Every finding on record at Louisiana Homecare of Miss-Lou, LLC

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

Recertification Survey Abbreviations: MSW-Medical Social Worker prn-as needed PT-Physical Therapist PTA-Physical Therapy Assistant POC-Plan of Care RN-Registered Nurse

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 plan of care was followed for 2 (#5 and #6) of 10 (#1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) sampled patients as evidenced by: 1. No evidence was found that Patient #5 was evaluated by a PT, as ordered in the POC, and 2. No evidence was found that Patient #6 was evaluated by a MSW, as ordered in the POC. Findings: Patient #5 Review of the clinical record for Patient #5 revealed a Start of Care date of 06/07/2024. Patient #5 had a primary diagnosis of Chronic Obstructive Pulmonary Disease for the Certification Period from 02/02/2025 to 04/02/2025. Review of the Orders of Discipline and Treatments revealed the following: Physical Therapy to evaluate/assess and develop physical therapy plan of care that will be approved by the physician prior to implementation. Review of Patient #5’s calendar and visit notes revealed no evidence of the patient having been evaluated by a Physical Therapist, as of 03/06/2025. Review of Patient #5’s clinical record and interview with S1 Executive Director on 03/06/2025 at 11:45 a.m. revealed Patient #5 had not been evaluated by a Physical Therapist during this certification period, as ordered, but should have been. Patient #6 Review of the clinical record for Patient #6 revealed a Start of Care date of 02/13/2025. Patient #6 had a primary diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery for the Certification Period from 02/13/2025 to 04/13/2025. Review of the Orders of Discipline and Treatments revealed the following: Medical Social Services to evaluate/assess and develop Social Work Plan of Care that will be approved by the Physician prior to implementation. Review of Patient #6’s calendar and visit notes revealed no evidence of the patient having been evaluated/assessed by a Medical Social Worker, as of 03/06/2025. Review of Patient #6’s clinical record and interview with S1 Executive Director on 03/06/2025 at 11:45 a.m. revealed Patient #6 had not been evaluated by a Medical Social Worker during this certification period as ordered, but should have been.

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 the patient’s physician was promptly notified when the patient’s pain level was high and outside of the physician ordered parameters for 1 (#5) of 10 (#1, #2, #3, #4, #5, #6, #7, #8, #9 and #10) sampled patients reviewed. Findings: Review on 03/06/2025 of the agency’s policy titled “Pain Assessment” with a last review date of 02/01/2024 revealed in part…A score of 7 or greater on any of the pain assessment tools below is indicative of severe pain, which will require physician/authorized practitioner notification and patient appropriate interventions….Numeric Rating Scale (0-10)…7-10=severe pain. Review of the clinical record for Patient #5 revealed a Start of Care date of 06/07/2024. Patient #5 had a primary diagnosis of Chronic Obstructive Pulmonary Disease for the Certification Period from 02/02/2025 to 04/02/2025. Physician’s orders included the following: SN 1wk9 (once per week for 9 weeks) with 2 prn visits. When vital signs are obtained, licensed professional to report vital signs falling outside the following established parameters…Pain greater than 6. Review of a visit note dated 02/04/2025 by S2 RN revealed Patient #5 reported pain of 10 on a scale of 0-10 at 8:37 a.m. Review of the visit note revealed the patient’s pain was interfering with patient’s activity, patient was unable to ambulate as easy, and pain was not relieved at an acceptable level. The visit note stated actions taken to assist patient with pain relief read “Patient has prescription ibuprofen for severe pain” and “Patient states she will take some today.” Patient #5’s clinical record was reviewed with S1 Executive Director on 03/06/2025 at 11:45 a.m. In an interview at that time, S1 Executive Director confirmed the visit note dated 02/04/2025 and clinical record revealed no documented evidence of S2 RN notifying the physician of Patient #5’s severe pain level, which was above the parameters ordered by the physician. S1 Executive Director confirmed S2 RN should have notified Patient #5’s physician of the patient’s pain level at the time of the visit, but did not.

Complaint LA00096776 Abbreviations: RN - Registered Nurse ED - Executive Director POC - Plan of Care wk - week RLE - Right Lower Extremity ABD - abdominal X - times ROC - Resumption of Care MVI - Multi-vitamin SN - Skilled Nurse

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 interview and record review the agency failed to ensure care was coordinated to meet patients' needs. The agency failed to communicate and coordinate care for a patient to receive the wound care as ordered by the physician for 1 (Patient #3) of 5 patients records reviewed out a total of 141 total patients. Review of Patient #3’s Home Health Care Certification and Plan of Care for Certification Period 09/26/2022 through 11/24/2022 revealed the primary diagnosis of Chronic Venus Hypertension with Ulcer to Right Lower Leg and secondary diagnosis of Non-Pressure Chronic Ulcer of the Right Ankle. Review of the POC’s orders dated 11/04/2022 revealed the SN was to perform/instruct/reinforce patient/caregiver on the procedure of wound care to the right ankle, Venous Stasis Ulcer, maintain aseptic technique, cleanse with wound cleanser, pat dry, apply silver alginate to the wound bed, pad ankle circumference with ABD pads, the apply two layer compression wrap. Wound clinic to change dressing once a week, Home Health change weekly. Caregiver is competent in providing appropriate wound care treatment. Review of Patient #3’s Nurses’ Note dated 11/07/2022 revealed S2 RN provided wound care as follows: cleansed wound to right ankle with wound cleanser, patted dry, applied Hydrofera Blue to the wound bed, covered with ABD pad, and applied two layer compression wrap. Review of Physician’s order dated 11/14/2022 revealed an order for SN to perform/instruct/reinforce patient/caregiver on the procedure of wound care to the right ankle, Venous Stasis Ulcer, maintain aseptic technique, cleanse with wound cleanser, pat dry, apply Gentamicin 0.1% topical ointment to wound bed twice daily, apply silver alginate to wound bed, cover with ABD dressing apply kerlix around ABD and secure with tape. Apply double tubi grip compression wrap until Gentamicin is complete. Dressing to be changed twice a week per home health, one time a week at wound clinic, and care giver to provide wound care all other days and as needed. Review of Patient #3’s Nurses’ Note dated 11/16/2022 revealed S3 RN provided wound care as follows: cleansed wound to right ankle with wound cleanser, patted dry, applied Hydrofera Blue to the wound bed, covered with ABD pad, and applied two layer compression wrap. Review of Patient #3’s Nurses’ Note dated 11/18/2022 revealed S2 RN provided wound care as follows: cleansed wound to right ankle with wound cleanser, patted dry, applied Hydrofera Blue to the wound bed, covered with ABD pad, and applied two layer compression wrap. Review of Physician’s order dated 11/22/2022 revealed an order for SN to perform/instruct/reinforce patient/caregiver on the procedure of wound care to the right ankle, Venous Stasis Ulcer, maintain aseptic technique, cleanse with wound cleanser, pat dry, apply Manuka Honey, apply silver alginate to wound bed, cover with ABD dressing apply kerlix around ABD dressing. Apply two layer compression wrap. Wound clinic to change dressing once a week every Monday, Home Health twice a week on Wednesdays and Fridays. Caregiver to provide wound care as needed if soiled or not intact. Review of Patient #3’s Nurses’ Note dated 11/23/2022 revealed S2 RN provided wound care as follows: cleanse wound to right ankle with wound cleanser, pat dry, apply Hydrofera Blue to the wound bed, cover with ABD pad, apply two layer compression wrap. Interview with S1 ED on 04/04/2023 at 3:45 p.m. revealed Patient #3 refused to allow the nurses to apply the treatment that was ordered by the physician, stating the wound treatment made Patient #3’s wound burn. S1 ED revealed there should have been communication notes documented on the patient’s refusal and the nurse should have contacted the Physician to coordinate care for Patient #3’s wound care, but that was not done. S1 ED revealed the nurses continued treating the wound with treatments that were not ordered on 11/07/2022, 11/16/2022, 11/18/2022 and 11/23/2022.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to comply with accepted professional standards and principles by failing to have a Registered Nurse assess a patient’s wounds, including the size and stage, weekly for 3 (#2, #4, and #5) of 5 (#1, #2, #3, #4, and #5) sampled patients with wounds out of a total of 141 active patients. Findings: Review of the agency’s Wound Assessment, Documentation, and Photography policy revealed in part …Unless otherwise ordered by the physician, the qualified clinician as defined above (Registered Nurse, Physical Therapist, or Occupational Therapist) will assess wounds at least weekly for patient receiving negative pressure wound therapy, receiving daily wound care performed by the agency, have an infected wound, or have stage IV pressure injury with evidence of infection or exposed bone, tendon, or muscle tissue; every other week for patients receiving wound care by the agency at a frequency less than daily; or as specified per state requirements if more stringent than above. 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. Wound care management requires the RN to collaborate with other members of the Interdisciplinary team to ensure that the individual’s nutritional and psychosocial needs are being met and to provide preventive and therapeutic measures. The RN should consult with the physician and/or CWCN (certified wound care nurse) to assure safe, quality nursing measures that facilitate appropriate skin and wound management. 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 ulcer 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. Patient #2 Review of Patient #2’s POC for certification period 2/22/23 to 4/22/23 reflected the skilled nurse frequency was 1wk1, 2wk8. Patient #1’s diagnoses included Type 2 Diabetes Mellitus with foot ulcer, Non-pressure chronic ulcer of right heel and mid foot, burn of third degree of left foot, and burn of third degree of left lower leg. Review of the plan of care revealed orders for skilled nurse to perform/instruct/reinforce patient/caregiver procedure of wound care to left lateral lower shin, left posterior ankle, left plantar foot, left lateral calf, left medial ankle diabetic ulcers daily with home health to provide wound care once a week, wound clinic on Wednesdays. Also, the POC revealed an order for Skilled nurse to perform/instruct/reinforce patient/caregiver procedure of wound care to right plantar foot diabetic ulcer daily with home health to provide wound care once a week and wound clinic on Wednesdays. Order dated 3/22/23 revealed SN to provide wound care twice weekly, Wound clinic on Wednesdays. SN to perform/instruct/reinforce patient/caregiver procedure of wound care to left plantar foot, left lateral lower shin … Wound to left posterior ankle healed. Wound to RLE right plantar heel: TCT cast applied at wound clinic (cast change weekly at Medcentris) Review of the skilled nurses’ notes revealed Patient #2’s wounds were not assessed by an RN from 2/28/23 until 3/24/23. In an interview on 04/05/2023 at 9:08 a.m. S1 ED confirmed no RN wound assessments were done week 3, 4, and 6. S1 ED stated she thought this patient only had to be assessed by an RN every other week. She confirmed Patient #2 was being treated for osteomyelitis and should have been seen weekly by an RN. Patient #4 Review of Patient #4’s POC for certification period 02/07/2023 to 04/07/2023 reflected the frequency of skilled nurse visits was 1wk9. Patient #4’s diagnoses included, in part, pressure ulcer of sacral region, stage 4, pressure ulcer of right buttock, stage 4, pressure ulcer of other site, stage 4, type 2 diabetes mellitus with other specified complication, and paraplegia. POC revealed orders for skilled nurse to perform/instruct/reinforce patient/caregiver procedure of wound care to left posterior leg, sacrum, and right outer abdominal stage 4 pressure ulcers. Wound care to be performed weekly by home health. Review of a physician’s order dated 03/07/2023 revealed skin sub was placed to Stage 4 pressure ulcers to right middle buttock and right lateral chest. Do not remove primary dressing, secondary dressing to be changed daily and prn soiled or non-intact dressing maintaining aseptic technique, apply alginate, gauze, abd pad, and secure with tape. Also noted was an order dated 03/07/2023 for skilled nurse to perform/instruct patient/caregiver procedure of wound care to stage 4 pressure ulcers: right buttocks, right lateral abd, and right posterior thigh with dressings to be changed daily and prn. Wound care to be performed once weekly by home health, once weekly at wound clinic, and caregiver to perform all other days. Review of the skilled nurses’ notes revealed Patient #4’s wounds were not assessed by an RN the following weeks: 02/19/2023-02/25/2023 03/05/2023-03/11/2023 03/19/2023-03/25/2023 In an interview on 04/05/2023 at 9:28 a.m., S1 ED acknowledged Patient #4’s wounds were not assessed on the three weeks listed above and should have been. Patient #5 Review of Patient #5’s POC for certification period 02/20/2023 to 04/20/2023 revealed the frequency of skilled nurse visits as 2wk8, 1wk1. Patient #5’s primary diagnosis was pressure ulcer of the sacral region, stage 3. The POC revealed an order for skilled nurse to perform procedure of wound care to Stage 3 Pressure Ulcer to sacrum 2 x week and wound clinic will perform once weekly. Review of skilled nurse visit notes revealed Patient #5’s wounds were not assessed by an RN the week of 02/26/2023 to 03/04/2023. Review of skilled nurses’ notes revealed Patient #5 was hospitalized from 03/06/2023 until 03/24/2023. A resumption of care visit was conducted on 03/25/2023 by an RN who documented “Pt’s had completed wound care prior to arrival of SNV. Last measurements were obtained from hospital records.” Patient #4’s wounds were not assessed by an RN the week of 03/26/2023 to 04/01/2023. In an interview on 04/05/2023 at 9:36 a.m., S1 ED stated wound should have been assessed during the ROC visit on 3/25/23. S1 ED stated an RN was assessing her wounds every other week according to their policy.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure nursing services ordered by the physician were provided as indicated in the plan of care for 1 (#3) of 5 (#1, #2, #3, #4, and #5) patient records reviewed for services provided per the plan of care and physician orders. The agency’s current census was 141 patients. Findings: Review of Patient #3’s Home Health Care Certification and Plan of Care for Certification Period 09/26/2022 through 11/24/2022 revealed the primary diagnosis of Chronic Venus Hypertension with Ulcer to Right Lower Leg and secondary diagnosis of Non-Pressure Chronic Ulcer of the Right Ankle. Review of the POC’s orders dated 11/04/2022 revealed the SN was to perform/instruct/reinforce patient/caregiver on the procedure of wound care to the right ankle, Venous Stasis Ulcer, maintain aseptic technique, cleanse with wound cleanser, pat dry, apply silver alginate to the wound bed, pad ankle circumference with ABD pads, the apply two layer compression wrap. Wound clinic to change dressing once a week, Home Health change weekly. Caregiver is competent in providing appropriate wound care treatment. Review of Patient #3’s Nurses’ Note dated 11/07/2022 revealed S2 RN provided wound care as follows: cleansed wound to right ankle with wound cleanser, patted dry, applied Hydrofera Blue to the wound bed, covered with ABD pad, and applied two layer compression wrap. Review of Physician’s order dated 11/14/2022 revealed an order for SN to perform/instruct/reinforce patient/caregiver on the procedure of wound care to the right ankle, Venous Stasis Ulcer, maintain aseptic technique, cleanse with wound cleanser, pat dry, apply Gentamicin 0.1% topical ointment to wound bed twice daily, apply silver alginate to wound bed, cover with ABD dressing apply kerlix around ABD and secure with tape. Apply double tubi grip compression wrap until Gentamicin is complete. Dressing to be changed twice a week per home health, one time a week at wound clinic, and care giver to provide wound care all other days and as needed. Review of Patient #3’s Nurses’ Note dated 11/16/2022 revealed S3 RN provided wound care as follows: cleansed wound to right ankle with wound cleanser, patted dry, applied Hydrofera Blue to the wound bed, covered with ABD pad, and applied two layer compression wrap. Review of Patient #3’s Nurses’ Note dated 11/18/2022 revealed S2 RN provided wound care as follows: cleansed wound to right ankle with wound cleanser, patted dry, applied Hydrofera Blue to the wound bed, covered with ABD pad, and applied two layer compression wrap. Review of Physician’s order dated 11/22/2022 revealed an order for SN to perform/instruct/reinforce patient/caregiver on the procedure of wound care to the right ankle, Venous Stasis Ulcer, maintain aseptic technique, cleanse with wound cleanser, pat dry, apply Manuka Honey, apply silver alginate to wound bed, cover with ABD dressing apply kerlix around ABD dressing. Apply two layer compression wrap. Wound clinic to change dressing once a week every Monday, Home Health twice a week on Wednesdays and Fridays. Caregiver to provide wound care as needed if soiled or not intact. Review of Patient #3’s Nurses’ Note dated 11/23/2022 revealed S2 RN provided wound care as follows: cleanse wound to right ankle with wound cleanser, pat dry, apply Hydrofera Blue to the wound bed, cover with ABD pad, apply two layer compression wrap. Review of Patient #3’s Home Health Care Certification and Plan of Care for Certification Period 11/25/2022 through 01/23/2023 revealed the primary diagnosis of Chronic Venus Hypertension with Ulcer to Right Lower Leg and secondary diagnosis of Non-Pressure Chronic Ulcer of the Right Ankle. Skilled nurse visits were ordered 1wk1 then 2wk8. Review of Physician’s order dated 11/29/2022 revealed an order for SN to perform/instruct/reinforce patient/caregiver on the procedure of wound care to the right ankle, Venous Stasis Ulcer, maintain aseptic technique, cleanse wound with wound cleanser, apply adaptic to wound bed, cover with gauze, apply two layer compression wrap. Dressings to be: changed twice a week per home health on Wednesdays and Fridays, and one time a week at the wound clinic every Monday. Caregiver to provide wound care as needed if soiled or not intact. Review of the Nurses Notes’ revealed no visits had been conducted after 11/23/2022 until 12/07/2022. Further review of the Nurses’ notes revealed Patient #3 was only seen one time the week of 12/11/2022 – 12/17/2022, not twice as ordered. Review of a Communication Note dated 12/12/2022 revealed a missed SN visit for 12/09/2022 due to no supplies. Review of a Communication Note dated 12/12/2022 revealed a missed SN visit for 12/12/2022 due to patient/caregiver refused due to no supplies in the home. Review of Physician’s order dated 12/20/2022 revealed an order for SN to perform/instruct/reinforce patient/caregiver on the procedure of wound care to the right ankle, Venous Stasis Ulcer, maintain aseptic technique, cleanse with Hibiclens wash, saline rinse, pat dry, apply skin prep to peri-wound, apply alginate with silver, then apply a two layer Drawtex cover with kerlix and secure with tape. Encourage off loading, add MVI with Zinc supplement. Dressing change daily, one time a week per home health and one time a week per wound care clinic and caregiver to provide on days SN not available and caregiver has provided competency. Review of a Communication Note dated 12/26/2022 revealed the following: check on ordered supplies from 12/22/2022. Review of a Communication Note dated 12/28/2022 revealed the following: On-Call – supplies ordered have not arrived and Patient #3 does not have any supplies. Review of Nurses’ note date 12/29/2022 revealed supplies were delivered. Review of Physician’s order dated 01/03/2023 revealed an order for SN to cleanse wound with wound cleanser, apply skin prep, apply Hydrofera Blue, apply a two layer Drawtex, cover with kerlix and secure with tape daily. Dressing change once a week per home health, once a week at the wound care clinic and caregiver to provide wound care on days SN not available. Caregiver has provided competency. Review of the Nurses Notes’ revealed no visits had been conducted after 01/05/2023 until 01/16/2023. Further review of the Nurses’ notes revealed Patient #3 not seen the week of 01/08/2023 – 01/14/2023 as ordered. Interview with S1 ED on 04/04/2023 at 3:50 p.m. confirmed Patient #3 patient’s orders and the skilled nurses notes that on 11/07/2022, 11/16/2022, 11/18/2022 and 11/23/2022 the nurses failed to follow the physician’s orders and provide the correct wound care that was order. S1 ED confirmed that skilled nurse visits were not done the week of 11/27/2022 – 12/03/2022 or 01/08/2023 – 01/14/2023 as ordered by the physician. S1 ED also confirmed skilled nurse visits should never be missed due to no supplies.

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

Recertification Survey Abbreviations: POC - Plan of Care w - week cm = centimeters RN - Registered Nurse LPN - Licensed Practical Nurse COVID-19 - Coronavirus Disease

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure staff that were not fully vaccinated for COVID-19 implemented additional precautions intended to mitigate the transmission and spread of COVID-19 for 2 (S2 RN and S3 LPN) of 2 staff observed that were not fully vaccinated for COVID-19. Findings: 1. Observation on 03/08/2022 at 10:30 a.m. with Patient #1 revealed S2 RN to provide skilled nursing services that included wound care to the patient wearing only a surgical mask. Interview with S2 RN on 03/08/2022 at 11:15 a.m. confirmed she had a religious exemption for not taking the COVID-19 vaccinations. She stated all staff have been instructed when seeing patients they only had to wear a surgical mask. 2. Observation on 03/09/2022 at 10:15 a.m. with Patient #2 revealed S3 LPN entered the patient’s home wearing only a surgical mask. Review of the COVID-19 Staff Vaccination Status for Providers revealed there were 12 staff that were not vaccinated but had either a medical or a religious exemption out of a total of 29 staff. Interview with S1 ED on 03/09/2022 at 11:00 a.m. revealed that all staff regardless of their vaccine status were to wear only a surgical mask when performing home skilled visits. She confirmed there were no additional precautions put in place to ensure staff that were not fully vaccinated. She also confirmed that all 12 staff that were not fully vaccinated worked in the field performing home visits on patients in their homes. She also confirmed that the unvaccinated staff were not receiving weekly COVID-19 testing. She stated she was not aware that she should have additional measures in place for staff that were not fully vaccinated.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to comply with accepted professional standards and principles by failing to have a Registered Nurse assess a patient's wounds, including the size and stage, weekly for 3 (#1, #4, and 6) of 5 (#1, #3, #4, #5, #6 and #7) sampled patients with wounds in a total sample of 10. Findings: Review of the agency’s Wound Assessment Policy revealed in part… unless otherwise ordered by the Physician, the Registered Nurse or Physical Therapist will assess wounds at least; 2. Every other week for patients, receiving wound care by the agency at a frequency less that daily. 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. Wound care management requires the registered nurse to collaborate with other members of the interdisciplinary team to ensure that the individual's nutritional and psychosocial needs are being met and to provide for preventive and therapeutic measures. The Registered Nurse should consult with the physician and/or CWCN (certified wound care nurse) to assure safe, quality nursing measures that facilitate appropriate skin and wound management. 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 ulcer 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. 1. Review of Patient #1's POC for certification period 12/26/2021 to 02/23/2022 reflected the skilled nurse frequency was 1w9 and for certification period of 02/24/2022 to 04/24/2022 reflected the skilled nurse frequency was 2w2, 1w7. The patient's primary diagnosis was Encounter for change or removal of non-surgical wound dressing and other pertinent diagnosis of Diabetes Mellitus Type 2 and Venous Insufficiency (Chronic-Peripheral). Review of Patient #1’s Skilled Nurses’ Note dated 01/11/2022 reflected the patient had a wound to his left heel that measured 2.8 cm X 2.0 cm X 0.6 cm and a wound to his left lower leg that measured 2.0 cm X 0.6 cm X 0.1 cm. Review of the Skilled Nurses’ Notes dated 01/21/2022 and 02/02/2022 revealed no documentation of a complete wound assessment. There was no documentation that the wounds had been re-assessed by the RN until 02/07/2022. Review of the Skilled Nurses’ Note dated 02/07/2022 revealed the following measurements: Left heel – 2.8 cm X 2.0 cm X 0.6 cm, which indicated there had been not changes since his last assessment by the RN on 01/11/2022. Left Lower Leg – 3.0 cm X 2.0 cm X 0.1 cm, which indicated there had been an increase in the size of the wound since his last assessment by the RN dated 01/11/2022. 2. Review of Patient #4's POC for certification period 01/16/2022 – 03/16/2022 reflected the skilled nurse frequency was 1w9. The patient's primary diagnosis was Pulmonary Hypertension, with other pertinent diagnosis included Chronic Obstructive Pulmonary Disease, Essential Hypertension, Polyosteoarthritis and History of Falls. Further review of the POC revealed the patient had a trauma wound to his mid back and was receiving daily wound care to the area. Review of Patient #4’ Skilled Nurses’ Notes revealed a re-assessment of the wound on 01/15/2022 that measured 4.0 cm X 4.0 cm X 0.1 cm. Review of the Skilled Nurses’ Notes from 01/20/2022 – 02/09/2022 revealed there was no re-assessment of the wound again by the RN until 02/09/2022, which indicated the wound measured 2.5 cm X 4.0 cm X 0.2 cm. Further review of the Skilled Nurses’ Notes revealed there had been no re-assessment of the wound by an RN after the 02/09/2022 assessment. Observation of Patient #4’s wound with S2 LPN on 03/08/2022 at 9:00 a.m. revealed the wound measured approximately 4.0 cm X 4.0 cm X 0.2 cm. The wound was clean, had scant drainage and defined edges. 3. Review of Patient #6's POC for certification period 12/22/2021 to 02/19/2022 reflected the skilled nurse frequency was 1w9 and on 01/13/2022, the skilled nurse frequency was increased to 2 times a week. For the certification period of 02/19/2022 to 04/20/2022 reflected, the skilled nurse frequency was 2w2. The patient's primary diagnosis was Encounter for change or removal of non-surgical wound dressing and other pertinent diagnosis of Diabetes Mellitus Type 2 and Venous Insufficiency (Chronic-Peripheral). Review of Patient #6’s Start of Care of 12/22/2021 revealed the patient had a wound to her Left Distal Calf that measured 2.9 cm X 2.4 cm X 0.1 cm. There were no further re-assessments conducted by the RN until 01/31/2022 that measured 2.2 cm X 2 cm X 0.1 cm. Review of the Skilled Nurses’ Notes from 02/04/2022 revealed there was no re-assessment of the wound again by the RN until 01/31/2022, which indicated the wound measured 2.5 cm X 4.0 cm X 0.2 cm. Further review of the Skilled Nurses’ Notes revealed there had been no re-assessment of the wound by an RN until 02/18/2022.