Every finding on record at Hood Home Health Service, LLC

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

Recertification Survey Abbreviations: CMS- Centers for Medicare & Medicaid Services HCHB- Home Care Home Base OASIS- Outcome and Assessment Information Set RN-Registered Nurse

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 reviews and interviews, the agency failed to ensure each OASIS was successfully transmitted to the CMS system within 30 days of completion. Findings: Review of the agency’s policy titled, “OASIS Data Capture, Transmission, Verification, Display and Reports” with a revision date of 10/01/2025, revealed the following, in part: Purpose: To ensure proper OASIS data capture and transmission to state agencies and to ensure compliance with regulatory guidelines. Procedure: 2. Transmittal of OASIS data a. At least monthly, the Agency will electronically transmit accurate, completed, encoded and locked OASIS data to the state agency. All OASIS assessments completed must be transmitted within thirty (30) days of M0090 (Date Assessment Completed) date. Review of the agency's OASIS Final Validation Report with a submission date of 09/16/2025 revealed 48 records were processed with 2 records receiving a message in which the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Final Validation Report with a submission date of 09/23/2025 revealed 64 records were processed with 2 records receiving a message in which the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Final Validation Report with a submission date of 09/30/2025 revealed 67 records were processed with 2 records receiving a message in which the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Final Validation Report with a submission date of 10/07/2025 revealed 50 records were processed with 4 records receiving a message in which the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Final Validation Report with a submission date of 10/14/2025 revealed 78 records were processed with 3 records receiving a message in which the record was submitted late due to a submission date of more than 30 days after date on the record. An interview was conducted with S4BM on 12/18/2025 at 10:25 a.m. She stated the agency’s process was once an OASIS was completed and approved, someone, unsure who, at the agency’s home office electronically submitted the OASIS to CMS. She stated once a week she received the OASIS validation reports via email and reviewed the report for any issues or late submissions. She stated there were a variety of reasons some of the OASIS were submitted late. She reviewed the above OASIS validation reports and confirmed 13 of the records were submitted late, more than 30 days after completion. An interview was conducted with S1ED on 12/18/2025 at 10:45 a.m. She confirmed of the above-mentioned OASIS validation reports, 13 of the records were submitted late, more than 30 days after completion.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the OASIS accurately reflected the patient’s Pressure Ulcer status at the time of the assessment for 1 (#14) of 4 patients reviewed with Pressure Ulcers. Findings: Review of Patient #14’s Clinical Record revealed a start of care date of 01/01/2025 and a discharge certification period of 03/02/2025 through 04/30/2025. Further review revealed Patient #14 had a Sacral Pressure Ulcer with an onset date of 03/17/2025. Review of Patient #14’s Nursing Visit Note dated 04/28/2025 revealed she had a Stage 2 Sacral Pressure Ulcer. Review of Patient #14’s Visit Notes for certification period of 03/02/2025 through 04/30/2025 revealed she did not have a visit conducted by the home health agency after the 04/28/2025 visit listed above. Review of Patient #14’s Discharge OASIS assessment dated 04/30/2025 revealed she had a Stage 3 Sacral Pressure Ulcer. An interview was conducted with S2PCM on 12/17/2025 at 3:15 p.m. S2PCM confirmed Patient #14’s discharge OASIS dated 04/30/2025 was coded to indicate Patient #14 had a Stage 3 Pressure Ulcer. S2PCM confirmed Patient #14 had a Stage 2 Pressure Ulcer and not a Stage 3 Pressure Ulcer. S2PCM confirmed Patient #14’s OASIS dated 04/30/2025 was coded inaccurately.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure the Plan of Care was signed by the authorized healthcare provider within 60 days for 1 (#16) of 17 sampled patients reviewed. Cross-referenced with State Regulations 9123. Patient Care Standards: C. Plan of Care. The POC for each patient shall be individualized to address the patient's problems, goals, and required services. 1. The POC, telephone and/or verbal orders shall be signed by the authorized healthcare provider within a timely manner, not to exceed 60 days. Findings: Review of the agency’s policy titled, “Physician Orders” with a revision date of 10/01/2023 revealed the following, in part: Policy: No medications, treatments, diagnostic studies or therapeutics will be administered without the order of a qualified physician or authorized practitioner, or as designated by State Practice Acts and that order be reduced to writing and signed/dated by the ordering physician. Procedure: 4. The Plan of Care, telephone and or verbal orders must be signed and dated by the physician or authorized practitioner within a timely manner per state regulation: State: Louisiana; Timeliness of Physician Signature: 60 days. Review of Patient #16’s Clinical Record revealed a start of care date of 12/21/2024, had a certification period of 12/21/2024 through 02/18/2025, 02/19/2025 through 04/19/2025, 04/20/2025 through 05/07/2025, and was discharged on 05/07/2025. Review of Patient #16’s Plan of Care for the certification period of 02/19/2025 through 04/19/2025 revealed it was not signed by the authorized healthcare provider, not within the 60 day requirement. Review of Patient #16’s Plan of Care for the certification period of 04/20/2025 through 06/18/2025 revealed it was not signed by the authorized healthcare provider, not within the 60 day requirement. An interview was conducted with S1ED on 12/17/2025 at 3:30 p.m. She stated S4BM was responsible for the agency’s orders. S1ED reviewed Patient #16’s clinical record and confirmed the Plan of Care dated 02/19/2025 and 04/20/2025 were not signed within 60 days as required. An interview was conducted with S4BM on 12/18/2025 at 8:45 a.m. She stated she was responsible for the agency’s orders. S4BM reviewed Patient #16’s clinical record and confirmed the Plan of Care dated 02/19/2025 and 04/20/2025 were not signed within 60 days as required.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (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 interviews and record review, the agency failed to assure communication with all physicians involved in the Plan of Care. The agency failed to ensure the physician was notified home health aide services were not provided as ordered for 1 (#1) of 4 patients reviewed with orders for home health aide services. Findings: Review of Patient #1’s Clinical Record revealed care was initiated on 11/11/2025 with a current certification period of 11/11/2025 through 01/09/2026. Further review revealed a physician’s order dated 11/06/2025 for admission to home health, which included to evaluate for home health aide services to provide assistance with personal care, activities of daily living, and vital signs. Review of Patient #1’s Admission Skilled Nursing Visit dated 11/11/2025 revealed the following, in part: Patient refused the home health aide. Review of Patient #1’s Coordination Note dated 11/07/2025 revealed the following, in part: Clinical Comment/Intake-Patient refused the home health aide on admit. Review of Patient #1’s Physician Orders and Coordination Notes for Certification Period 11/11/2025 through 01/09/2026 revealed no documented evidence the provider was notified home health aide services were not provided as ordered. An interview was conducted with the nurse at Patient #1’s physician’s office on 12/18/2025 at 8:20 a.m. She reviewed Patient #1’s clinical record and confirmed the physician ordered home health services on 11/06/2025. She further confirmed there was no documented evidence the physician was notified home health aide services were not provided to Patient #1 as ordered. An interview was conducted with S1ED on 12/15/2025 at 1:25 p.m. She reviewed Patient #1’s Clinical Record and Home Health referral dated 11/06/2025. S1ED confirmed the physician ordered home health aide services and the patient refused the aide services on admit. S1ED further confirmed there was no documented evidence the physician was notified home health aide services were not provided as ordered.

Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to integrate and provide home health aide services ordered at the time of referral for 1 (#11) of 4 patients reviewed for home health aide services. Findings: Review of Patient #11’s Clinical Record revealed he was referred to the home health agency on 10/21/2025 with an order for home health aide services. Patient #11 began receiving services from the agency on 10/28/2025 and had a current certification period of 10/28/2025 through 12/26/2025. Review of Patient #11’s Plan of Care for certification period of 10/28/2025 through 12/26/2025 revealed no documentation pertaining to home health aide services. Review of Patient #11’s Physician Orders and Coordination Notes for the certification period of 10/28/2025 through 12/26/2025 revealed no documented evidence the physician was contacted for clarification of the home health aide order, to discontinue the order, or that the home health aide services would not be provided. An interview was conducted with S1ED on 12/17/2025 at 11:05 a.m. She confirmed home health aide services were ordered for Patient #11’s referral on 10/21/2025. She confirmed home health aide services were not provided for Patient #11. She confirmed there was no documentation in Patient #11’s Clinical Record to indicate why the home health aide services were not provided. She confirmed there was no physician order to discontinue the home health aide services. She confirmed the home health services should have been provided on admission or the physician should have been contacted to clarify the order or discontinue the order.

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 provided Skilled Professional Services in accordance with current clinical practice guidelines as set forth by the Louisiana State Board of Nursing Declaratory Statement for Scope of Practice for Registered Nurses - Wound Care Management and accepted professional standards as set forth by National Pressure Ulcer Advisory Panel for Prevention and Treatment of Pressure Ulcers for 3 (#9, #14, and #16) of 4 patients reviewed with Pressure Ulcers. The agency failed to ensure the RN assessed Patient #9, #14, and #16’s Pressure Ulcers, including size and stage, on a weekly basis. Findings: Review of the Louisiana State Board of Nursing, Declaratory Statement Scope of Practice for Registered Nurses - Wound Care Management revealed, in part, the following: Registered nurses render care that is directed towards the prevention and the treatment of wounds. Scope of Practice - The Louisiana State Board of Nursing recognizes that assessment, planning, intervention, teaching, evaluation, and supervision are the major responsibilities of the registered nurse in the practice setting. The Registered Nurse initiates appropriate wound prevention measures, stages wounds and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by the authorized prescriber. The Registered Nurse initiates appropriate wound preventative measures, stages wounds and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by an authorized prescriber. Delegation - In accord with the Law Governing the Practice of Nursing (RS 37:913(14) the Registered Nurse may delegate select nursing interventions to qualified nursing personnel as set forth in the Board's rules on delegation (LAC 46:XLVII.3703.). The Registered Nurse retains the accountability for the total nursing care of the individual. The Registered Nurse may delegate to a Licensed Practical Nurse wound care interventions in any situation when the Registered Nurse has deemed the patients status is stable, the intervention is based on a relatively fixed and limited body of scientific knowledge, can be performed by following a defined nursing procedure with minimal alteration, responses of the individual to the nursing care are predictable and changes in the patient's clinical condition are predictable. Furthermore, the patient's medical and nursing orders are not subject to continuous change or complex modification, and appropriate RN supervision is available. Review of the National Pressure Ulcer Advisory Panel Prevention and Treatment of Pressure Ulcers: Quick Reference Guide revealed, in part, the following: Pressure Ulcer Assessment 1. Assess the Pressure Ulcers initially and re-assess it at least weekly. 1.1. Document the results of all wound assessments. Assess and document physical characteristics including: location, category/stage, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. Review of the agency’s policy titled, “Wound Assessment, Documentation, and Photography,” with a revision date of 09/01/2024, revealed the following, in part: Policy: Wound assessment findings will be documented within the Integumentary Command Center by utilizing the Wound Assessment Tool, within HCHB computer system. Patient #9 Review of Patient #9’s Clinical Record revealed a start of care date of 07/31/2025, a current certification period of 11/28/2025 through 01/26/2026, and a diagnosis of Stage 2 Pressure Ulcer of Right Buttock. Review of Patient #9’s Plan of Care for certification period of 07/31/2025 through 09/28/2025 revealed the following, in part: Skilled Nursing Visits once weekly for one week and twice weekly for eight weeks; and Skilled Nurse to perform/instruct patient/caregiver on wound care to Right Buttock every three days. Review of Patient #9’s Nursing Visits conducted for the certification period of 07/31/2025 through 09/28/2025 revealed Patient #9’s Right Buttock Pressure Ulcer was not assessed, including measurements, by a RN on the weeks of 08/03/2025, 08/10/2025, 08/17/2025, 08/24/2025, 08/31/2025, 09/07/2025, 09/14/2025, and 09/21/2025. Review of Patient #9’s Plan of Care for certification period of 09/29/2025 through 11/27/2025 revealed the following, in part: Skilled Nursing Visits once weekly for one week, twice weekly for seven weeks, and once weekly for one week; and Skilled Nurse to perform/instruct patient/caregiver on wound care to Right Buttock every three days. Review of Patient #9’s Nursing Visits conducted for the certification period of 09/29/2025 through 11/27/2025 revealed Patient #9’s Right Buttock Pressure Ulcer was not assessed, including measurements, by a RN on the weeks of 09/28/2025, 10/12/2025, 10/19/2025, 10/26/2025, 11/02/2025, 11/09/2025, and 11/16/2025. Review of Patient #9’s Plan of Care for certification period of 11/28/2025 through 01/26/2026 revealed the following, in part: Skilled Nursing Visits once weekly for one weekly for eight weeks effective 11/30/2025; and Skilled Nurse to perform/instruct patient/caregiver on wound care to Right Buttock every three days. Review of Patient #9’s Nursing Visits conducted for the certification period of 11/28/2025 through 01/26/2026 revealed Patient #9’s Right Buttock Pressure Ulcer was not assessed, including measurements, by a RN on the week of 11/30/2025. An interview was conducted with S1ED on 12/17/2025 at 10:46 a.m. S1ED reviewed Patient #9’s Clinical Record and confirmed there were no RN assessments or measurements conducted of Patient #9’s Pressure Ulcer on the weeks of 08/03/2025, 08/10/2025, 08/17/2025, 08/24/2025, 08/31/2025, 09/07/2025, 09/14/2025, 09/21/2025, 09/28/2025, 10/12/2025, 10/19/2025, 10/26/2025, 11/02/2025, 11/09/2025, 11/16/2025, and 11/30/2025. Patient #14 Review of Patient #14’s Clinical Record revealed a start of care date of 01/01/2025 and a discharge certification period of 03/02/2025 through 04/30/2025. Further review revealed Patient #14 had a Sacral Pressure Ulcer with an onset date of 03/17/2025. Review of Patient #14’s Plan of Care for certification period of 03/02/2025 through 04/30/2025 revealed the following, in part: Skilled Nursing Visits once weekly for eight weeks effective 03/09/2025; and Skilled Nurse to perform/instruct to patient/caregiver on wound care to Sacral Pressure Ulcer every 3-5 days. Review of Patient #14’s Nursing Visits conducted for the certification period of 03/02/2025 through 04/30/2025 revealed Patient #14’s Sacral Pressure Ulcer was not assessed, including measurements, by a RN on the weeks of 03/23/2025, 03/30/2025, 04/13/2025, and 04/20/2025. An interview was conducted with S1ED on 12/17/2025 at 3:00 p.m. S1ED reviewed Patient #14’s Clinical Record and confirmed there were no RN assessments or measurements conducted of Patient #14’s Pressure Ulcer on the weeks of 03/23/2025, 03/30/2025, 04/13/2025, and 04/20/2025. Patient #16 Review of Patient #16’s Clinical Record revealed a start of care date of 12/21/2024, a certification period of 12/21/2024 through 02/18/2025, 02/19/2025 through 04/19/2025, 04/20/2025 through 05/07/2025, and was discharged on 05/07/2025. Further review revealed Patient #16 had a Stage 3 Pressure Ulcer of Other Site (Bilateral Ischial) with an exacerbation date of 12/18/2024 and Stage 3 Left Buttock Pressure Ulcer with an exacerbation date of 02/18/2025. Review of Patient #16’s Plan of Care for certification period of 12/21/2024 through 02/18/2025 revealed the following, in part: Skilled Nursing visits once weekly for one week, twice weekly for eight weeks, then once weekly for one week; and Skilled Nurse to perform/instruct caregiver on wound care to Bilateral Ischial Stage 3 Pressure Ulcers daily. Review of Patient #16’s Nursing Visits conducted for the certification period of 12/21/2024 through 02/18/2025 revealed Patient #16’s Bilateral Ischial Pressure Ulcer was not assessed, including measurements, by a RN on the weeks of 12/29/2024 and 02/02/2025. Review of Patient #16’s Plan of Care for certification period of 02/19/2025 through 04/19/2025 revealed the following, in part: Skilled Nursing visits twice weekly for nine weeks; and Skilled Nurse to perform/instruct to patient/caregiver on wound care to Left Buttock Pressure Ulcer and Bilateral Ischial Pressure Ulcers three days a week. Review of Patient #16’s Nursing Visits conducted for the certification period of 02/19/2025 through 04/19/2025 revealed Patient #16’s Left Buttock and Bilateral Ischial Pressure Ulcer was not assessed, including measurements, by a RN on the week of 03/23/2025. An interview was conducted with S3PCM on 12/17/2025 at 2:50 p.m. She reviewed Patient #16’s Clinical Record and confirmed there were no RN assessments or measurements conducted of Patient #16’s Pressure Ulcers on the weeks of 12/29/2024, 02/02/2025, and 03/23/2025. An interview was conducted with S1ED on 12/17/2025 at 3:30 p.m. She reviewed Patient #16’s Clinical Record and confirmed there were no RN assessments or measurements conducted of Patient #16’s Pressure Ulcers on the weeks of 12/29/2024, 02/02/2025, and 03/23/2025. She stated an RN should have assessed and measured patients’ Pressure Ulcers weekly.

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 reviews and interviews, the agency failed to ensure a registered nurse or qualified therapist prepared written patient care instructions for the home health aide for 1 (#16) of 4 patients reviewed for home health aide services. Findings: Review of the agency’s policy titled, “Home Health Aide Supervision” with a revision date of 12/01/2024, revealed the following, in part: Policy: The Registered Nurse and/or Qualified Therapist, as appropriate, will supervise the Home Health Aides according to State and Federal Conditions of Participation to ensure the quality and appropriateness of the home health aides’ services. Procedure: 6. Home Health Aides are assigned to patients based on the assessment made by staff RN or qualified therapist. Review of Patient #16’s Clinical Record revealed a start of care date of 12/21/2024, a certification period of 12/21/2024 through 02/18/2025, 02/19/2025 through 04/19/2025, 04/20/2025 through 05/07/2025, and a discharge date of 05/07/2025. Review of Patient #16’s Physician Ordered visit frequencies for the certification period of 12/21/2024 through 02/18/2025 revealed Home Health Aide visits once weekly for nine weeks. Review of Patient #16’s Aide Care Plan for the certification period of 12/21/2024 through 02/18/2025 revealed it was prepared and approved by S7LPN. Review of Patient #16’s discipline visit notes for the certification period of 12/21/2024 through 02/18/2025 revealed home health aide visits were conducted on 12/24/2024, 12/30/2024, 01/06/2025, 01/13/2025, 01/20/2025, 01/27/2025, 02/03/2025, 02/14/2025 and 02/17/2025. Review of Patient #16’s Physician Ordered visit frequencies for the certification period of 02/19/2025 through 04/19/2025 revealed Home Health Aide visits once weekly for eight weeks. Review of Patient #16’s Aide Care Plan for the certification period of 02/19/2025 through 04/19/2025 revealed it was prepared and approved by S7LPN. Review of Patient #16’s discipline visit notes for the certification period of 02/19/2025 through 04/19/2025 revealed home health aide visits were conducted on 02/24/2025, 03/03/2025, 03/12/2025, 03/17/2025, 03/24/2025, 04/01/2025, and 04/11/2025. Review of Patient #16’s Physician Ordered visit frequencies for the certification period of 04/20/2025 through 06/18/2025 revealed Home Health Aide visits once weekly for nine weeks. Review of Patient #16’s Aide Care Plan for the certification period of 04/20/2025 through 06/18/2025 revealed it was prepared and approved by S7LPN. Review of Patient #16’s discipline visit notes for the certification period of 04/20/2025 through 06/18/2025 revealed home health aide visits were conducted on 04/21/2025, 04/28/2025, and 05/06/2025. An interview was conducted with S7LPN on 12/18/2025 at 9:40 a.m. She stated for patients with ordered home health aide services, an aide care plan had to be completed prior to the home health aide entering a patient’s home. She stated sometimes the RN or therapist forgot to complete the aide care plan. She stated she would then complete a standard aide care plan which included bathing, dressing, and vital signs. S7LPN confirmed she had prepared and completed the home health aide care plans for Patient #16. An interview was conducted with S3PCM on 12/17/2025 at 2:50 p.m. She reviewed Patient #16’s clinical record for the certification periods of 12/21/2024 through 02/18/2025, 02/19/2025 through 04/19/2025, and 04/20/2025 through 06/18/2025. She stated the admitting clinician, an RN or therapist should develop the aide care plan. She stated S7LPN developed the aide care plan if the admitting clinician forgot to. She stated she was not aware an RN or qualified therapist were required to prepare and develop the home health aide care plan. She confirmed S7LPN developed and approved Patient #16’s home health aide care plan for the above certification periods. An interview was conducted with S1ED on 12/17/2025 at 3:30 p.m. She stated the admitting clinician, an RN or therapist should develop the home health aide care plan. She stated if the admitting clinician forgot to develop the aide care plan and the home health aide arrived for the visit, then S7LPN developed the aide care plan. She stated she was not aware an RN or qualified therapist were required to prepare and develop the home health aide care plan. She reviewed Patient #16’s clinical record for the certification periods of 12/21/2024 through 02/18/2025, 02/19/2025 through 04/19/2025, and 04/20/2025 through 06/18/2025. S1ED confirmed S7LPN developed and approved Patient #16’s home health aide care plans for the above certification periods.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (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) 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 paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on interviews and record reviews, the agency failed to ensure home health aide supervisory assessments were completed no less than every 14 days for 2 (#3 and #16) of 4 patients reviewed for home health aide services. Findings: Review of the agency’s policy titled, “Home Health Aide Supervision” with a revision date of 12/01/2024, revealed the following, in part: Policy: The Registered Nurse and/or Qualified Therapist, as appropriate, will supervise the Home Health Aides according to State and Federal Conditions of Participation to ensure the quality and appropriateness of the home health aides’ services. Procedure: If home health aide services are provided to a patient who is receiving skilled nursing, physical therapy, occupational therapy, or speech therapy, a registered nurse or other appropriate skilled professional (physical therapist, occupational therapist, or speech therapist) who is familiar with the patient and the plan of care, will perform the supervisory visit. These visits are made according to specific state guidelines below: Louisiana – at least every 14 days. Patient #3 Review of Patient #3’s Clinical Record revealed care was initiated on 09/09/2025 with a current certification period of 11/08/2025 through 01/06/2026. Review of Patient #3’s Physician Ordered visit frequencies revealed Skilled Nursing visits once weekly for nine weeks, Occupational Therapy visits once weekly for eight weeks, and Home Health Aide visits twice weekly for eight weeks then once weekly for one week. Review of Patient #3’s discipline visit notes for the certification period of 11/08/2025 through 01/06/2025 revealed home health aide visits were conducted on 11/11/2025, 11/13/2025, 11/18/2025, 11/21/2025, 11/25/2025, 12/01/2025, 12/05/2025, 12/08/2025, and 12/12/2025. Further review of Patient #3’s discipline visit notes revealed no home health aide supervisory assessments were conducted. A telephone interview was conducted with S6RN on 12/17/2025 at 8:16 a.m. She confirmed she had never conducted a home health aide supervisory assessment for Patient #3. She stated she was unaware she should have conducted home health aide supervisory assessments. An interview was conducted with S1ED on 12/15/2025 at 4:10 p.m. She reviewed Patient #3’s clinical record for the certification period of 11/08/2025 through 01/06/2026 and confirmed the home health aide supervisory assessments had not been conducted as required. She stated Patient #3’s home health aide supervisory visit assessments were scheduled for S6RN to conduct on 11/19/2025 and 12/10/2025, however, S6RN’s documentation revealed the supervisory assessments were not conducted. Patient #16 Review of Patient #16’s Clinical Record revealed care was initiated on 12/21/2024 with certification periods including, 12/21/2024 through 02/18/2025, 02/19/2025 through 04/19/2025, and 04/20/2025 through 05/07/2025. Further review of Patient #16’s clinical record revealed she was discharged on 05/07/2025. Review of Patient #16’s Physician Ordered visit frequencies for the certification period of 12/21/2024 through 02/18/2025 revealed Skilled Nursing visits once weekly for one week, twice weekly for eight weeks, then once weekly for one week, Occupational Therapy visits once weekly for five weeks, Physical Therapy visits once weekly for four weeks, and Home Health Aide visits once weekly for nine weeks. Review of Patient #16’s discipline visit notes for the certification period of 12/21/2024 through 02/18/2025 revealed home health aide visits were conducted on 12/24/2024, 12/30/2024, 01/06/2025, 01/13/2025, 01/20/2025, 01/27/2025, 02/03/2025, 02/14/2025 and 02/17/2025. Further review of Patient #16’s discipline visit notes revealed no home health aide supervisory assessments were conducted from 12/24/2024 through 01/13/2025 and from 01/31/2025 through 02/17/2025. Review of Patient #16’s Physician Ordered visit frequencies for the certification period of 02/19/2025 through 04/19/2025 revealed Skilled Nursing visits twice weekly for nine weeks, Occupational Therapy visits once weekly for four weeks, Physical Therapy visits twice weekly for three weeks then once weekly for one week, and Home Health Aide visits once weekly for eight weeks. Review of Patient #16’s discipline visit notes for the certification period of 02/19/2025 through 04/19/2025 revealed home health aide visits were conducted on 02/24/2025, 03/03/2025, 03/12/2025, 03/17/2025, 03/24/2025, 04/01/2025, and 04/11/2025. Further review of Patient #16’s discipline visit notes revealed no home health aide supervisory assessments were conducted from 03/15/2025 through 04/08/2025. An interview was conducted with S3PCM on 12/17/2025 at 2:50 p.m. She reviewed Patient #16’s clinical record for the certification period of 12/21/2024 through 02/18/2025 and 02/19/2025 through 04/19/2025. She confirmed the home health aide supervisory assessments had not been conducted as required. An interview was conducted with S1ED on 12/17/2025 at 3:30 p.m. She stated patients receiving home health aide services should have home health aide supervisory assessments every 14 days. She reviewed Patient #16’s clinical record for certification period of 12/21/2024 through 02/18/2025 and 02/19/2025 through 04/19/2025 and confirmed the home health aide supervisory assessments had not been conducted as required.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure a completed discharge summary was sent to the patients’ primary care practitioner or other health care professional responsible for providing care and services to the patient after discharge within 5 business days of the patients’ discharge from the agency for 2 (#15 and #17) of 5 discharged patients reviewed. Findings: Review of the agency’s policy titled, “Patient Discharge/Transfer Process,” with a revised date of 10/01/2023, revealed the following, in part: Purpose: To ensure continuity of care when a patient is discharged… Procedure: 21. A discharge summary including admission and discharge dates, reason for admission to home health, reason for discharge, services provided to the patient, patient’s condition at time of discharge, a brief summary of care provided, progress toward goals, patient’s discharge goals of care, patient’s treatment preferences, a list of community resources or referrals made, along with a current medication list is sent to the physician or other healthcare professional responsible for care after discharge from the agency within 5 business days of patient’s discharge. Patient #15 Review of Patient #15’s Clinical Record revealed she began receiving services from the Home Health Agency on 01/31/2025, had a certification period of 01/31/2025 to 03/31/2025, and was discharged from the agency on 03/14/2025. Review of Patient #15’s Clinical Record revealed a completed discharge summary was sent on 04/08/2025 to the health care provider who would be assuming responsibility for Patient #15’s care and services upon their discharge from the agency. Patient #17 Review of Patient #17’s Clinical Record revealed he began receiving services from the Home Health Agency on 06/19/2025, had a Certification Period of 06/19/2025 to 08/17/2025, and was discharged from the agency on 08/14/2025. Review of Patient #17’s Clinical Record revealed a completed discharge summary was sent on 09/24/2025 to the health care provider who would be assuming responsibility for Patient #17’s care and services upon their discharge from the agency. On 12/16/2025 at 3:45 p.m., an interview was conducted with S1ED. S1ED reviewed Patient #15’s Clinical Record and confirmed Patient #15 was discharged from the agency on 03/14/2025. S1ED confirmed Patient #15’s discharge summary was sent to the physician on 04/08/2025. S1ED reviewed Patient #17’s Clinical Record and confirmed Patient #17 was discharged from the agency on 08/14/2025. S1ED confirmed Patient #17’s discharge summary was sent to the physician on 09/24/2025. S1ED stated discharge summaries should have been sent to the patients’ physician within 5 business days of the patient’s discharge.

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

Recertification Survey Abbreviation: mg - milligrams ED - Executive Director 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 during a home visit, interviews, and record review, the agency failed to ensure the patient’s comprehensive assessment included a review of all medications the patient was currently using. The agency failed to ensure skilled nursing staff reconciled a patient’s medications for 1 (#3) of 5 (#1, #2, #3, #4, and #5) patients reviewed with home visits. Findings: Review of the Agency’s Policy titled, “Monitoring Medications” revealed the following, in part: Purpose: To provide a process to ensure continuous monitoring of medications in the patient’s home. Policy: A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode. Procedure: 2. All clinicians participating in the patient’s care are responsible to assist with the maintenance of accurate patient medication information throughout the episode of care. During the patient’s episode of the care the following will occur: a. Through a collaborative process the care team will: i. Compare medications patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies; Review of the Clinical Record for Patient #3 revealed he began receiving services from the Home Health Agency on 08/19/2022 and had a current Certification Period of 12/17/2022 to 02/14/2023. Patient #3 had diagnoses, which included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Hypertensive Heart & Chronic Kidney Disease with Heart Failure, Chronic Combined Diastolic and Systolic Heart Failure, and End Stage Renal Disease. Further review revealed Patient #3 received Skilled Nursing Visits once weekly for Certification period of 10/18/2022 to 12/16/2022 and once weekly for eight weeks effective 12/18/2022. A home visit was conducted with Patient #3 on 01/10/2023 at 9:00 a.m. with S2RN present in the home. A review of Patient #3’s medications was conducted during the home visit. The following medication discrepancies were identified when compared to the Current Medication Profile for Patient #3 provided by the Home Health Agency: Auryxia 210mg iron tablet by mouth three times daily – on the Medication Profile and not present in the home Carvedilol 6.25mg by mouth daily – on the Medication Profile and not present in the home Glipizide 5mg by mouth daily – on the Medication Profile and not present in the home An interview was conducted with Patient #3’s family member during the home visit. She confirmed she managed Patient #3’s medications. She stated Patient #3 had not taken Auryxia since November 2022 and Carvedilol and Glipizide in one month. An interview was conducted with S1ED on 01/10/2022 at 11:30 a.m. She stated medications should have been reconciled during each visit by the Home Health Agency. She confirmed the above discrepancies for Patient #3.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on observation, interviews, and record review, the agency failed to communicate with the Physician and Dialysis Center for 1 (#3) of 5 (#1, #2, #3, #4, and #5) patients reviewed with home visits. The agency failed to ensure the Physician and Dialysis Center were notified when Patient #3 was not taking his physician prescribed dialysis medication. Findings: Review of the Agency’s Policy titled, “Coordination of Care From Admit Through Discharge” revealed the following, in part: Purpose: To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge. Policy: The agency provides care and services within an integrated continuum of care system. This is accomplished by: Identifying patient needs through assessment and communication with other health care providers. Procedure: 4. Coordination of care with physician: e. When there is need to change the patient’s plan of care. 6. Coordination of services with other organizations and community: When the patient received services from other organizations and/or individual’s care is coordinated to ensure that patient’s needs are met efficiently, without duplication of services, including: b. Communication with other health care providers when there are significant changes in patient care and/or condition. Review of the Clinical Record for Patient #3 revealed he began receiving services from the Home Health Agency on 08/19/2022 and had a current Certification Period of 12/17/2022 to 02/14/2023. Patient #3 had diagnoses, which included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Hypertensive Heart & Chronic Kidney Disease with Heart Failure, Chronic Combined Diastolic and Systolic Heart Failure, and End Stage Renal Disease. Further review revealed Patient #3 received Skilled Nursing Visits once weekly for Certification Period of 10/18/2022 to 12/16/2022 and once weekly for eight weeks effective 12/18/2022. Review of the Clinical Record for Patient #3 for the certification periods of 10/18/2022 – 12/16/2022 and 12/17/2022 – 02/14/2023 revealed no documentation Patient #3’s physician or dialysis center had been notified Patient #3 had not been taking his prescribed Auryxia. Review of the current Medication Profile for Patient #3 provided by the Home Health Agency revealed the following, in part: Start date: 10/18/2022 – Auryxia 210mg iron tablet by mouth three times daily A home visit was conducted with Patient #3 on 01/10/2023 at 9:00 a.m. with S2RN present in the home. Patient #3’s medications were reviewed during the home visit. Observation revealed the medication Auryxia was not present in the home. An interview was conducted with Patient #3’s family member during the home visit on 01/10/2023. Patient #3’s family member confirmed she managed Patient #3’s medications. She confirmed Patient #3 received hemodialysis on Mondays, Wednesdays, and Fridays. She stated Patient #3 had not taken Auryxia since November 2022 because his insurance would not cover it. An interview was conducted with S1ED on 01/10/2023 at 12:45 p.m. She confirmed there was no documentation in Patient #3’s clinical record that the physician and dialysis center were notified he could not fill his Auryxia. An interview was conducted with S3RN on 01/11/2023 at 10:15 a.m. S3RN confirmed she was Patient #3’s nurse at the Dialysis Center. She stated Patient #3 was prescribed Auryxia 210mg by mouth three times a day in October 2022. S3RN stated Patient #3’s dietician at the dialysis center recommended he be on a phosphate binder (Auryxia) related to elevated phosphorus levels. She stated she was not aware Patient #3 did not have his Auryxia filled due to insurance coverage. S2RN stated the Home Health Agency did not notify the dialysis center Patient #3 was not taking the prescribed Auryxia. An interview was conducted with S1ED on 01/11/2023 at 10:30 a.m. She confirmed there was no documentation in Patient #3’s clinical record that the physician and dialysis center were notified he could not fill his Auryxia. She confirmed the Home Health Agency Nurse should have identified Patient #3 did not have the Physician Prescribed Auryxia in his home and communicated that with Patient #3’s Physician and Dialysis Center.