ulcer is noted, the wound should be assessed by a skilled nurse and documented in the wound assessment area of the nursing note. Wound documentation in the skilled nursing note shall include: wound location, wound size (measurements performed weekly in centimeters) including length, width, and depth. Wounds will be assessed each skilled nurse visit. Review of the Louisiana State Board of Nursing’s Declaratory Statement Scope of Practice for RNs - Wound Care Management revealed, in part, the following: Scope of Practice - The State’s Board of Nursing recognizes that assessment, planning, intervention, teaching, evaluation, and supervision are the major responsibilities of the registered nurse who measures, stages wounds, and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by the authorized prescriber. Review of the clinical record for Patient #2 revealed he began receiving services from the agency on 12/18/2025 with diagnoses, which included in part, Pressure Ulcer to Right Heel, Stage 2. Review of Patient #2’s Plan of Care for Certification Period dated 12/18/2025 through 02/15/2026 revealed the following, in part: Skilled Nurse to perform wound care to Right Heel Pressure Ulcer Stage 2 every Wednesday and Friday. SN to assess/evaluate wound(s) at each dressing change and PRN for signs/symptoms of infection. Review of Patient #2’s Skilled Nurse Visit Notes, Physician Orders, and Communication Notes for Certification Period dated 12/18/2025 to 02/15/2026 revealed Patient #2’s Pressure Ulcer to Right Heel was not assessed, staged, or measured by the RN the weeks of 12/31/2025 or 01/14/2026. An interview was conducted with S2RN on 01/30/2026 at 2:12 p.m. S2RN reviewed Patient #2’s clinical record and confirmed his pressure ulcer was not assessed, staged, or measured by a RN on the weeks of 12/31/2025 or 01/14/2026 and should have been. An interview was conducted with S3NC on 01/30/2026 at 2:28 p.m. S3NC reviewed Patient #2’s clinical record and confirmed his pressure ulcer was not assessed, staged, or measured by a RN the weeks of 12/31/2025 or 01/14/2026. S3NC confirmed an RN should assess, stage, and measure pressure ulcer wounds weekly. An interview was conducted with S1OWN on 01/30/2026 at 2:30 p.m. S1OWN confirmed an RN should assess, stage and measure pressure ulcer wounds weekly.

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 record reviews and interviews, the agency failed to provide services as ordered by the physician in the Plan of Care (POC) for 1 (#3) of 3 sampled patients reviewed for wound care. Findings: Review of the agency’s revised policy dated November 2020, and titled, “Care Planning Process” revealed, in part: Procedure 4. The care planning decisions will be reflected in the specific services that will be provided and the associated actions planned and implemented to meet individualized patient problems and goals. 5. The plan of care will be based upon the physician’s or other authorized licensed independent practitioner’s orders and will encompass the equipment, supplies, and services required to meet the patient’s needs. Review of Patient #3’s clinical record revealed she began receiving services from the agency on 05/02/2024, with diagnoses, which included in part, Pressure Ulcer of Sacral Region, Stage 4. Review of Patient #3s POC for Certification Period 12/23/2025 through 02/20/2026 revealed in part: Skilled Nursing Visits once weekly for nine weeks. SN to instruct patient/ caregiver to perform on non-nursing days on signs/symptoms of wound infection to report to physician. SN to instruct patient/ caregiver on proper wound care procedure. SN to instruct and demonstrate proper wound care technique as follows: cleanse with non-cytotoxic cleanser, apply triad to wound bed/ peri wound, cover with foam border dressing daily. Review of Patient #3 agency’s calendar of completed visits for Skilled Nursing Visits made during this episode of care revealed no visit was conducted on 12/23/2025. Further review revealed no other SN visit was attempted or completed the week of 12/23/2025. An interview and record review was conducted with S2RN on 01/30/2026 at 2:15 p.m. S2RN reviewed Patient #3s master visit calendar and confirmed Patient #3s wound care services were not provided on 12/23/2025, per the physician-ordered frequency per POC, and should have been. An interview and record review was conducted with S3NC on 01/30/2026 at 2:28 p.m. S3NC reviewed Patient #3s master visit calendar and confirmed Patient #3s wound care services were not provided on 12/23/2025, per the physician-ordered frequency per POC, and should have been. An interview was conducted with S1OWN on 01/30/2026 at 2:30 p.m. The above nursing visit for Patient #3 on 12/23/2025 was reviewed. S1OWN confirmed all wound care services should be provided per the physician-ordered frequency per POC, and Patient #3s was not. An interview was conducted with S5RN on 01/30/2026 at 3:20 p.m. S5RN confirmed a skilled nurse visit was not attempted or completed with Patient #3 the week of 12/23/2025, per POC orders, and should have been.

Complaint Survey #2680301. Abbreviations: CDC- Centers for Disease Control mcg- microgram mg- miligram mmHg- Millimeters of Mercury NP- Nurse Practitioner POC- Plan of Care PRN- as needed SN- Skilled Nurse SOC- Start of Care

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 reviews, and interviews, the agency failed to maintain an accurate medication profile for 2 (#2 and #3) of 2 sampled patients reviewed who received home visits. This deficient practice had the potential to affect all 101 patients, according to the agency’s current active census reported on 12/18/2025. Findings: Review of the agency’s policy with revision date November 2020 titled, “Medication Profile” revealed, in part: Procedure 1. Upon admission to the organization, the admitting clinician will initiate a medication profile to document the current medication regimen. 2. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, when care is resumed after a patient is placed on hold, and with the addition of a new medication. 4. Each patient will receive appropriate written material for specific medications he/she is receiving. The material will contain information the patient should be aware of, and any special instructions when taking the specific medication. Patient #2 Review of Patient #2’s Start of Care (SOC) orders dated 11/28/2025, for Certification Period 11/28/2025 through 01/26/2026, revealed a Skilled Nursing frequency of 1 visit every week for 1 week and 3 times every week for 7 weeks then 1 visit every week for 1 week effective 11/28/2025. Review of Patient #2's medication profile provided by the agency on 12/18/2025 revealed the following, in part: Percocet 10-325mg 1 tablet by mouth every 6 hours as needed for pain. Doxycycline Hyclate 100mg 1 tablet by mouth two times a day x 7 days. Amlodipine Besylate 10mg 1 tablet by mouth daily. Celebrex 200mg 1 capsule by mouth daily. An observation was made on 12/19/2025 at 8:30 a.m. during a home visit with Patient #2, Patient #2’s family member, and S2RN. Patient #2’s home folder was reviewed. There was no medication profile in the home folder available. An interview was conducted with Patient #2 on 12/19/2025 at 8:50 a.m. Patient #2 stated he was taking Percocet 5-325mg tablets every 8 hours as needed for pain. Patient #2 further stated he was not taking Doxycycline Hyclate 100mg, Amlodipine Besylate 10mg, or Celebrex 200mg. These medications were listed on the agency’s current medication profile. An interview was conducted with S2RN on 12/19/2025 at 1:00 p.m. S2RN confirmed Patient #2’s home folder had no medication profile available for review. S2RN confirmed the medication profile provided by the agency dated 12/18/2025 was not accurate and should have been. An interview was conducted with S3CN on 12/19/2025 at 1:10p.m. The medication profile and discrepancies found during the home visit above were discussed. S3CN confirmed all patients should have a current medication profile available for review in their home folder. S3CN confirmed Patient #2’s agency medication profile list should have accurately reflected the medications currently prescribed and did not. Patient #3 Review of Patient #3’s Start of Care (SOC) orders dated 10/08/2025, for Certification Period 12/07/2025 through 02/04/2026, revealed a Skilled Nursing frequency of 3 visits every week for 8 weeks and 2 times every week for 1 week. Review of Patient #3's medication profile provided by the agency on 12/19/2025 revealed the following medications were not included: Furosemide 20mg 1 tablet by mouth one time a day. Potassium Chloride 10mcg 1 capsule two times a day. Hydrocortisone 5mg 1 tablet one time daily in the morning. An observation was made on 12/22/2025 at 10:00 a.m. during a home visit conducted with Patient #3 and S2RN. Patient #3’s home folder and medication profile were reviewed. An interview was conducted with Patient #3 on 12/22/2025 at 10:20 a.m. Patient #3 stated she was taking Furosemide 20mg, Potassium Chloride 10mcg, and Hydrocortisone 5mg. A phone interview was conducted with S7LPN on 12/22/2025 at 12:30 p.m. S7LPN stated she was assigned visits with Patient #3. S7LPN stated she had not reconciled Patient #3’s medications at her last visit, and to her knowledge her medication profile was up to date. She stated all meds should be reconciled when changes were made and the home medication list should accurately reflect medications the patient was taking. An interview was conducted with S2RN on 12/22/2025 at 2:10 p.m. S2RN confirmed Patient #3’s medication profile provided by the agency on 12/19/2025 was not accurate, and should have been. An interview was conducted with S3CN on 12/19/2025 at 2:15 p.m. The medication profile and discrepancies found during the home visit above were discussed. S3CN confirmed all patients should have a current medication profile available for review in their home folder. S3CN confirmed Patient #3’s agency medication profile list should have accurately reflected the medications currently prescribed and did not. An interview was conducted with S1OWN on 12/22/2025 at 2:40 p.m. S1OWN confirmed the Patient #2’s home folder should have had a current medication profile provided and updated at each comprehensive assessment, resumption of care, and after any medication changes, and did not. S1OWN confirmed the medication profiles in Patient #2 and #3’s homes should have accurately reflected the current medications taken by Patient #2 and #3 and did not.

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 record reviews and interviews, the agency failed to ensure all services and treatments were administered only as ordered by a physician or allowed practitioner for 1(#1) of 3 sampled patients reviewed for wound care. Findings: Review of the agency’s revised policy dated November 2020 and titled, “Care Planning Process,” revealed in part: Policy All clinicians involved in the patient’s care, either directly or indirectly, will contribute to the plan of care. Definitions 1. Individualized Plan of Care: the specific clinical plan of care includes: D. All patient care orders including verbal orders. Procedure 5. The plan of care will be based on the physician’s orders (or other authorized licensed independent practitioner’s orders) and will encompass the equipment, supplies, and services required to meet the patient’s needs. 10. Clinicians will inform the patient’s physician of any changes that suggest a need to alter the plan of care. Changes must be written, dated, and signed by the professional making the changes. Review of Patient #1s clinical record revealed a Start of Care (SOC) date of 02/28/2025 and a current Plan of Care (POC) for Certification Period 02/28/2025 through 04/28/2025 with diagnoses which included, in part: Osteomyelitis of Vertebra, Sacral and Sacrococcygeal Region, Pressure Ulcer of Sacral Region, Stage 4, and Pressure Ulcer of Left Hip, Stage 4. Review of Patient #1s Communication Note dated 03/10/2025, completed by S5LPN, revealed the following in part: Per phone communication with Wound NP-Seeing patient tomorrow, leave Vac off. After cleaning wounds, apply mepilex foam borders to wound. A review of Patient #1s Physician orders revealed no documented evidence of a written wound care physician order for the 03/10/2025 wound care provided by S5LPN. Review of Patient #1s SNV dated 03/11/2025 per S5LPN revealed, in part: Wound care performed to Stage 4 wounds to sacral and left ischium. Cleansed with wound cleanser, black foam to wound bed, covered with Vac drape and set to 125mmHg continuous suction provided. Review of Patient #1s SNV dated 03/14/2025 per S4RN revealed in part: Wound care to Stage 4 Sacral and L Ischium- Vac dressing changed- cleansed with Vashe solution, applied black foam, secured with Vac drape to continuous suction at 125mm Hg. Review of Patient #1s SNV dated 03/21/2025 per S5LPN revealed, in part: Wound care performed to Stage 4 wounds to sacral and left ischium. Cleansed with Vashe wound cleanser, black foam to wound bed, covered with Vac drape and set to 125mmHg continuous suction provided. A review of Patient #1’s Physician orders revealed no documented evidence of a written wound care physician order to resume the wound Vac dressings on or after 03/11/2025. An interview was conducted with S2RN on 12/19/2025 at 2:55 p.m. The above nursing documentation for Patient #1s wound care provided on 03/10/2025, 03/11/2025, 03/14/2025, and 03/21/2025 were reviewed. S2RN confirmed all services and treatments should be administered only as ordered by a physician or allowed practitioner. S2RN confirmed there was no written orders available for review for Patient #1s wound care on the above dates and should have been. An interview was conducted with S3CN on 12/19/2025 at 3:00 p.m. The above nursing documentation for Patient #1s wound care provided on 03/10/2025, 03/11/2025, 03/14/2025, and 03/21/2025 were reviewed. S3CN confirmed there was no written Physician order available for review for Patient #1s wound care on the above dates and should have been. S3CN confirmed all services and treatments should have been administered only as ordered by a physician or allowed practitioner. An interview was conducted with S1OWN on 12/22/2025 at 2:37 p.m. The above wound care documentation for Patient #1 was reviewed. S1OWN confirmed all services and treatments should have been administered only as ordered by a physician or allowed practitioner.

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 observations, interviews, and record reviews, the agency failed to ensure nursing staff followed accepted standards of practice to prevent the transmission of infections and communicable diseases for 1(#2) of 2 patients reviewed with home visits. The agency failed to ensure nursing staff performed proper glove changes and hand hygiene during Patient #2’s wound care. Findings: Review of the agency’s revised policy dated November 2020 titled “Infection Control Plan” revealed in part: Purpose 1. Establish the mechanism by which the organization will address prevention, control, and reporting of infections, utilizing current scientific methods and epidemiologic principles. 5. Comply with applicable local, state, federal regulations, and acceptable standards of practice including but not limited to: B. CDC recommendations and guidelines. Review of the Centers for Disease Control and prevention (CDC) guidelines at www.cdc.gov Hand Hygiene and Glove use recommendations included, in part: 1. Indications for handwashing and hand antisepsis: C. Decontaminate hands before having direct contact with patients. E. Change gloves during patient care if moving from a contaminated body site to a clean body site. G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings. H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care. Review of Patient #2’s Clinical Record revealed a start of care date of 11/28/2025, a current certification period of 11/28/2025 to 01/26/2026, and diagnoses, which included in part, Other Complications of Procedures (Non-healing Surgical Wound), Local Infection of the Skin and Subcutaneous Tissue, and Presence of Right Artificial Ankle Joint. Further review of the Clinical Record revealed Patient #2 was ordered to receive skilled nursing visits once weekly for one week, three times weekly for seven weeks then once weekly for one week for treatments, including wound care. Further orders revealed wound care was ordered three times a week on non-clinic weeks and two times a week on clinic weeks. A home visit was conducted with Patient #2 on 12/19/2025 at 8:30 a.m. with S2RN. An observation was made of S2RN performing wound care to Patient #2’s right ankle surgical wound. S2RN donned a pair of clean gloves and removed Patient #2’s soiled dressing on his right foot. Without changing her gloves or performing hand hygiene, S2RN touched a wound cleanser bottle, grabbed a clean gauze, cleaned Patient #2’s surgical wound, and discarded the soiled gauze into a trash bag. S2RN touched the wound cleanser bottle again and placed it on the table in the living room, then reached into her pants pocket, touched her ink pen, measured the wound with a wound measure tape, touched her cell phone to photograph the wound, and touched her scrub pants to return her ink pen to her pants pocket. S2RN then removed her gloves, performed hand hygiene, applied clean gloves, and a clean dressing. Without changing gloves, S2RN palpated Patient #2’s foot, opened a sanitizing wipe packet, and cleaned her equipment. S2RN removed her gloves and touched the used barrier pads and soiled dressing trash bag to discard them. Without performing hand hygiene, S2RN returned all cleaned equipment to her bag then left the home. An interview was conducted with S2RN on 12/19/2025 at 8:50 a.m. S2RN confirmed hand hygiene and glove changes should have been performed between moving from a soiled area to a clean area with wound care and was not. S2RN confirmed hand hygiene should have been performed after touching the used barrier pads and soiled dressing trash bag prior to returning clean equipment to her bag and was not. An interview was conducted with S3CN on 12/19/2025 at 1:10 p.m. The above home visit was discussed. S3CN confirmed hand hygiene and glove changes should have been performed between moving from a soiled area to a clean area during wound care for Patient #2. S3CN confirmed hand hygiene should have been performed after touching the barrier pads and soiled dressing trash bag prior to returning clean equipment to the clinician’s bag and was not.

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 record reviews and interviews, the agency failed to provide services as ordered by the physician in the Plan of Care (POC) for 1 (#2) of 3 sampled patients reviewed for wound care. Findings: Review of the agency’s revised policy dated November 2020, and titled, “Care Planning Process” revealed, in part: Procedure 5. The plan of care will be based upon the physician’s or other authorized licensed independent practitioner’s orders and will encompass the equipment, supplies, and services required to meet the patient’s needs. Review of Patient #2’s clinical record revealed he began receiving services from the agency on 11/28/2025, with diagnoses, which included in part, Other Complications of Procedures (Non-Healing Surgical Wound), Local Infection of the Skin and Subcutaneous Tissue, and Presence of Right Artificial Ankle Joint. Review of Patient #2s POC for Certification Period 11/28/2025 through 01/26/2026 revealed in part: Skilled Nursing Visits once weekly for one week, then three times weekly for seven weeks, then once weekly for one week. Nurse to perform wound care to right ankle incision site three times a week on non-clinic weeks and two times a week on clinic weeks as follows: cleanse with vashe wound cleanser and pat dry with gauze, apply mepilex Ag (silver) cut to wound size to wound bed, cover with ABD pad secure with cast padding, conform and secure with elastic netting Size 7. Review of the agency’s calendar of completed visits for Skilled Nursing Visits made during this episode of care revealed wound care was not provided, as ordered by the Physician, on 12/03/2025 and 12/12/2025. Review of Patient #2s Skilled Nurse Visit Note dated 12/03/2025 by S4RN revealed: Wounds not addressed this visit; next Physician visit 12/09/2025. Wound location Right ankle anterior Surgical wound. Review of Patient #2s Skilled Nurse Visit Note dated 12/12/2025 by S6RN revealed: Wounds not addressed this visit; next Physician visit 12/16/2025. There was no missed visit or patient refusal documented. An interview and record review was conducted with S2RN on 12/19/2025 at 1:26 p.m. S2RN reviewed the nursing visit documentation for the dates above. S2RN confirmed Patient #2s wound care services were not provided per the physician-ordered frequency per POC and should have been. An interview and record review was conducted with S3CN on 12/19/2025 at 2:15 p.m. S3CN reviewed the nursing visit documentation for the dates above. S3CN confirmed Patient #2s wound care services were not provided per the physician-ordered frequency per POC and should have been. An interview was conducted with S1OWN on 12/22/2025 at 2:40 p.m. The above nursing visits for Patient #2 on 12/03/2025 and 12/12/2025 were discussed. S1OWN confirmed all wound care services should be provided per the physician-ordered frequency per POC.

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

Recertification Survey Abbreviations: CMS- Center for Medicare and Medicaid Services HHA- Home Health Agency POC- Plan of Care SOC- Start of Care OASIS- Outcome and Assessment Information Set

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 record review and interview, the agency failed to encode and electronically transmit each completed OASIS (Outcome and Assessment Information Set) within 30 days of completion date of the assessment. Findings: Review of the agency’s undated policy, titled “Reporting Oasis Information”, revealed, in part: Policy: The Home Health Agency (HHA) shall encode and electronically transmit each completed OASIS assessment to the State agency or CMS (Center for Medicare and Medicaid) within 30 days of completing the assessment of the beneficiary. Review of the agency's OASIS Agency Final Validation Report with a submission date of 09/04/2024 revealed 1 out of 7 records were submitted more than 30 days after the date of completion on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 09/05/2024 revealed 1 out of 1 record was submitted more than 30 days after the date of completion on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 09/13/2024 revealed 13 out of 18 records were submitted more than 30 days after the date of completion on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 09/13/2024 revealed 4 out of 5 records were submitted more than 30 days after the date of completion on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 09/13/2024 revealed 1 out of 1 record was submitted more than 30 days after the date of completion on the record, which was late. Review of the agency's OASIS Agency Final Validation Report with a submission date of 09/17/2024 revealed 2 out of 9 records were submitted more than 30 days after the date of completion on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 09/18/2024 revealed 1 out of 6 records were submitted more than 30 days after the date of completion on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 09/18/2024 revealed 1 out of 2 records were submitted more than 30 days after the date of completion on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 09/23/2024 revealed 1 out of 8 records were submitted more than 30 days after the date of completion on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 09/26/2024 revealed 3 out of 11 records were submitted more than 30 days after the date of completion on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 09/26/2024 revealed 1 out of 1 record was submitted more than 30 days after the date of completion on the record. An interview was conducted with S1OWN on 10/30/2024 at 10:00 a.m. S1OWN stated OASIS should be transmitted within 30 days of the completion date. S1OWN confirmed the above OASIS submissions completed from 09/04/2024-09/26/2024 were submitted greater than 30 days of the completion date and were late.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record reviews and interviews, the agency failed to have a plan of care reviewed and revised no less frequently than once every 60 days of the start of care date for 2 (#6 and #7) of 13 (#1- #13) sampled patients reviewed. Findings: Review of the agency’s undated policy titled, “Coordination of Patient Services” revealed, in part: The Plan of Care (POC) shall be reviewed in its entirety by the physician responsible for the Home Health Plan of Care and HHA(Home Health Agency) staff as often as the severity and/or instability of the patient’s condition requires, but at least every 60 days, beginning with the Start of Care (SOC) date. Patient #6 Review of Patient #6’s clinical record revealed a SOC (Start of Care) date of 07/14/2023. Review of the Plan of Care for the certification period of 09/12/2023 to 11/10/2023 revealed a physician’s signature dated 02/23/2024. Patient #7 Review of Patient #7’s clinical record revealed a SOC date of 09/22/2023. Review of the Plan of Care for the certification period of 09/22/2024 to 11/20/2023 revealed a physician’s signature dated 12/21/2023. An interview was conducted with S2DON on 10/31/2024 at 12:00 p.m. The Plan of Care for Patients #6 and #7 were reviewed. S2DON confirmed Patients #6 and #7’s POCs were signed by the physician greater than 60 days of the start of care date and were not reviewed by the physician within the required 60 day time frame. An interview was conducted with S1OWN on 10/31/2024 at 12:05 p.m. The Plan of Care for Patients #6 and #7 were reviewed. S1OWN confirmed Patient #6 and #7’s POCs were signed by the physician greater than 60 days of the start of care date and were not reviewed by the physician within the required 60 day time frame.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record reviews and interviews, the agency failed to notify the physician a patient’s plan of care should be altered for Home Health Aide services for 1 (#4) of 13 (#1-#13) sampled patients reviewed. Findings: Review of the agency’s undated policy titled “Coordination of Patient Services” revealed, in part: Procedure: Coordination of service activities shall be documented in the patient’s medical record. Each medical record shall contain up-to-date information regarding: The services that are being provided. All orders are renewed or updated to reflect: Changes in the care, treatment, and/or services being provided. Any changes in the patient’s Plan of Care shall be communicated to other members of the healthcare team, including all physicians involved, either verbally or in writing. The patient’s physician shall be contacted with reports of changes in patient’s needs, and for necessary orders. Patient #4 Review of Patient #4’s plan of care for the certification period of 09/17/2024 to 11/15/2024 revealed a primary diagnosis of Covid-19 Acute Respiratory Disease. Further review of the plan of care revealed Home Health Aide services were ordered twice weekly for four weeks beginning 09/22/2024. Review of the agency’s visit summary for Patient #4’s home health aide visits, revealed the following: 09/24/2024 Missed visit, 09/26/2024 Missed visit, 10/01/2024 Missed visit, 10/08/2024-completed, and 10/17/2024-completed. Review of a patient communication note for Patient #4, dated 10/07/2024, and written by S3VP, revealed, in part: Spoke with Patient #4’s son. Son requesting Aide to come back out to help with ADLs. Aide agreed to see patient on 10/08/2024, with a frequency of once weekly for four weeks. Further review of Patient #4’s October 2024 physician orders and patient communication notes revealed no documentation, on or after 10/07/2024, that Patient #4’s physician was notified or approved verbal or written orders to change the Home Health Aide frequency to once weekly for four weeks effective 10/08/2024. An interview was conducted with S2DON on 10/31/2024 at 12:00 p.m. S2DON confirmed all changes in services provided required physician notification and an approved written or verbal order. S2DON confirmed there was no documentation Patient #4’s physician had been notified, on or after 10/07/2024, to request Home Health Aide frequency change orders to once weekly for four weeks and should have been. An interview was conducted with S1OWN on 10/31/2024 at 12:05 p.m. S1OWN confirmed all changes in services provided required physician notification and an approved written or verbal order. S1OWN confirmed there was no documentation Patient #4’s physician had been notified on or after 10/07/2024, to request Home Health Aide frequency change orders to once weekly for four weeks and should have been.

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 record reviews and interviews, the agency failed to provide skilled professional services according to the patient’s Plan of Care (POC) for 1(#4) of 13 (#1-#13) sampled patients reviewed. Findings: Review of the agency’s undated policy, titled “Coordination of Patient Services”, revealed, in part: Purpose: To ensure effective and appropriate coordination and continuity of care, treatment, and/or services to promote positive patient outcomes. Policy: Care, treatment, and/or services shall be provided by the Home Health Agency as appropriate to the needs of the patient. Patient #4 Review of Patient #4’s plan of care for the certification period of 09/17/2024 to 11/15/2024 revealed home health aide services were ordered twice a week for four weeks, beginning 09/22/2024. Review of the agency’s visit summary for Patient #4 revealed home health aide visits were not completed on the following dates: 10/03/2024, 10/10/2024 and 10/15/2024. An interview was conducted with S2DON on 10/31/2024 at 12:00 p.m. S2DON reviewed Patient #4’s POC dated 09/17/2024 to 11/15/2024 and visit summary, and confirmed Patient #4 did not receive home health services per their POC and should have. An interview was conducted with S1OWN on 10/31/2024 at 12:05 p.m. S1OWN reviewed Patient #4’s POC dated 09/17/2024 to 11/15/2024 and visit summary, and confirmed Patient #4 did not receive home health services per their POC and should have.

The entity is in compliance with the Federal Emergency Preparedness requirements.

Recertification Survey Abbreviations: PRN- As Needed MD- Medical Doctor MSW- Masters in Social Work PT/INR- Prothrombin Time/International Normalized Ratio 485/PoC- Patient Plan of Care

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 interviews, the home health agency failed to ensure care and services were provided in accordance with the written plan of care for 1 (#7) of 17 (#1 - #17) sample patients. The agency failed to provide MSW visits as ordered on the Post Hospital Orders for Patient #7. Findings: Review of Patient #7's Plan of Care for certification period 10/12/2021 – 12/10/2021 revealed diagnoses that included Unspecified Dementia with behavioral disturbance, Hypothyroidism, Disorder of Kidney and Ureter, Atherosclerosis of Aorta, Depression, Hyperlipidemia, Insomnia, Long term use of inhaled steroids, Long term use of Aspirin, and History of Falls. Further review of the Plan of Care revealed Patient #7 was admitted to the hospital 10/15/2021-10/20/2021. Post Hospital orders written on 10/20/2021 included the following: MSW 1-3 visits in certification period for assistance with community services. Review of the MSW notes revealed the following: 10/20/2021 Missed visit form- MSW evaluation Reason: No answer to phone call Comments: MSW attempted to meet with patient today- MSW left a detailed message on daughter’s voicemail and requested a return call. An interview was conducted on 12/01/2021 at 2:15 pm with S3SW. He said on 10/20/2021 he left a message on Patient #7’s daughter voicemail regarding assistance with community services. He said he did not attempt another call or visit. He said he did not want to be accused of harassing the patient or her daughter. He said he was unsure if Patient #7’s daughter received his message. He confirmed he was unsure if Patient #7 needed assistance with community services. An interview was conducted on 12/01/2021 at 2:30 p.m. with S1DON. He reviewed Patient #7’s medical record and verified an order was written on 10/20/2021 for the social worker to assist with community services. He said there was no documentation the social worker attempted to contact Patient #7’s daughter after 10/20/2021. He said it was the agency’s expectation the social worker make additional attempts to contact the patient’s daughter to assess the need for community services.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record reviews, the agency failed to ensure communication with physicians involved in the plan of care for 1 (#5) of 17 (#1-#17) patient records reviewed. The agency failed to ensure the skilled nurse obtained new physician orders after obtaining PT/INR lab results on 10/20/2021. Findings: Review of the clinical record for Patient #5 revealed the patient had a start of care date of 10/12/2020 with diagnoses that included Essential Primary Hypertension, Alzheimers, Dementia, Schizophrenia, Depression, Long Term use of Anticoagulants and Personal History of other Venous Thrombosis and Embolism. Further review revealed the patient was to receive skilled nursing services once a week for 8 weeks. Review of the current 485/PoC for the certification period 10/07/2021- 12/05/2021 revealed the following MD order: Current Medications included the following: Warfarin Sodium Oral 5 mg 1 tablet, take 2 tablets on 05/04/2021 and then take 1 tablet by mouth 5 mg everyday starting on 05/05/2021. Skilled Nurse to perform PT/INR via finger stick per MD and PRN adverse reactions of Warfarin. An interview was held with S2Com on 12/01/2021 at 10:00 a.m. She stated when the skilled nurse would obtain the PT/INR during the home visit and notify the MD of the results. She stated based on those results, they would obtain a new order when they would need to obtain the next PT/INR. She verified this would be documented in the physician communication section. Review of the Skilled Nursing note for 10/01/2021 revealed the nurse obtained a PT/INR on the patient that resulted with 21.1/1.8. Review of the Physician orders for Patient #5 from 10/06/2021 revealed the following order in response to PT/INR lab obtained on 10/01/2021: Continue Warfarin 5 mg by mouth daily in the evening, recheck PT/INR in two weeks and notify MD. Review of the Skilled Nursing Note for 10/20/2021 revealed the following: Skilled Nurse checked PT/INR today via finger stick, results were 37.8/3.2. Patient currently taking Warfarin 5 mg daily. Results reported to MD nurse at office. Review of the MD notifications for Patient #5 revealed no documentation when the next PT/INR was ordered to be drawn by the skilled nurse based on the PT/INR results obtained on 10/20/2021. Review of the Skilled Nursing documentation revealed there was a missed visit note documented on 11/24/2021 due to patient refusing to have skilled nursing visit due to Thanksgiving Holiday. Review of the Skilled Nursing notes for 11/30/2021 revealed a PT/INR was obtained which resulted in 28.5/2.7. Review of the Physician Orders for 11/30/2021 revealed for Patient #5 was to continue to take Warfarin 5 mg daily. There were no orders regarding the frequency as to when the next lab should be obtained by the skilled nurse. An interview was held with S2Com on 12/01/2021 at 10:50 a.m. She reviewed all of the skilled nursing notes and physician communication documentation for Patient #5. She verified there was no documentation regarding any new orders for the medication dosage the patient was to continue taking after the PT/INR lab was obtained on 10/20/2021. She also verified there was no documentation when the next PT/INR lab was to be obtained. She confirmed there should have been documentation of the MD communication showing what the next order should be.

Complaint #LA00058670 and COVID-19 Focused Infection Control Survey. Tag # 430 was cited as a result of Complaint #LA00058670. COVID-19 Focused Infection Control Survey with no related deficiencies cited.

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to report allegations of potential neglect of a resident to the appropriate agency for investigation for 1 of 5 patients (Patient #1) reviewed for care and services. Findings: Review of Patient #1's record revealed Patient #1 was discharged from home health on 03/30/2021 due to physician no longer willing to sign home health orders due to patient failure to follow up with the physician. Review of Patient #1's Hospital History and Physical dated 05/19/2021 revealed Patient #1 was treated for altered mental status. Further review revealed during hospitalization, there was documented concerns from Patient #1's family member of Patient #1's caregiver may not be doing a good job. Review revealed Patient #1's family member stated to the hospital she was unsure if the patient was receiving her medication. Review revealed Patient #1's family member was concerned because the patient had a large stage IV pressure ulcer (wound were the bone is exposed) and the caregiver had cancelled home health and wound care. Patient #1 was also not brought to her PCP (primary care physician) appointments. Patient #1's family member stated she was so concerned about her mother's care she was attempting to file a report with Elderly Protective Services (EPS). Review of Patient #1's Home Health Certification and Plan of Care 05/25/2021 to 07/23/2021 revealed Patient #1 was to receive skilled nursing services twice a week for two weeks then three times a week for seven weeks effective week of 05/25/2021. Further review revealed Patient #1 was to receive wound care to a sacral stage IV pressure ulcer; a left hip stage III (subcutaneous (fat tissue) tissue exposed) pressure ulcer; and a left shoulder stage III pressure ulcer. Review of Patient #1's Skilled Nursing Note dated 05/27/2021 revealed Patient #1 was soaked with urine on arrival wearing two diapers. Review of Patient #1's Missed Visit Form dated 06/14/2021 revealed a missed visit was recorded due to no answer to phone call. Skilled nurse tried to contact caregiver by phone, then passed by home and still no answer to the locked door. Review of Patient #1's Missed Visit Form dated 06/21/2021 revealed a missed visit was recorded due to no answer to phone call. Skilled nurse went to the door, knocked on the door, and waited for 10 minutes still no one came to locked door. Review of Patient #1's Missed Visit Form dated 06/23/2021 revealed a missed visit was recorded due to no answer to phone call. Review of Patient #1's Patient Communication dated 06/24/2021 revealed patient canceled wound care appointment for 06/24/2021. Review of Patient #1's Skilled Nursing Note dated 06/26/2021 revealed skilled nurse educated Patient #1's caregiver again on the home health wound care visits being on Monday, Wednesday, and Friday. Caregiver stated he sleeps through phone calls and doorbells. Review revealed patient was soaked in urine with two diapers on. Further review revealed Patient #1 with new stage III pressure ulcer to the left upper back measuring 5 cm (centimeters) by 4.1 cm by 0.1cm with 80% slough (nonviable tissue). Review of Patient #1's Missed Visit Forms dated 06/28/2021, 06/30/2021, 07/02/2021, and 07/06/2021 revealed no answer to locked door during home visit attempts with multiple voice mails left with no return call. Review of Patient #1's Picture of Door Hanger dated 07/07/2021 revealed skilled nurse left door hanger on door with date of 07/07/2021 at 3:50pm with note for caregiver to call her to reschedule ASAP (as soon as possible) with agency phone number and her cell number listed. Review of Patient #1's Skilled Nursing Notes dated 07/08/2021 revealed the skilled nurse met with Patient #1's caregiver and daughter. Skilled nurse documented the patient was soiled on arrival wearing two diapers again. Caregiver stated he is usually sleeping and does not hear the door or phone. Patient #1's family informed the agency had notified Patient #1's physician of the caregiver's noncompliance with visits. Review of Patient #1's Communication Note dated 07/08/2021 revealed Patient #1's family was informed a MSW (master social worker) would be contacted to report to EPS if missed visits continue. Review of Patient #1's Missed Visit Form dated 07/09/2021 revealed no answer to locked door. Review of Patient #1's Skilled Nursing Note dated 07/12/2021 and 07/15/2021 revealed Patient #1 was soaked/soiled. Review of Patient #1's Wound Care Clinic documentation dated 07/16/2021 revealed third time the patient had confirmed the appointment and had not come to the door when the provider was there. Review of Patient #1's Missed Visit Form dated 07/17/2021 revealed second attempt for visit and no answer to attempts for visit. Review of Patient #1's Transfer OASIS (Outcome and Assessment Information Set) dated 07/19/2021 revealed Patient #1 was admitted to the hospital for, in part: wound infection or deterioration. In an interview on 08/06/2021 at 1:23pm, S4LPN (Licensed Practical Nurse) stated prior to 07/08/2021 she was concerned about neglect so she had contacted Patient #1's daughter to be present at the next visit. S4LPN had difficulty getting into the home visits because the caregiver would not answer her phone calls or the door. S4LPN stated on multiple occasions Patient #1 was soaked with urine and once the sheets even had a urine ring noted. S4LPN stated they had not contacted EPS prior to the hospital admission. In an interview on 08/06/2021 at 2:00pm, S5RN (Registered Nurse) stated the nurses had difficulty getting into the home for visits because the caregiver would not answer phone or door. S5RN stated Patient #1 was soiled on multiple home visit. S5RN stated she and S4LPN had spoken about contacting EPS but did not prior to Patient #1 being hospitalized. In an interview on 08/06/2021 at 2:35pm, S1DON (Director of Nursing), S2Owner, and S3Consultant stated S4LPN and S5RN were considering contacting EPS over their concerns and met with the family and was expecting an improvement. S1DON (Director of Nursing), S2Owner, and S3Consultant stated looking back at the concerns brought to the hospital in the previous admission by the family they should have reported to EPS when they observed the soiled double diapering and the missed visits.