Every finding on record at Chateau Home Health Inc.

Emergency Preparedness Survey.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, it was determined that the agency failed to develop emergency preparedness policies and procedures which addressed the use of volunteers in an emergency. Findings included: Review of the agency’s Emergency Preparedness Plan revealed, no documented evidence, and the agency presented no documented evidence, that the agency had policies and procedures which addressed the use of volunteers in an emergency or emergency staffing strategies. In an interview on 12/12/2024 at 11:45AM, S1Administrator indicated the agency did not have a policy or procedure which included the use of volunteers and/or emergency staffing strategies in the event of an emergency.

Reporting OASIS information CFR(s): 484.45 Condition of participation: HHAs must electronically report all OASIS data collected in accordance with §484.55. This CONDITION is not met as evidenced by: Based on record review and interview the agency failed to meet the Condition of Participation for late OASIS submissions as evidenced by: Findings included: Based on record review and interviews, it was determined that the agency failed to encode OASIS (Outcome and Assessment Information Set) information into a computer, and failed to transmit the encoded OASIS information to iQIES (internet Quality Improvement Evaluation System) within 30 days of the OASIS assessment. For 7 (Patient #1, Patient #2, Patient #5, Patient #6, Patient #7, Patient #R8, and Patient #R9) of the 9 patients on the agency’s census. (see G372).

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 interviews, it was determined that the agency failed to encode OASIS (Outcome and Assessment Information Set) information into a computer, and failed to transmit the encoded OASIS information to iQIES (internet Quality Improvement Evaluation System) within 30 days of the OASIS assessment. For 7 (Patient #1, Patient #2, Patient #5, Patient #6, Patient #7, Patient #R8, and Patient #R9) of the 9 patients on the agency’s census reviewed for OASIS information. Findings included: Record review of iQIES revealed no documented evidence the agency electronically encoded OASIS information which was required to be transmitted within 30 days of the OASIS assessment for each patient on the agency’s census. Further review revealed an electronic search in iQIES for a for list of HHAs in Louisiana for a report titled ‘No Successful Production Submissions Report’ indicated the agency Date of Last Submission was 11/03/2022. In an interview on 12/09/2024 at 10:00AM, S1Administrator indicated the agency had not transmitted the required OASIS information to iQIES in at least two to three months. S1Administrator indicated she had completed handwritten OASIS assessments on newly admitted patients and their recertifications, and she did not use a computer to input this information. In an interview on 12/11/2024 at 3:00PM, S1Administrator indicated the following: -Patient #1’s last OASIS was transmitted on 08/31/2024 (3 months and 12 days ago) which was over 30 days ago; -Patient #2’s last OASIS was transmitted on 05/21/2024 (6 months and 21 days ago) which was over 30 days; -Patient #3 was admitted on 11/30/2024 (12 days ago) and his OASIS was never transmitted; -Patient #4 was admitted on 11/08/2024 (33 days ago) and his OASIS was never transmitted; -Patient #5 was admitted on 11/14/2024 (28 days ago) and his OASIS was never transmitted; -Patient #6 was admitted on 11/05/2024 (36 days ago) and his OASIS was never transmitted; -Patient #7’s last OASIS was transmitted on 5/3/24 (7 months and 9 days ago) which was over 30 days; -Patient #R8’s last OASIS was transmitted on 05/08/2024 (7 months and 5 days ago) which was over 30 days; and -Patient #R9’s last OASIS was transmitted on 04/19/2024 (7 months and 23 days ago) which was over 30 days. In an interview on 12/12/2024 at 2:00PM, S1Administrator confirmed the agency did not transmit OASIS information as required.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, it was determined that the agency failed to implement an effective QAPI (Quality Assessment and Performance Improvement) program by not including OASIS (Outcome and Assessment Information Set) data. Findings included: Record review of iQIES ((internet Quality Improvement Evaluation System) was unable to find any evidence of electronically encoded OASIS information which was required to be transmitted within 30 days of the OASIS assessment for each patient on the agency’s census. Further review revealed an electronic search in iQIES for a for list of HHAs (Home Health Agencies) in Louisiana for a report titled ‘No Successful Production Submissions Report’ indicated the agency’s Date of Last Submission was 11/03/2022. In an interview on 12/09/2024 at 10:00AM, S1Administrator indicated the agency had not transmitted OASIS information for at least 2 to 3 months. In an interview on 12/12/2024 at 12:20PM, S1Administrator acknowledged she had not identified the lack of OASIS submissions as a priority issue in the agency’s QAPI program.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record reviews and interview, it was determined the agency failed to maintain an agency-wide program for infection control, identification, and surveillance for 6(Patient#1, Patient#2, Patient#3, Patient#5, Patient#6, and Patient#7) of 7 patient records reviewed for infection control requirements. Findings included: Review of the agency’s Infection Control binder revealed, in part, no separate documentation of the anti-infective medications ordered for the current patients, and no documentation of the infections or communicable diseases of the patients. Review of Patient #1’s clinical record revealed he was admitted on 04/07/2023 with a diagnosis, in part, of chronic multifocal osteomyelitis (an infection of the bone); and an order for Vashe (a wound cleansing solution) Wound Solution to be used as needed (PRN) for wound care. Review of Patient #2’s clinical record revealed he was admitted on 03/31/2023 with a diagnosis, in part, of osteomyelitis and an urinary tract infection (UTI); and an order for sulfamethoxazole-trimethoprim (a medication used to treat infections) 800 milligrams (mg) by mouth twice daily. Review of Patient #3’s clinical record revealed he was admitted on 11/30/2024 with a diagnosis, in part, of acute osteomyelitis; and an order for pipercillin/tazobactam (a medication used to treat infections) 4.5 grams (g) intravenously every 8 hours. Review of Patient #5’s clinical record revealed he was admitted on 11/14/2024 with a diagnosis, in part, of gluteal abscess; and an order for amoxicillin (a medication used to treat infections) 500 mg by mouth three times daily. Review of Patient #6’s clinical record revealed he was admitted on 11/04/2024 with a diagnosis, in part, of acute osteomyelitis; and an order for ceftriaxone (a medication used to treat infections) 2g intravenously every 24 hours. Review of Patient #7’s clinical record revealed he was admitted on 01/30/2024 with a diagnosis, in part, osteomyelitis. There was no documented evidence, and the provider did not present any documented evidence of maintaining an agency-wide program for infection control, identification, and surveillance. In an interview on 12/12/2024 at 12:32PM, S1Administrator indicated she had knowledge of all the infections and anti-infective use of all patients on the census, but did not have any separate documentation in the binder for the tracking and trending of these infections and anti-infective drugs of the patients in the Infection Control binder.

Complaint #LA00059197

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient received skilled nurse visits, and a physical therapy and occupational therapy evaluation as ordered on the patient's plan of care. This deficient practice was identified for 1 (Patient #1) of the 5 patients reviewed for care and services provided in accordance with the individualized plan of care. Findings: Review of Patient #1's Plan of Care revealed Patient#1’s start of care was 08/27/2021. Review of Patient #1’s physician orders dated 09/09/2021 revealed documentation in part, to resume home health services following evacuation from area related to storm to include skilled nurse visits 3 times a week, and physical therapy and occupational therapy evaluation for home health program. Review of Patient #1's medical record revealed documentation the registered nurse made only 2 skilled nurse visits on 09/09/2021 and 09/10/2021. Further review revealed no documentation of a skilled nurse visit being made on 09/11/2021. Review of Patient #1's medical record revealed documentation the physical therapist made an initial evaluation for Patient #1 on 10/02/2021 Further review revealed no documented evidence Patient #1's received a physical therapy evaluation on or before 10/02/2021 as ordered per Patient# 1's Plan of Care. Review of Patient #1's medical record revealed documentation the occupational therapist made an initial evaluation for Patient #1 on 10/04/2021. Further review revealed no documented evidence Patient #1's received an occupational evaluation on or before 10/04/2021 as ordered per Patient #1's Plan of Care. In an interview on 11/17/2021 at 3:00pm, S1Administrator/Director of Nurses confirmed Patient #1 did not receive 3 skilled nursing visits from 09/09/2021 to 09/11/2021. S1Administrator/Director of Nurses further confirmed Patient #1 did not receive a physical therapy and occupational evaluation as ordered per Patient #1’s Plan of Care.