Every finding on record at Lhcg Xiii, LLC

Lourdes Home Health is in compliance with the federal emergency preparedness requirements.

Recertification Survey

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's written individualized POC (Plan of Care) was followed as evidenced by the SN (Skilled Nurse) failing to make visits as ordered for 2 (#4 and #12) of 17 sampled patients. Findings: Patient #4 Review of the patient's electronic clinical record revealed the start of care date was 11/23/2025. The patient's diagnosis included acute kidney failure. The certification period reviewed was 11/23/2025 to 1/21/2026. Review of the patient's POC for certification period 11/23/2025 to 1/21/2026 revealed an order for "SN 6wk1,3wk2,1wk6 (skilled nurse visit 6 times a week for one week, 3 times a week for 2 weeks, 1 time a week for 6 weeks)". Review of the patient’s skilled nurse visit notes for the week of 11/23/2025 to 11/29/2025 revealed he received 4 of 6 skilled nurse visits ordered for that week. Patient #12 Review of the patient’s electronic clinical record revealed the start of care date was 11/11/2025. The patient’s diagnosis included muscle wasting and atrophy. The certification period reviewed was 11/11/2025 to 1/9/2026. Review of the patient’s POC for certification period 11/11/2025 to 1/9/2026 revealed an order for “SN 3wk1,1wk8 (skilled nurse visit 3 times a week for one week, 1 time a week for 8 weeks)”. Review of the patient’s skilled nurse visit notes for the week of 11/11/2025 to 11/15/2025 revealed she received 1 of 3 skilled nurse visits ordered for that week. On 12/03/2025 at 8:45 a.m., an interview and record review was conducted with S1ED (Executive Director). She confirmed that patient #4 had orders for SN visits 6 times a week for week 1, but only received 4 visits that week. She confirmed patient #12 had orders for SN visits 3 times a week for week 1, but only received 1 visit that week.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure Patient #3's physician was notified of a four-pound weight gain in one day that was noted by the skilled nurse during the skilled nurse visit made on 11/24/2025 for 1 (#3) out of 17 sampled patients. Patient #3. Review of the patient's electronic clinical record revealed the start of care date was 11/23/2025. The patient's diagnoses included infection/inflammation reaction due to cardiac valve prosthesis and chronic diastolic congestive heart failure. The certification period reviewed was 11/23/2025 to 01/21/2026. Review of the patient's POC (Plan of Care) for certification period 11/23/2025 to 01/21/2026 revealed the following order, SN 2wk1, 1wk8, 2 prns for… cardiac complications… (skilled nurse visit two times a week for one week, one visit a week for eight weeks, two visits as needed for cardiac complications). Further review of the POC revealed, “Skilled nurse to obtain weight every visit and notify RN (Registered Nurse)/physician of weight gain of 3 lbs (pounds) within one day or 5 lbs within one week.” Review of the patient's SN Visit Note dated 11/23/2025 revealed the patient’s weight was 200 pounds. Review of the patient’s SN Visit Note dated 11/24/2025 revealed the patient’s weight was 204 pounds, which was a four-pound weight gain in one day. There was no evidence the SN, which was a RN, notified the physician of the patient’s four-pound weight gain in one day. On 12/02/2025 at 10:52 a.m., a telephone interview was conducted with S2RN. S2RN reviewed Patient #3’s electronic clinical record and she verified the patient had a four pound weight gain in one day. S2RN confirmed she did not notify the patient’s physician of the four pound weight gain. S2RN stated that she should have notified the physician concerning the weight gain. On 12/02/2025 at 1:20 p.m., an interview was conducted with S1ED (Executive Director). S1ED reviewed Patient #3’s clinical record and she confirmed the patient had a four pound weight gain in one day. S1ED confirmed there was no evidence the physician was notified of the patient’s weight gain. Also, S1ED stated that S2RN should have notified the patient’s physician of the weight gain.

Lourdes Home Health is in compliance with the federal emergency preparedness requirements.

Recertification Survey

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's written individualized POC (plan of care) was followed as evidenced by the SN (skilled nurse) failing to record blood sugar readings for patient (#8) as ordered per the POC for 1 out of 17 sampled patients. (#8) Patient #8. Review of the patient's electronic clinical record revealed the start of care date was 11/12/2022. The patient's diagnoses included Diabetes Mellitus with Hyperglycemia, Hypertension, Dementia and Presence of Insulin Pump. The certification period reviewed was 11/12/2022 to 1/10/2023. Review of the patient's POC for certification period 11/12/2022 to 1/10/2023 revealed an order for skilled nurse 1wk9 (skilled nurse visits one time a week for nine weeks). Further review of the patient's POC revealed an order for the skilled nurse to record the patient’s blood sugar reading every visit. Review of the patient's electronic clinical record and the SN visit note dated 11/12/2022 revealed that there was no evidence that the patient's blood sugar reading was recorded as ordered on 11/12/2022. On 12/12/2022 at 11:58 am, S1ED (Executive Director) reviewed the patient’s electronic clinical record and the patient’s SN visit note dated 11/12/2022 and confirmed that there was no evidence that the skilled nurse had recorded the patient’s blood sugar reading for that date.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to coordinate care delivery to meet the patient's needs as evidenced by the agency nurse failing to verify a change in the insulin dosage with the patient’s physician for 1 (#8) out of 17 sampled patients. Patient #8. Review of the agency’s policy and procedure for Coordination of Care, From Admit Through Discharge revealed, “… 4. Coordination of care with physician: At admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient’s physician: a. When changes occur in the patient’s condition or response to treatment…” Review of the patient's electronic clinical record revealed the start of care date was 11/12/2022. The patient's diagnoses included Diabetes Mellitus with Hyperglycemia, Hypertension, Dementia and Presence of Insulin Pump. The certification period reviewed was 11/12/2022 to 1/10/2023. Review of the patient's POC for certification period 11/12/2022 to 1/10/2023 revealed an order for skilled nurse 1wk9 (skilled nurse visits one time a week for nine weeks). Further review of the patient's POC revealed an order for the skilled nurse to review the patient’s blood sugar reading log and to record the patient’s blood sugar reading on every visit. Review of the patient’s Client Coordination Note Report dated 11/23/2022 revealed that the note was an on call note. The report revealed, “Late entry start time: 11/22/2022 6:38 pm Completion time: 11/22/2022 Caller/Reason for call: Caregiver (Daughter) called to report patient had CBG (Capillary Blood Glucose) 565 at 3:50 pm. Patient took 8-9 Lispro Insulin units (bolus) using pump. And at 5:50 pm CBG was 508… CBG was 490 at 7:50 pm and contacted Dr. ______ … on call service. MD contacted patient’s caregiver directly and gave instructions to increase the bolus by 2 units each time CBG remained elevated. CBG 301 after patient given 10 units bolus…” Review of the patient’s SN visit note report dated 11/23/2022 revealed, “…Daughter reports pt’s (patient’s) meter stopped working 2 days ago and pt has not been able to control sugar since. Daughter spoke with RN with our agency on call last night and was given directions after Dr. _______ … on call service was contacted. Instructions given to increase the bolus by 2 units each time CBG remained elevated. Daughter states pt went to bed last night with CBG 301. Pt’s fasting readings this AM at 8:30- 388, 9:35- 400, and now 454…” On 12/13/2022 at 2:50 pm, an interview was conducted with S1ED (Executive Director) and S2PCM (Patient Care Manager). S2PCM stated the patient’s daughter had called her on 11/22/2022 concerning the patient’s high blood sugar readings and that the insulin pump had stopped working 2 days ago, which would have been on 11/20/2022. S2PCM stated she left a phone message with the patient’s specialty physician (Endocrinologist) concerning the patient’s high blood sugar readings and the insulin pump not working. S2PCM stated the Endocrinologist did not call the home health agency back. S2PCM stated the patient’s daughter told her the Endocrinologist gave her (the patient’s daughter) instructions to increase the insulin by 2 units each time the CBG reading remained elevated. S2PCM stated that she did not call the Endocrinologist back to verify the instructions that were given to the patient’s daughter. S1ED was present during the interview and she stated the Endocrinologist should have communicated those changes to the agency nursing staff. S1ED and S2PCM both confirmed that the agency nursing staff and the Endocrinologist did not coordinate the patient’s care.