Every finding on record at Excellent Home Health Care, LLC

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, the agency failed to develop emergency preparedness policies and procedures which addressed the use of volunteers in an emergency. Findings: 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 03/08/2024 at 3:50 p.m., S3Registered Nurse indicated the agency did not have a policy or procedure for the use of the volunteers and/or emergency staffing strategies in the event of an emergency. In an interview on 03/08/2024 at 4:30 p.m., S1Administrator acknowledged the agency did not have a policy or procedure for the use of the volunteers and/or emergency staffing strategies in the event of an emergency.

Recertification Survey

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 the Home Health Aide (HHA) is supervised every 14 days by the registered nurse (RN) for 2(Patient #1 and Patient #7) of 2 patients (Patient #1 and Patient #7) receiving Home Health Aide services in a total sample of 7 patients. Findings: Patient #1 Review of Patient #1’s records revealed an admission date of 12/17/2019 with diagnoses in part; diabetes mellitus type II, neurogenic bladder, and neuropathy. Review Patient #1's Plan of Care for certification period 01/25/2024 - 03/24/2024 revealed a doctor’s order for home health aide services and skilled nursing once in the first week and four per week for 8 weeks. Further review revealed no documentation of HHA supervisory visits by a registered nurse from 01/25/2024 – 03/07/2024. Patient #7 Review of Patient #7’s records revealed an admission date of 07/23/2023 with diagnoses in part; cerebral stroke, dysarthria, and the presence of a tracheostomy and a percutaneous endoscopic gastrostomy (PEG). Review Patient #7's Plan of Care for certification period 11/10/2023 - 01/08/2024 revealed a doctor’s order for HHA services and skilled nursing once in the first week; twice per week for next two weeks; and then once per week for the next four weeks. Further review revealed no documentation of HHA supervisory visits by a registered nurse from 11/10/2023 – 01/08/2024. In an interview on 03/07/2024 at 2:22 p.m., S2Director of Nursing (S2DON) indicated the agency did not perform RN supervisory HHA visits every 14 days.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure a registered nurse(RN) assessed and measured pressure ulcers and wounds weekly for 1 (Patient #2) of 2 (Patient #2 and Patient #6) patients records reviewed for pressure ulcers and wounds in a sample of 7 patients. Findings: Review of the Wound Ostomy and Continence Nurses Society's Guidelines revealed assessment and documentation of wound status, which includes comprehensive clinical data demonstrating evidence of progress in healing or failure to heal. Comprehensive wound assessment includes: dimensions and depth; presence, location and depth of any sinus tracts or undermining areas; status and characteristics of the wound bed; volume, color, and odor of exudates; evidence of infection in surrounding tissues. Further review revealed when recorded over time this information can be used to track the progress of wound healing. Review of the Louisiana State Board of Nursing Declaratory Statement Scope of Practice for Registered Nurses Wound Care Management revealed, in part: the registered nurse may delegate to a LPN (Licensed Practical Nurse) wound care if the RN had deemed the wound stable; and provides appropriate supervision. Review of Patient #2's Home Health Certification and Plan of Care for certification period of 01/01/2024 to 02/29/2024 and 03/01/2024 to 04/29/2024 revealed Patient #2 was to receive skilled nursing services three times per week for 5 weeks; then once for one week; then two times per week for two weeks. Further review revealed skilled nurse to provide in part, dressing change and wound/pressure ulcer care. Review of Patient #2's Skilled Nursing Visit Note Reports revealed S4LPN measured wounds weekly form 01/01/2024 to 01/29/2024, and no measured wounds after 01/29/2024. Further review of Patient #2's Skilled Nursing Visit Note Reports revealed no documentation of any RN visits with wound/pressure ulcer documentation. Review of Patient #2's RN Recertification Oasis Reports dated 02/02/2024 and 02/29/2024 revealed no documentation of wounds/pressure ulcers, and the provider did not present any documentation related to wounds/pressure ulcers In an interview on 03/08/2024 at 10:00 a.m., S2Director of Nursing (DON) indicated S4LPN measured wounds for all patients in his care, and was not aware that RNs had to measure wounds weekly. S2DON acknowledged the agency did not have any documentation of wound/pressure ulcer measurements or staging by an RN for Patient #2.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA 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. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure every patient had individualized emergency disaster plans for 7 of 7 patients (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, and Patient #7) reviewed for individualized disaster plans. Findings: Review of Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, and Patient #7's records revealed blank copies of a document labeled My Emergency Preparedness Plan. Further review of the record revealed no documented evidence of an emergency disaster plan having been developed. In an interview on 04/15/2021 at 1:04pm, S2RN (Registered Nurse) and S3DON(Director of Nursing)/Acting Administrator stated the agency did not have individualized emergency preparedness plans for each patient.

The survey was aborted on 09/16/2020. Recertification Survey, Covid-19 Focused Infection Control Survey, and Re-licensing Survey. Tag #536, #574, #798, and #0017 were cited as a result of the Recertification Survey. Tag # 682 was cited as a result of the Covid-19 Focused Infection Control Survey. Tag #9109, #9123, and #9129 were cited as a result of the Re-licensing Survey. Census: 53

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 the agency had an accurate list of medication taken by the patients for 3 of 3 sampled patients (Patient #1, Patient #2, and Patient #3) reviewed for medication reconciliation during home visits in a total sample of 7. Findings: Patient #1 Review of Patient #1's Home Health Certification and Plan of Care for the certification period of 03/27/2021 to 05/25/2021 revealed Patient #1 was to receive daily services from the skilled nurse. Review of Patient #1's Patient Active Medication Sheet revealed no documented evidence of Trazadone (depression medication) 100mg (milligrams), or Trulicity (diabetic medication) 0.75mg/0.5ml (milliliter) having been listed as a medication Patient #1 was currently taking as of 04/13/2021. Observation on 04/13/2021 at 2:54pm, revealed the following medications were in Patient #1's home, in part: Trazadone 100mg two tablets by mouth daily with a fill date of 03/20/2021, and Trulicity 0.75mg/0.5ml one injection once a month with a fill date of 03/26/2021. Review of Patient #1's Record revealed Patient #1 was seen by the skilled nurse on four occasions after Patient #1's Trazadone and Trulicity was prescribed. In interview on 04/14/2021 at 11:30am, S2RN (Registered Nurse) and S3DON (Director of Nursing)/Acting Administrator stated the agency was unable to explain the discrepancy in Patient #1's medication in the home versus her Active Medication Sheet. Patient #2 Review of Patient #2's Home Health Certification and Plan of Care for certification period of 03/18/2021 to 05/16/2021 revealed Patient #2 was to receive physical therapy services. Review of Patient #2's Patient Active Medication Sheet revealed the following, in part: Alendronate Sodium (medication for healthy bone growth) 70mg one tablet by mouth daily. Further review revealed no documented evidence of the following medication on the Patient Active Medication Sheet: Hydroxychloroquine (for arthritis) 200mg; Timolol Maleate (eye drops) 0.25% opthamalic solution; or Probiotic (healthy bacteria for stomach) 100 million units. Observation on 04/13/2021 at 1:33pm, revealed the following medications were in Patient #2's home, in part: Alendronate Sodium 70mg one tablet weekly; Hydroxychloroquine 200mg one tablet by mouth daily with fill date of 01/26/2021; Timolol Maleate 0.25% opthamalic solution one drop to each eye once a day; and Probiotic 100 million units one by mouth daily. In an interview on 04/13/2021 at 1:33pm, Patient #2's daughter stated Patient #2 was taking the Alendronate Sodium once a week, Hydroxychloroquine daily; Timolol Maleate eye drops daily for a few months; and the probiotic daily. Review of Patient #2's Record revealed Patient #2 was seen by the physical therapy services on seven occasions after the medications were prescribed. In an interview on 04/14/2021 at 1:20pm, S5PT (Physical Therapist) stated he was not sure why he did not capture Patient #2's medications on the admission paperwork. Patient #3 Review of Patient #3's Home Health Certification and Plan of Care for certification period of 03/17/2021 to 05/15/2021 revealed the patient was to receive, in part: skilled nursing services four visits, physical therapy six visits, and speech therapy two visits. Review of Patient #3's Patient Medication Sheet revealed no documented evidence of Patient #3 was assessed as taking Famotidine (stomach medication) 20mg. Observation on 04/14/2021 at 10:50am, revealed the following medication was in Patient #2's home, in part: Famotidine 20mg one tablet by mouth twice a day with a filled date of 03/16/2021. Review of Patient #3's Record revealed Patient #3 received skilled services a total of 19 times since Patient #3's Famotidine 20mg was filled. In interview on 04/14/2021 at 11:30am, S2RN and S3DON/Acting Administrator stated the agency was unable to explain the discrepancy in Patient #3's medication in the home versus her Active Medication Sheet.

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 and interview, the agency failed to ensure each patient's individualized plan of care contained all pertinent diagnoses and the frequency and duration of visits to be conducted for 5 of 7 sampled patients (Patient #1, Patient #2, Patient #3, Patient #4, and Patient #7) reviewed for plans of care. Findings: Patient #1 Review of Patient #1's Home Health Certification and Plan of Care for Certification Period of 03/27/2021 to 05/25/2021 revealed the only diagnosis listed was Infective Tenosynovitis of the Left Hand. Review of the Home Health Certification and Plan of Care revealed a list of medication which revealed in part: Amlodipine Besylate (medication used for heart condition); Atorvastatin Calcium (medication for cholesterol); Hydroxyzine as needed for anxiety; Insulin (medication for diabetes); Metoprolol Succinate (medication for blood pressure); Oxcarbazepine (medication for seizures); and Paliperidone ER (extended release) (medication used to treat mental disorders). Further review revealed Patient #1 was to receive Occupational Therapy (OT) services for two visits, with no documented evidence of when the two visits were to occur. Patient #2 Review of Patient #2's Home Health Certification and Plan of Care for Certification Period of 03/18/2021 to 05/16/2021 revealed the only diagnosis listed was Difficulty in Walking. Review of the Home Health Certification and Plan of Care revealed a list of medication which contained revealed in part: Alendronate Sodium (medication used for osteoporosis), Donepezil HCL (hydrochloride) (medication used for dementia); Levothyroxine Sodium (medication used for thyroid issues); Memantine HCL (medication used for dementia); Simvastatin (medication used for cholesterol); and Pregabalin (medication used for nerve pain or seizures). Further review revealed Patient #2 was to receive Physical Therapy (PT) services for six visits, with no documented evidence of when the six visits were to occur. Patient #3 Review of Patient #3's Home Health Certification and Plan of Care for Certification Period of 03/17/2021 to 05/15/2021 revealed the only diagnosis listed was Cerebrovascular Disease (disease of brain caused by bleeding or damage of the blood vessels). Review of the Home Health Certification and Plan of Care revealed a list of medication, which revealed in part: Losartan (medication used high blood pressure). Further review revealed Patient #3 was to receive Skilled Nursing (SN) services for four visits, PT services for six visits, Speech Therapy (ST) services for two visits, and Home Health Aide (HHA) services for four visits with no documented evidence of when the visits were to occur. Review of Patient #3's Hospital documentation dated 02/26/2021 revealed Patient #3 had the following diagnoses: Hypertension (high blood pressure), Mixed Hyperlipidemia (high cholesterol); Arthritis; and Cerebral Vascular Accident (stroke). Patient #4 Review of Patient #4's Home Health Certification and Plan of Care for Certification Period of 03/09/2021 to 05/07/2021 revealed the only diagnosis listed was Vascular Dementia (Dementia caused damage of the blood vessels of the brain). Review of the Home Health Certification and Plan of Care revealed a list of medication, which contained in part: Losartan Potassium (medication used to treat high blood pressure) and Trazadone HCL (medication used to treat depression). Further review revealed Patient #4 was to receive SN services for four visits, PT services for six visits, ST services for two visits, and HHA services for four visits with no documented evidence of when the visits were to occur. Review of Patient #4's Physician Office Visit dated 03/05/2021 revealed Patient #4 had the following diagnoses, in part: History of Cancer, Hypertension, Seizure-like Activity, and Anxiety. Patient #7 Review of Patient #7's Home Health Certification and Plan of Care for Certification Period of 01/06/2021 to 03/05/2021 revealed the only diagnosis listed was Wedge Compression Fracture of the First Lumbar Vertebra. Review of the Home Health Certification and Plan of Care revealed a list of medication, which contained in part: Allopurinol (medication used for gout); Amlodopine Besylate (medication used for heart condition); Carvedilol (medication used for heart condition); Dapagliflozin Propanediol (medication used to treat diabetes); and Tamsulosin HCL (medication used for the bladder). In an interview on 04/14/2021 at 1:36pm, S2RN (Registered Nurse) and S3DON (Director of Nursing)/Acting Administrator stated the Home Health Certification and Plan of Care only contained the primary diagnosis for Patient #1, Patient #2, Patient #3, Patient #4, and Patient #7. S3DON/Acting Administrator stated she was not aware she had to document the actual frequency; she was using the amount of authorized visits from the insurance authorization as the amount of visits for the Plan of Care. S3DON/Acting Administrator further stated she would tell the individual staff when to start the care and what date all the amount of visits had to be completed by (authorization period) and never documented or stated the frequency of visits.

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 record review and interview the agency failed to ensure the agency field staff were being screened for signs and symptoms of COVID-19 prior to performing home visits for patients for 7 of 10 agency employees (S4LPN (Licensed Practical Nurse), S5Physical Therapist, S6Physical Therapy Assistant, S7Speech Therapist, S8Occupational Therapist, S9Home Health Aide, and S10LPN) reviewed for COVID-19 screenings. Findings: Review of the agency's COVID-19 (Coronavirus Disease 19) Employee Screening, Assessment, and Contact Policy and Procedure revealed, in part: 1. All employees will be pre-screened using the following questions before they come within six feet of the client: a. Have you traveled internationally in the last 14 days to any country currently designated by the CDC (Centers for Disease Control) as a high- risk location for COVID-19? b. Have you had signs of respiratory infection in the last 14 days such as a fever, cough, and/or sore throat? c. Has anyone you live with had signs of respiratory infection in the last 14 days such as a fever, cough and/or sore throat? d. Have you had contact with anyone who has been diagnosed with, or screened for COVID-19? e. Have you traveled to another state with widespread community transmission of COVID-19 in the last 14 days? f. Temperature will also be taken (must not have fever 100.4 degrees Fahrenheit/38 degrees Celsius 2. If an employee answers "yes" to any of the above questions he/she must be sent home. 3. The screener must notify their supervisor and fill out the necessary document (COVID-19 Incident Report). 4. Daily screening results will be retained in employee files. Review of S4LPN (Licensed Practical Nurse), S5Physical Therapist, S6Physical Therapy Assistant, S7Speech Therapist, S8Occupational Therapist, S9Home Health Aide, and S10LPN's Personnel Files revealed no documented evidence of the staff having been screened for COVID-19 prior to providing in home services. The agency was unable to present any documented evidence of screening the staff for COVID-19 exposure and screening staff for signs and symptoms of COVID-19 prior to providing patient care. In an interview on 04/15/2021 at 12:45pm S10LPN, stated she had never had to complete paperwork or call in with screening for COVID-19 prior to patient visits. In an interview on 04/15/2021 at 1:30pm, S2RN (Registered Nurse) and S3DON/Acting Administrator (Director of Nursing) stated they only screen staff prior to coming into the office and not prior to providing care for patients. S2RN stated the field staff were only instructed to screen patients prior to each visit, but were not instructed to screen themselves prior to providing care for patients.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure the registered nurse or therapist provided the home health aide (HHA) with written patient instructions prior to the HHA providing care to the patient for 2 of 2 sampled patients (Patient #3 and Patient #4) reviewed for HHA care plans in a total sample of 7 patients. Findings: Patient #3 Review of Patient #3's Home Health Certification and Plan of Care dated 03/17/2021 to 05/15/2021 revealed Patient #3 was to receive four HHA visits. Review of Patient #3's Record revealed Patient #3 received HHA services on 03/18/2021, 03/23/2021, 03/30/2021, and 03/31/2021. Review of Patient #3's Clinical Documents screen on the electronic medical record revealed the only HHA Care Plan developed was on 04/13/2021. Review of Patient #3's Physical (paper) Record revealed no documented evidence of a HHA Care Plan or written patient instructions having been developed prior to 04/13/2021. In an interview on 04/14/2021 at 2:17pm, S3DON(Director of Nursing)/Acting Administrator stated Patient #3's HHA Care Plan was not created until 04/13/2021. S3DON/Acting Administrator stated she had spoken to the aide and explained what services to provide but did not document the conversation or services she told the HHA to provide, and did not develop the written HHA Care Plan until 04/13/2021. Patient #4 Review of Patient #4's Home Health Certification and Plan of Care dated 03/09/2021 to 05/07/2021 revealed Patient #4 was to receive four HHA visits. Review of Patient #4's Record revealed Patient #4 received HHA services on 03/23/2021, 03/30/2021, and 04/01/2021. Review of Patient #4's electronic medical record and physical (paper) record revealed no documented evidence of a HHA Care Plan or written patient instructions having been created for Patient #4. In an interview on 04/14/2021 at 2:38pm, S2RN (Registered Nurse) and S3DON/Acting Administrator stated the agency did not develop a HHA Care Plan for Patient #3 and Patient #4, and the patients had already received HHA services.