Every finding on record at Central Louisiana Health Services, Inc.

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

Recertification Survey Abbreviations: DON-Director of Nursing po-by mouth RN-Registered Nurse

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on record review, observation and interview, the agency failed to ensure patients were advised of the state toll free home health hotline telephone number, its hours of operation, and that its purpose is to receive complaints or questions about local home health agencies for 1 (Patient #1) of 5 (Patients #1, #2, #4, #5 & #6) sampled patients observed during home visits. Findings: Patient #1 Observation of the home and interview with Patient #1 on 03/12/2024 at 8:30 a.m. revealed there was no information in the home regarding how to file a complaint, the state toll-free home health hotline telephone number, or the agency number in the home. Interview on 03/12/2024 at 8:40 a.m. with Patient #1 revealed he did not have a home folder nor did he have anything with the agency’s telephone number or state home health hotline in his home. Patient #1 stated he had moved in December and believed the folder may have been left behind. Patient #1 stated he was not sure who to call if he had a complaint with the agency and would probably just call the VA (Veterans’ Administration). Interview on 03/12/2024 at 8:44 a.m. with S2 RN revealed Patient #1 should have information in the home about how to file a complaint, the state home health hotline telephone number, and how to contact the agency and did not. Interview on 03/12/2024 at 10:15 a.m., S1 DON confirmed Patient #1 should have had a folder in the home that contained instructions on how to file a complaint, the state toll-free home health hotline telephone number, and the agency number in the home.

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 and interview, the agency failed to ensure a patient's medication regimen was reviewed and updated for accuracy for 1 (#1) of 5 (#1, #2, #4, #5, & #6) sampled patients reviewed during home visits. Findings: Observation on 03/12/2024 at 8:30 a.m. during a home visit accompanied by S2 RN revealed Patient #1 had medication bottles in the home that included Multivitamin 1 tablet po daily filled on 01/09/2024 and Albuterol Sulfate 90mcg HFA Inhaler filled on 12/26/2023 with instructions to use 2 puffs four times a day as needed. Interview on 03/12/2024 at 8:31 a.m. with Patient #1 revealed the nurse did not go through each of his medication bottles at each visit. Interview on 03/12/2024 at 8:32 a.m. with S2 RN revealed Patient #1’s last skilled nurse visit was on 03/04/2024. S2 RN confirmed Patient #1’s medication list should have been updated to reflect the medications in the home and had not been. Interview on 03/12/2024 at 10:15 a.m. with S1 DON revealed Patient #1’s medication list should have been updated to reflect the prescriptions added in December of 2023 and January of 2024.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation and interview the skilled nurse failed to follow standards of practice, including the use of proper hand hygiene during wound care, to prevent the transmission of infections and communicable diseases for 1 (Patient #6) of 5 (Patient #1, Patient #2, Patient #4, Patient #5, and Patient #6) sampled patients with home visits conducted. Findings: Review of the agency policy titled Hand Hygiene revealed in part…Purpose to improve hand hygiene practices of agency staff and to reduce transmission of pathogenic microorganisms to patients and team members in the home health and hospice setting. Indications for hand hygiene include: before performing any aseptic task, after removal of personal protective equipment (PPE), after contact with blood or any bodily fluids. Observation on a home visit conducted on 03/11/2024 at 12:15 p.m. accompanied by S3 LPN revealed the following: S3 LPN sanitized her hands, donned gloves and removed the dressing from Patient #6’s right foot. S3 LPN then proceeded to clean Patient #6’s right foot wound with wound cleanser and 4X4 gauze, placed the soiled gauze in a plastic bag and then proceeded to open the clean dressing supplies and cut an ABD pad and Calcium Alginate dressing while wearing the same soiled gloves. S3 LPN then proceeded to apply the clean dressing to Patient #6’s right heel wound without removing soiled gloves, performing hand hygiene and applying clean gloves. Interview on 03/12/2024 at 12:49 p.m. with S3 LPN confirmed she did not perform hand hygiene and change gloves after removing Patient #6’s right heel dressing, cleaning the right heel wound, and applying the new dressing to Patient #6’s right heel wound and should have. Interview on 03/12/2024 at 1:30 p.m. with S1 DON confirmed S3 LPN should have removed her soiled gloves and sanitized her hands after removing Patient #6’s soiled dressing, and applied clean gloves before applying Patient #6’s new dressing.

Recertification Survey A COVID-19 Focused Infection Control Survey was conducted on 03/25/2021. The facility was found to be in compliance with 42 CFR 484.70 infection control regulations and has implememted the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. Census: 119 Abbreviations: a.m. - morning DON - Director of nursing LPN - Licensed Professional Nurse mg - milligram p.m. - evening 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, record review and interview the agency failed to ensure a medication review was conducted on all visits to assess for ineffective (expired) drug therapy for 1 (Patient #3) out of 10 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10) sampled patients. The agency census was 119. Findings: Observation of the medication review during the home visit at 9:30 a.m. on 03/23/2021 with S3 RN revealed Patient #3 had an expired bottle of Nitroglycerin 0.4mg sublingual tablets. The expiration date was noted to be 2019. Interview on 03/23/2021 with Patient #3 at the above time revealed he had taken a dose of nitroglycerin in 2020 for chest pain. He stated he could not remember the exact date. Interview on 03/23/2021 at 10:30 a.m. with S3 RN revealed that all medications should be reviewed during every nursing visit. She further stated that the bottle was so small it had probably been missed. She continued by saying this should have been caught. Review of the agency's Medication Management Policy revealed in part "Medications in the home are reviewed with the client/family to determine current medications...Client will be instructed to remove all expired, damaged, or contaminated medications from the home. Review of Patient #3's 01/25/2021 - 03/25/2021 Care Plan revealed the following: 1. Medication in part: "Nitroglycerin 0.4 mg sublingual tablet as directed prn chest pain - Take one tab every 5 minutes up to 3 doses for chest pain". 2. Orders of Discipline and Treatments in part: "Skilled nurse to review patient medications. Instruct patient/caregiver on monitoring of effectiveness, adverse drug reactions, side effects of all mediations (prescription/OTC), and how and when to report problems". 3. Safety Measures including "Proper and Safe use of medications". Review of 02/24/2021 Nurse Note revealed S4 LPN documented that the patient's medication regimen review/reconciliation was omitted. Interview on 03/25/2021 at 12:07 p.m. with S1 Administrator and S2 DON revealed that all medications should be reviewed at each skilled nurse visit.