Every finding on record at Lhcg Xv, LLC

St. Landry Homecare is in compliance with 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 obtain the weight for patient (#6) per the POC for 1 out of 17 sampled patients. Patient #6. Review of the patient’s electronic clinical records revealed the start of care date was 12/20/2023. The patient’s diagnoses included Diabetes and Congestive Heart Failure. The certification period reviewed was 12/20/2023 to 2/17/2024. Review of the patient’s Plan of Care (POC) for certification period 12/20/2023 to 2/17/2024 revealed the following order - SN (Skilled Nurse) 1wk4, 1every2wk2, 1wk3 (one time a week for four weeks, one visit every two weeks for two weeks, one time a week for three weeks). Further review of the patient’s POC revealed an order for “Skilled nurse to obtain weight every visit and notify RN/MD (Registered Nurse/Medical Director) of weight gain or loss of 2-3 lbs (pounds) within 24 hours or 5 lbs within 7 days…” The POC revealed orders for “Skilled nurse to obtain body measurements of bilateral ankles if unable to weigh every visit. Skilled nurse to notify physician of 3 cm (centimeter) increase”. Review of the patient’s SN visit notes dated 12/27/2023 and 1/3/2024 revealed that there was no evidence the SN obtained the patient’s weight and there was no evidence body measurements of the patient’s bilateral ankles were done. On 1/10/2024 at 12:55 p.m., S1ED (Executive Director) reviewed the patient’s SN visit notes dated 12/27/2023 and 1/3/2024. She confirmed that there was no evidence the patient's weight was obtained for the SN visits made on 12/27/2023 and 1/3/2024 and that there was no evidence body measurements of the patient’s bilateral ankles were done.

Recertification Survey A COVID-19 Focused Infection Control Survey was conducted on 3/24/2021. The facility was found to be in compliance with 42 CFR §484.70 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. Total Census: 346 Unduplicated admissions census: 957

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 agency's staff followed the patient's individualized plan of care as evidenced by: 1. No evidence found in the electronic medical records that the skilled nurse obtained a pulse oximetry reading as ordered during the visit on 3/3/2021 for Patient #1 and; 2. No evidence found in the electronic medical records that the skilled nurse performed a blood glucose as ordered during the visit on 3/15/2021 for Patient #4 and; 3. No evidence found in the electronic medical records that the home health aide (HHA) preformed 2 visits as ordered for the week of 2/28/2021 for Patient #7 out of a total of 17 sampled patients. Findings: 1. Patient #1. The patient was admitted to the agency with the start of care (SOC) date of 2/19/2021. The patient's admitting diagnoses included Acute Embolism and Thrombosis of Right Femoral Vein, Pressure Ulcer to Right and Left Buttocks Stage 2 and Rheumatoid Arthritis. The certification period reviewed was 2/19/2021 to 4/19/2021. The patient's Plan of Care (POC) was reviewed and revealed under the section Orders of Discipline and Treatments - Skilled Nurse to perform pulse oximetry every visit on room air to monitor patient's respirator status. The patient's Visit Note Reports for the certification period was reviewed. There was no evidence found on the Visit Note Report dated 3/3/2021 that the skilled nurse obtained a pulse oximetry reading during the skilled visit. On 3/23/2021 at 9:35 am, an interview was conducted with S1ED (Executive Director) and she stated the skilled nurse should obtain a pulse oximetry reading on every skilled visit. S1ED reviewed the patient's electronic medical record and she verified there was no evidence the skilled nurse obtained a pulse oximetry reading on 3/3/2021. 2. Patient #4. The patient was admitted to the agency with the start of care (SOC) date of 3/10/2021. The patient's admitting diagnoses included Type 2 Diabetes Mellitus, Hypertensive heart Disease with Heart Failure and Chronic Obstructive Pulmonary Disease. The certification period reviewed was 3/10/2021 to 5/8/2021. The patient's Plan of Care (POC) was reviewed and revealed under the section Orders of Discipline and Treatments: Skilled nurse to instruct patient on blood glucose testing. Frequency for blood glucose testing ... ... SN (skilled nurse) to assess every visit and to perform if not done or if symptomatic. The patient's electronic Visit Note Reports dated 3/15/2021 were reviewed. The skilled nurse documented the following under the Narrative - Awake and alert. Able to make needs known ... ... .....Unable to perform CBG (capillary blood glucose) due to unable to find machine ... ..... There was no evidence found for the skilled visit on 3/15/2021 that the skilled nurse obtained blood glucose as ordered on the plan of care. On 3/23/2021 at 3:01 pm, an interview was conducted with S1ED (Executive Director). S1ED reviewed the patient's electronic medical record and she verified there was no evidence the skilled nurse obtained a blood glucose as ordered on 3/15/2021. 3. Patient #7. The patient was admitted to the agency with the start of care (SOC) date of 2/27/2021. The patient's admitting diagnoses included Unspecified Fracture of Humerus, and Left Arm, and Essential Hypertension. The certification period reviewed was 2/27/2021 to 4/27/2021. The patient's Plan of Care (POC) was reviewed and revealed under the section Frequency/Duration of Visits: HHA effective 02/28/2021 2WK3 (2 visits a week for 3 weeks), and 1wk1 (1 visit a week for 1 week). Documentation found under the section Orders of Discipline and Treatments - Home Health Aide service for assistance with personal care and ADL's secondary to functional limitations, which prevent self-care. The patient's Visit Note Reports for the home health aide was reviewed. There was no evidence found for the week of 2/28/2021 that the home health aide conducted 2 visits as ordered on the plan of care. On 3/23/2021 at 3:01 pm, an interview was conducted with S1ED (Executive Director). S1ED reviewed the patient's electronic medical record and she verified there was no evidence the home health aide conducted 2 visits for the week of 2/28/2021.

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 review and interview, the agency failed to ensure skilled professional services were delivered as evidenced by patient #6 not receiving a social worker consult for 1 out of 17 sampled patients. (#6) Findings: Patient #6. Review of the patient's electronic clinical records revealed the start of care date was 2/24/2021. The patient's diagnosis included Hemiplegia following Cerebral Infarction. The certification period reviewed was from 2/24/2021 to 4/24/2021. Review of the patient's POC for certification period 2/24/2021 to 4/24/2021 revealed that there was no order for a social worker. Review of the patient's Client Coordination Note Report dated 3/3/2021 revealed, "Significant Event/Problem: Patient's caregiver is requesting social worker consult for additional help with patient." Follow-up comment dated 3/5/2021 revealed, "Currently no MSW available." There was no documented evidence that a social worker consult was done to the present date of 3/23/2021. On 3/23/2021 at 2:45 pm, S1ED (Executive Director) reviewed the patient's electronic clinical records and confirmed that the patient's caregiver requested a social worker consult. S1ED stated that a social worker consult was not done because the social worker was not available and out on leave.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the accuracy of skilled nurse assessment as evidenced by inaccurate documentation found on the skilled note dated 3/15/2021 under the section for the endocrine assessment for Patient #4 out of a total of 17 sampled patients. Findings: Patient #4. The patient was admitted to the agency with the start of care (SOC) date of 3/10/2021. The patient's admitting diagnoses included Type 2 Diabetes Mellitus, Hypertensive heart Disease with Heart Failure and Chronic Obstructive Pulmonary Disease. The certification period reviewed was 3/10/2021 to 5/8/2021. The patient's Plan of Care (POC) was reviewed and revealed under the section Orders of Discipline and Treatments: Skilled nurse to instruct patient on blood glucose testing. Frequency for blood glucose testing ... ... SN (skilled nurse) to assess every visit and to perform if not done or if symptomatic. The patient's electronic Visit Note Reports dated 3/15/2021 was reviewed. The skilled nurse documented the following under the Narrative - Awake and alert. Able to make needs known ... ... .....Unable to perform CBG (capillary blood glucose) due to unable to find machine ... ..... The skilled visit note on 3/15/2021 was reviewed and the skilled nurse documented the following documentation during the visit. Under the section Endocrine - CBG results obtained by: Patient. Is patient performing CBG per physician orders: Yes. Does patient demonstrate understanding and competency in CBG testing: Yes. Is CBG results within patient specific Parameters? Yes. Does patient check controls according to manufacturer guidelines? Yes. On 3/23/2021 at 12:24 pm an interview was conducted with S1ED (Executive Director) and the patient's electronic medical record was reviewed. S1ED verified the skilled nurse's assessment under the section Endocrine was incorrectly documented by S2LPN due to the patient not being able to find his glucometer in his home. On 3/23/2021 at 12:33 pm, a phone interview was conducted with S2LPN and she stated the patient did not remember where he had put his glucometer in his home and he was not checking his sugars. S2LPN stated she saw the patient one time and was currrently in the field making visits and she did not remember what she had documented on the patient's skilled notes during the visit.