Every finding on record at Louisiana Homecare of Slidell, LLC

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

Recertification Survey Abbreviations: CMS- Centers for Medicare and Medicaid Services OASIS- Outcome and Assessment Information Set OT- Occupational Therapy PT-Physical Therapy POC- Plan of Care SOC- Start of Care

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 review and interview, the agency failed to ensure each OASIS (Outcome and Assessment Information Set) was successfully transmitted to the Centers for Medicare and Medicaid Services (CMS) system within 30 days of completion. This deficient practice had the potential to affect all 394 patients according to the agency’s active census. Findings: Review of the agency’s revised policy dated 10/01/2025 and titled “OASIS Data Capture, Transmission, Verification, Display and Reports” revealed, in part: Procedure 2. Transmittal of OASIS data a. At least monthly, 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 the completion (M0090) date. Review of the agency’s OASIS Final Validation Report dated 04/07/2026 revealed 133 total records were submitted with 1 record submitted greater than 30 days of the completion date. Review of the agency’s OASIS Final Validation Report dated 04/08/2026 revealed 18 total records were submitted with 1 record submitted greater than 30 days of the completion date. Review of the agency’s OASIS Final Validation Report dated 04/21/2026 revealed 113 total records were submitted with 1 record submitted greater than 30 days of the completion date. Review of the agency’s OASIS Final Validation Report dated 05/05/2026 revealed 136 total records were submitted with 2 records submitted greater than 30 days of the completion date. Review of the agency’s OASIS Final Validation Report dated 05/20/2026 revealed 161 total records were submitted with 1 record submitted greater than 30 days of the completion date. Review of the agency’s OASIS Final Validation Report dated 05/26/2026 revealed 105 total records were submitted with 2 records submitted greater than 30 days of the completion date. Review of the agency’s OASIS Final Validation Report dated 06/02/2026 revealed 119 total records were submitted with 3 records submitted greater than 30 days of the completion date. An interview was conducted with S1ED on 06/22/2026 at 1:05 p.m. S1ED stated all OASIS assessments should be submitted within 30 days of the completion date. The above OASIS Final Validation Reports and the Agency Oasis Data Error Report dated 04/01/2026 through 06/18/2026 were reviewed with S1ED. S1ED confirmed the above OASIS assessments were submitted greater than 30 days of the completion date.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to have the Plan of Care (POC) reviewed and revised by the physician every 60 days, beginning with the SOC (Start of Care) date for 3 (#4, #13, and #14) of 17 sampled patients reviewed. Patient #14 Review of Patient #14’s clinical record revealed a SOC date of 01/07/2026. Review of Patient #14’s POC for the certification period dated 01/07/2026 through 03/07/2026 revealed the POC was not reviewed, revised, or approved by Patient #14’s physician every 60 days. Findings: Review of the agency’s revised policy dated 03/01/2026, and titled “Plan of Care (POC)” revealed, in part: Purpose To assure an appropriate plan of care is developed and revised in a timely manner for each patient. To ensure the physician/authorized practitioner’s orders are followed. Procedure 1. A POC is developed for all patients and updated no less than every 60 days. Patient #4 Review of Patient #4’s clinical record revealed a SOC date of 01/21/2026. Review of Patient #4’s POC for the certification period dated 03/22/2026 through 05/20/2026 revealed the POC was not reviewed, revised, or approved by Patient #4’s physician every 60 days. Patient #13 Review of Patient #13’s clinical record revealed a SOC date of 06/04/2025. Review of Patient #13’s POC for the certification period dated 06/04/2025 through 08/02/2025 revealed the POC was not reviewed, revised, or approved by Patient #13’s physician every 60 days. An interview was conducted with S1ED on 06/15/2026 at 1:32 p.m. S1ED reviewed the above mentioned POC’s for Patients #4, #13 and #14, and confirmed their POC’s had not been reviewed, revised, or approved by their physicians every 60 days and should have been.

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 reviews and interview, the agency failed to provide services as ordered by the physician in the Plan of Care (POC) for 1 (#11) of 17 sampled patients reviewed. Findings: Review of the facility’s revised policy dated 03/01/2026 and titled “Plan of Care” revealed, in part: Policy Each patient has an individualized Plan of Care (POC) developed in consultation with the patient, physician or authorized practitioner, and staff that integrates comprehensive assessment findings to address patient problems, needs, and goals, as well as to address specific services being provided. Procedure 2. The POC includes: b. Types, frequency, and duration of services required that may include virtual services. n. All patient care orders. Review of Patient #11’s clinical record revealed she began receiving services from the agency on 05/13/2026, with diagnoses, which included in part, Sepsis Due to Escherichia Coli, Tubulo-Interstitial Nephritis, Pneumonitis Due to Inhalation of Food and Vomit, and History of Falling. Review of Patient #11’s POC for the certification period dated 05/13/2026 through 07/11/2026, reviewed and signed by Patient #11’s physician on 06/10/2026, revealed in part: Physical Therapy to evaluate/ assess and develop a Physical Therapy Plan of Care that will be approved by the physician prior to implementation. Occupational Therapy to evaluate/assess and develop an Occupational Therapy Plan of Care that will be approved by the physician prior to implementation. Supporting Documentation for Home Health Eligibility: The patient has a normal inability to leave the home and when leaving the home, requires considerable and taxing effort as evidenced by: Easily fatigued, poor respiratory status, unsteady gait, physical limitation and/or paralysis impacting mobility, ability, and effort to leave home, weakness in lower extremities causing balance or gait disturbances, and/or falls. Review of Patient #11’s Start of Care (SOC) clinical summary completed by S2RN on 05/13/2026, revealed, in part: In addition to skilled care the patient needs the following: PT, OT evaluations for safety and strengthening exercises. Review of Patient #11’s agency calendar of completed visits for Physical Therapy (PT) and Occupational Therapy (OT) revealed PT and OT services were not provided, as ordered by the physician, on or after 06/10/2026. An interview was conducted with S1ED on 06/17/2026 at 2:00 p.m. S1ED stated all home health services should be provided according to the clients’ physician approved POC. S1ED reviewed Patient #11’s POC for the certification period dated 05/13/2026 through 07/11/2026. S1ED confirmed there was no documented evidence PT and OT services were provided as ordered by the physician, on or after 06/10/2026 and should have been.

Emergency Preparedness Survey

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure all new and existing staff and individuals providing services under arrangement received initial training in Emergency Preparedness policies and procedures, had training at least every 2 years, and documentation of training was maintained with demonstration of staff knowledge of emergency procedures. The agency failed to have documented evidence of Emergency Preparedness training provided by the agency for 2 individuals (S2LPN, S3PT) who provided services under arrangement. Findings: A review of the agency’s training logs revealed no documented evidence of initial training, annual training, and documentation of demonstrated knowledge of emergency procedures for 2 (S2LPN and S3PT) contracted employees’ personnel records reviewed for Emergency Preparedness training. On 07/06/2023 at 4:15 p.m., an interview was conducted with S1ED. He verified a hire date of 05/10/2023 for S2LPN for a 13 week contract. S1ED verified a hire date of 03/12/2015 for S3PT. He further verified he had no documentation of Emergency Preparedness training on hire for S2LPN. S1ED verified he had no documentation of Emergency Preparedness training in the last 2 years for S3PT.

Recertification Survey Abbreviations: ED Executive Director PT Physical Therapist LPN Licensed Practical Nurse PRN as needed RN Registered Nurse SN Skilled Nurse mg milligrams mcg micrograms PM Evening OT Occupational Therapy COTA Certified Occupational Therapy Assistant cm centimeters MD Medical Doctor

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 observations during home visits, interviews, and record reviews, 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 therapy and skilled nursing staff reconciled a patient’s medications during subsequent home visits for 7 of 7 (#6, #7, #8, #9, #10, #11 and #12) 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. For patients receiving skilled nursing and therapy services, the skilled nurse is responsible for medication review and reconciliation throughout the episode. The therapist will participate by monitoring and reporting any identified medication issues or non-compliance to the Patient Care Manager. The physician is contacted immediately if any discrepancies between agency information and patient medications are found. Procedures: The discipline responsible for the drug regimen review will: a. Compare medication list obtained from the facility from which the patient was transferred and/or physician orders to actual medications the patient is taking. b. Review all medications including over the counter (OTC) medications, vitamins, herbs and herbal products, creams and topical ointments, to identify issues such as: i. Potential adverse effects and drug interactions; ii. Ineffective drug therapy; iii. Significant side effects; iv. Drug allergies; v. Contraindicated medications; viii. Noncompliance with drug therapy; ix. Dosage errors; and x. Drug omissions. Patient #6 Review of the Clinical Record for Patient #6 revealed he began receiving services from the Home Health Agency on 06/21/2023 and had a current Certification Period of 06/21/2023 to 08/19/2023. Patient #6 had diagnoses, which included Acute on Chronic Combined Systolic and Diastolic Heart Failure, End Stage Renal Disease, Dependence on Renal Dialysis, and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Further review revealed Patient #6 received Skilled Nursing Visits once weekly, Physical Therapy Visits and Occupational Therapy Visits once weekly effective 06/25/2023 for Certification period of 06/21/2023 to 08/19/2023. A home visit was conducted with Patient #6 on 06/26/2023 at 11:05 a.m. with S4PT present in the home. A review of Patient #6’s medications were conducted during the home visit. The following medication discrepancies were identified when compared to the Current Medication Profile for Patient #6 provided by the Home Health Agency: Vitamin D3 125 mcg (5,000 IU) -present in the home and not on the Medication Profile Polyethylene glycol (MiraLAX) 17 gm powder- present in the home and not on the Medication Profile Systane Ultra High Performance dry eye relief instill one drop in each eye every morning - present in the home and not on the Medication Profile An interview was conducted with Patient #6 during the home visit. He stated he took Vitamin D3, Systane eye drops, and MiraLAX every morning and had for “awhile”. He further stated he had been on these medications prior to his Home Health admission. Patient #7 Review of the Clinical Record for Patient #7 revealed she began receiving services from the Home Health Agency on 07/06/2022 and had a current Certification Period of 05/02/2023 to 06/30/2023. Patient #7 had diagnoses, which included Unspecified Open Wound Left Lower Leg, Chronic Diastolic Congestive Heart Failure, and Hypertensive Heart Disease with Heart Failure. Further review revealed Patient #7 received Skilled Nursing Visits once weekly for one week, three times weekly for one week, two times weekly for one week, and three times weekly for six weeks for Certification period of 05/02/2023 to 06/30/2023. A home visit was conducted with Patient #7 on 06/26/2023 at 12:15 p.m. with S5OT present in the home. A review of Patient #7’s medications were conducted during the home visit. The following medication discrepancies were identified when compared to the Current Medication Profile for Patient #7 provided by the Home Health Agency: Midodrine 2.5 mg tablet take one tablet three times daily- on Medication Profile and patient stated she was taking the medication as needed for low blood pressure Ondansetron 4 mg disintegrating tablet take one tablet every 8 hours as needed for nausea- on Medication Profile and not in home Tylenol PM Extra Strength 25 mg-500 mg tablet one tablet at bedtime as needed- on Medication Profile and patient stated she took 2 tablets An interview was conducted with Patient #7 during the home visit. She stated she threw away the Ondansetron about “a year ago” because she did not need it anymore. She stated the Midodrine was changed to as needed last week because her blood pressure was high. She stated she had taken 2 tablets of Tylenol PM for “years”. Patient #8 Review of the Clinical Record for Patient #8 revealed he began receiving services from the Home Health Agency on 06/20/2023 and had a current Certification Period of 06/20/2023 to 08/18/2023. Patient #8 had diagnoses, which included Essential Hypertension, Vascular Dementia Unspecified Severity without Behavior/Psych/Mood/Anxiety, and Type 2 Diabetes Mellitus. Further review revealed Patient #8 received Skilled Nursing Visits once weekly, Physical Therapy Visits once weekly for one week, twice weekly for three weeks, once weekly for one week, and Occupational Therapy Visits twice weekly for four weeks for Certification period of 06/20/2023 to 08/18/2023. A visit was conducted with Patient #8 on 06/26/2023 at 2:45 p.m. at a local assisted living facility with S6COTA present. A review of Patient #8’s medications were conducted during the visit. The following medication discrepancies were identified when the Current Medication Profile for Patient #8 provided by the Home Health Agency was compared to the medication list provided by the assisted living facility: Esomeprazole Magnesium 40 mg capsule take one capsule daily- patient not prescribed, listed on the Medication Profile with an Allergy to Nexium. Hydrochlorothiazide 12.5 mg tablet take one tablet daily- on Medication Profile and patient prescribed one 25 mg tablet daily Acetaminophen 500 mg tabs take 2 capsules (1000 mg total) by mouth every 6 hours as needed for pain- patient prescribed and not on Medication Profile Imodium A-D 2 mg capsules take 1 capsule by mouth three times daily as needed for diarrhea- patient prescribed and not on Medication Profile MiraLAX 17 gm/scoop powder give 17 grams by mouth as needed in the morning- patient prescribed and not on Medication Profile Sertraline 50 mg tablet take one tablet daily- on Medication Profile and patient prescribed 100 mg by mouth daily Thiamine HCL 100 mg tabs take one tablet 2 times daily- on Medication Profile and patient prescribed one 100 mg tablet once daily Utiva Cranberry take one cranberry supplement once daily- patient prescribed and not on Medication Profile An interview was conducted with the assisted living LPN on 06/26/2023 at 3:15 p.m. She reported she administered Patient #8 his medications. She stated Patient #8’s Sertraline dose was increased from 50 mg to 100 mg daily on 06/13/2023, the Thiamine HCL dose had been ordered once daily since 10/04/2022, and the Utiva Cranberry had been ordered since 03/25/2023. She further stated Patient #8 was not taking Esomeprazole Magnesium as he had a documented allergy to this medication. She stated the home health nurse should have reconciled Patient #8’s medications with her each visit and did not. An interview was conducted with S7RN on 06/28/2023 at 11:00 a.m. She stated Patient #8 lived at an assisted living facility and was a frequent patient of home health. She verified she admitted Patient #8 to home health services on 06/20/2023. She stated medications should be reviewed and reconciled on admit and with each visit. She stated she received a medication list from the assisted living facility nurse to reconcile his medications on admit. She reviewed the home health agency’s Medication Profile and the medication list provided by the assisted living facility on 06/26/2023. She confirmed the above medication discrepancies and stated the Medication Profile was not accurate and should have been. Patient #9 Review of the Clinical Record for Patient #9 revealed he began receiving services from the Home Health Agency on 09/12/2022 and had a current Certification Period of 05/10/2023 to 07/08/2023. Patient #9 had diagnoses, which included Atrial Fibrillation, Chronic Combined Systolic and Diastolic Heart Failure, Chronic Kidney Disease Stage 4, and Parkinson’s Disease. Further review revealed Patient #9 received Skilled Nursing Visits once weekly and Physical Therapy Visits twice weekly for two weeks and once weekly for one week effective 05/14/2023 for Certification period of 05/10/2023 to 07/08/2023. A home visit was conducted with Patient #9 and his spouse on 06/27/2023 at 10:00 a.m. with S8LPN present in the home. A review of Patient #9’s medications were conducted during the home visit. The following medication discrepancies were identified when compared to the Current Medication Profile for Patient #9 provided by the Home Health Agency: Cyanocobalamin (Vitamin B-12) 1,000 mcg sublingual tablet take one tablet by mouth daily-on Medication Profile, discontinued by physician on 06/19/2023 Furosemide 20 mg tablet take one tablet by mouth as needed for bilateral lower extremity swelling- on Medication Profile, Patient #9’s spouse stated he was prescribed Furosemide 40 mg tablet take one tablet by mouth twice daily as needed for bilateral lower extremity swelling Furosemide 20 mg tablet take one tablet by mouth daily-on Medication Profile, Patient #9’s spouse stated he was prescribed to take one tablet twice daily Gabapentin 300 mg capsule take one capsule every PM-on Medication Profile, Patient #9’s spouse stated this medication was discontinued by physician on 06/19/2023 Miconazole Nitrate 2% Topical Powder- per instructions 2 times daily- on Medication Profile, Patient #9’s spouse stated he was prescribed this medication as needed for a rash Warfarin 3 mg tablet take 0.5 tablet by mouth daily- on Medication Profile, Patient #9’s spouse stated he was not currently taking this dose Warfarin 1 mg tablet take by mouth every evening as directed by Coumadin clinic-in home and not on Medication Profile An interview was conducted with Patient #9’s spouse during the home visit. She stated she managed and administered his medications daily. She stated Patient #9 was seen by his physician on 06/19/2023 and the Gabapentin and Vitamin B-12 were discontinued. She stated she notified S2LPN of the medication changes during the skilled nurse visit on 06/20/2023. She stated Patient #9 had been on the same dosage of Furosemide 20 mg twice daily “for a long time”. She further stated he had not needed to use the Miconazole topical powder in months. She stated his current Warfarin dosage was to take 1 mg by mouth on Sunday, Tuesday and Thursday and 1.5 mg all other days. An interview was conducted with S8LPN during the home visit on 06/27/2023 at 10:30 a.m. She stated medications should be reconciled with each skilled nurse visit. She confirmed the above discrepancies between the medication profile and what the patient had been taking. A telephone interview was conducted with S2LPN on 07/06/2023 at 4:30 p.m. She stated medications should be reconciled every visit. She confirmed Patient #9’s spouse notified her of the above medication changes during her skilled nurse visit on 06/20/2023. She stated she did not update the medication profile and should have. Patient #10 Review of the Clinical Record for Patient #10 revealed he began receiving services from the Home Health Agency on 06/21/2023 and had a current Certification Period of 06/21/2023 to 08/19/2023. Patient #10 had diagnoses, which included Pneumonia due to Methicillin Staph, Hypokalemia, Unspecified Bipolar Disorder, and Acute Respiratory Failure with Hypoxia. Further review revealed Patient #10 received Skilled Nursing Visits once weekly, and Physical Therapy Visits and Occupational Therapy Visits once weekly for one week effective 06/25/2023 for Certification period of 06/21/2023 to 08/19/2023. A home visit was conducted with Patient #10 and his spouse on 06/27/2023 at 11:00 a.m. with S9RN present in the home. A review of Patient #10’s medications were conducted during the home visit. The following medication discrepancies were identified when compared to the Current Medication Profile for Patient #10 provided by the Home Health Agency: Divalproex 500 mg tablet take one tablet by mouth four times daily- on Medication Profile, Divalproex 500 mg tablet take one tablet by mouth twice daily and 2 tablets by mouth at bedtime- per medication bottle present in the home An interview was conducted with Patient #10 during the home visit. He stated he had been on Divalproex “for years” and the dose on the medication bottle was correct. He stated he took one 500 mg tablet of Divalproex twice daily and two tablets at bedtime. He further stated he had been on these medications prior to his Home Health admission. Patient #11 Review of the Clinical Record for Patient #11 revealed she began receiving services from the Home Health Agency on 03/18/2023 and had a current Certification Period of 05/17/2023 to 07/15/2023. Patient #11 had diagnoses, which included Chronic Diastolic Congestive Heart Failure, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Pressure Ulcer of Sacral Region Stage 4, Chronic Obstructive Pulmonary Disease, and Chronic Respiratory Failure with Hypoxia. Further review revealed Patient #11 received Skilled Nursing Visits once weekly for one week and twice weekly for eight weeks for Certification period of 05/17/2023 to 07/15/2023. A home visit was conducted with Patient #11 on 06/27/2023 at 2:30 p.m. with S10LPN present in the home. A review of Patient #11’s medications were conducted during the home visit. The following medication discrepancies were identified when compared to the Current Medication Profile for Patient #11 provided by the Home Health Agency: Furosemide 40 mg tablet take one tablet by mouth daily- on Medication Profile, prescription bottle in home stated Furosemide 20 mg take one tablet by mouth daily, filled on 06/11/2023 Equate Daily Fiber capsule take one capsule by mouth daily- present in home and not on Medication Profile An interview was conducted with Patient #11 during the home visit. She stated she was recently in the hospital and was not sure when the Furosemide dose changed. She further stated she had taken the Daily Fiber supplement for “at least 2 years”. An interview was conducted with S10LPN on 06/27/2023 at 3:15 p.m. during the home visit. She stated each patient’s medications should be reviewed and reconciled every visit by the Home Health Agency nurse. She reviewed Patient #11’s Medication Profile, medication bottles in the home, and the medication list from the local hospital dated 06/11/2023. She verified the medication lists and medication bottles for the above discrepancies did not match and should have. Patient #12 Review of the Clinical Record for Patient #12 revealed she began receiving services from the Home Health Agency on 01/16/2023 and had a current Certification Period of 05/16/2023 to 07/14/2023. Patient #12 had diagnoses, which included Other Complications of Procedures Necrotizing Enterocolitis, Morbid Severe Obesity due to excess calories, and Bariatric Surgery Status. Further review revealed Patient #12 received Skilled Nursing Visits once weekly for one week, twice weekly for four weeks, three times weekly for one week, twice weekly for one week, three times weekly for one week, and two times weekly for one week for Certification period of 05/16/2023 to 07/14/2023. A home visit was conducted with Patient #12 on 06/28/2023 at 11:05 a.m. with S7RN present in the home. A review of Patient #12’s medications were conducted during the home visit. The following medication discrepancies were identified when compared to the Current Medication Profile for Patient #12 provided by the Home Health Agency: Ferrous Sulfate 324 mg tablet take one tablet daily-on Medication Profile and not in home Hydrocodone 5 mg-Acetaminophen 325 mg tablet take 1 tablet as needed- on Medication Profile and not in home Tylenol PM Extra Strength 25 mg-500 mg tablet take 3 tablets at bedtime as needed- on Medication Profile, patient stated she took 2 tablets One A Day Women’s Multivitamin take one tablet weekly- present in home and not on Medication Profile Aspirin 81 mg tablet take one tablet daily as needed for pain- present in home and not on Medication Profile An interview was conducted with Patient #12 during the home visit at 11:10 a.m. She stated she stopped taking Ferrous Sulfate in 04/2023, stopped taking Hydrocodone in 02/2023, and started the Multivitamin, Aspirin, and decreased Tylenol PM from 3 tablets to 2 tablets in 01/2023 after her surgery. She stated she did not know she needed to tell the home health staff about any OTC medications she was taking. An interview was conducted with S7RN on 06/28/2023 at 11:35 a.m. She verified the medications on Patient #12’s Medication Profile and what the patient reported taking did not match and should have. An interview was conducted with S1ED on 07/06/2023 at 3:50 p.m. He was notified of the medication discrepancies found during the home visits for Patients #6, #7, #8, #9, #10, #11 and #12. He stated each patient’s medications should have been reconciled every visit by the Home Health Agency nurse. He stated the Home Health Agency therapist were to ask the patient’s if there were any medication changes each visit and report them to the nurses. He verified the medication profiles should have been updated accordingly.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record reviews and interviews, the agency failed to conform with physicians' orders by failing to ensure Skilled Nursing Services were provided per physician's orders for 10 (#1, #2, #3, #4, #5, #9, #11, #12, #14, and #17) of 17 (#1-#17) sampled patients reviewed for Skilled Nursing Services. The agency failed to: 1. Ensure the skilled nurse assessed weights every visit as ordered for Patients #2, #9, and #12; 2. Ensure the skilled nurse obtained vital signs every visit for Patient #9; 3. Ensure the skilled nurse obtained calf measurements every visit as ordered for Patients #1, #2, #3, and #14; 4. Ensure the skilled nurse obtained a pulse oximetry every visit as ordered for Patients #4, #5, #9, and #12; and 5. Ensure the skilled nurse assessed lower extremities for the presence of lesions every visit as ordered for Patients #1, #11, and #17. Findings: Review of the Agency’s Policy titled, “Vital Signs” revealed the following, in part: Policy: Vital signs are documented for each nursing visit to minimally include: Blood pressure Pulse Respirations Temperature Procedure: 1. Documentation of vital signs will be present on each clinical note. Review of the Agency’s Policy titled, “Physician Orders” revealed the following, in part: Purpose: To outline the process for documenting physician or authorized practitioner orders. Policy: Routine monitoring of vital signs, including pulse oximetry, will not require a physician/authorized practitioner’s order. 10. Services are provided according to the most recent orders updating the patient’s Plan of Care. 13. All care and services are provided within acceptable standards of practice. Patient #1 Review of the Clinical Record for Patient #1 revealed she began receiving services from the Home Health Agency on 11/02/2022 and had a current Certification Period of 05/01/2023 to 06/29/2023. Patient #1 had diagnoses, which included Type 2 Diabetes Mellitus Without Complications, Multiple Sclerosis, and Essential Hypertension. Review of the Orders of Discipline and Treatments for Patient #1 revealed the following: Skilled Nurse (SN) to assess lower extremities for presence of lesions on every visit. SN to obtain body measurement of calves every skilled nurse visit (SNV) and notify physician of 3 cm increase. Review of SN visits for Patient #1 conducted on the following dates revealed no documentation of the patient's calf measurements: 05/04/2023, 05/25/2023 and 06/21/2023. Review of SN visit conducted on 05/04/2023 revealed no documentation of the patient's lower extremity assessments. Patient #2 Review of the Clinical Record for Patient #2 revealed he began receiving services from the Home Health Agency on 04/12/2023 and had a current Certification Period of 06/11/2023 to 08/09/2023. Patient #2 had diagnoses, which included Type 2 Diabetes Mellitus With Foot Ulcer, Essential Hypertension, Obesity and Presence of Cardiac Pacemaker. Review of the Orders of Discipline and Treatments for Patient #2 revealed the following: SN to obtain weight every visit and notify RN/MD of weight gain or loss of 3lbs overnight or 5lbs within 7 days. SN to assess lower extremities for presence of lesions on every visit. Review of SN visits for Patient #2 conducted on the following dates revealed no documentation of the patient's calf measurements: 06/12/2023, 06/14/2023, 06/19/2023, 06/21/2023, and 06/27/2023. Review of SN visits conducted on the following dates revealed no documentation of the patient's weight: 06/12/2023, 06/19/2023, 06/21/2023, and 06/27/2023. Patient #3 Review of the Clinical Record for Patient #3 revealed she began receiving services from the Home Health Agency on 02/04/2023 and had a current Certification Period of 06/04/2023 to 08/02/2023. Patient #3 had diagnoses, which included Hemiplegia following Cerebral Infarction Affecting Left Nondominant Side, Acute Embolism and Thrombus of Deep Veins of Bilateral Upper Extremities, and Bed Confinement Status. Review of the Orders of Discipline and Treatments for Patient #3 revealed the following: SN to obtain body measurement of calves every visit. SN to notify MD of 3cm increase in one week. Review of the SN visit for Patient #3 conducted on 06/12/2023 revealed no documentation of the patient's left calf measurements. Review of SN visits conducted on the following dates revealed no documentation of the patient's right calf measurements: 06/07/2023, 06/12/2023, and 06/26/2023. Patient #4 Review of the Clinical Record for Patient #4 revealed she began receiving services from the Home Health Agency on 03/22/2023 and had a current Certification Period of 05/21/2023 to 07/19/2023. Patient #4 had diagnoses, which included Heart Failure, End Stage Renal Disease, Dependence on Renal Dialysis, Acute Respiratory Failure with Hypoxia and Hypercapnia, and Acute Embolism and Thrombus of Right Internal Jugular, Right Axillary Vein and Right Subclavian Vein. Review of the Orders of Discipline and Treatments for Patient #4 revealed the following: SN to perform pulse oximetry every SNV on room air to monitor patient’s respiratory status. Review of SN visits for Patient #4 conducted on the following dates revealed no documentation of the patient's pulse oximetry: 06/21/2023 and 06/28/2023. Patient #5 Review of the Clinical Record for Patient #5 revealed she began receiving services from the Home Health Agency on 03/11/2023 and had a current Certification Period of 05/10/2023 to 07/08/2023. Patient #5 had diagnoses, which included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Pressure Ulcer of Sacral Region Unstageable, and Acute Respiratory Failure with Hypoxia. Review of the Orders of Discipline and Treatments for Patient #5 revealed the following: SN to perform pulse oximetry every SNV on room air to monitor patient’s respiratory status. Review of SN visits for Patient #5 conducted on the following dates revealed no documentation of the patient's pulse oximetry: 06/05/2023, 06/12/2023 and 06/19/2023. Patient #9 Review of the Clinical Record for Patient #9 revealed he began receiving services from the Home Health Agency on 09/12/2022 and had a current Certification Period of 05/10/2023 to 07/08/2023. Patient #9 had diagnoses, which included Atrial Fibrillation, Chronic Combined Systolic and Diastolic Heart Failure, Chronic Kidney Disease Stage 4, and Parkinson’s Disease. Review of the Orders of Discipline and Treatments for Patient #9 revealed the following: SN to obtain weight every SNV and notify MD of weight gain or loss of 3lbs within 1 day or 5lbs in 1 week. SN to perform pulse oximetry every SNV on room air to monitor patient’s respiratory status. Review of SN visits for Patient #9 conducted on 06/13/2023 revealed no documentation of the patient's weight. Review of SN visits conducted on the following dates revealed no documentation of the patient's pulse oximetry: 06/06/2023, 06/13/2023, and 06/20/2023. Further review of Patient #9’s Clinical Record revealed no documentation of vital signs on the following SNV: 06/13/2023. Patient # 11 Review of the Clinical Record for Patient #11 revealed she began receiving services from the Home Health Agency on 03/18/2023 and had a current Certification Period of 05/17/2023 to 07/15/2023. Patient #11 had diagnoses, which included Chronic Diastolic Congestive Heart Failure, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Pressure Ulcer of Sacral Region Stage 4, Chronic Obstructive Pulmonary Disease, and Chronic Respiratory Failure with Hypoxia. Review of the Orders of Discipline and Treatments for Patient #11 revealed the following: SN to assess lower extremities for presence of lesions on every visit. Review of SN visits for Patient #11 conducted on the following dates revealed no documentation of the patient's lower extremity assessments: 05/18/2023, 05/25/2023, and 06/23/2023. Patient #12 Review of the Clinical Record for Patient #12 revealed she began receiving services from the Home Health Agency on 01/16/2023 and had a current Certification Period of 05/16/2023 to 07/14/2023. Patient #12 had diagnoses, which included Other Complications of Procedures Necrotizing Enterocolitis, Morbid Severe Obesity Due to Excess Calories, and Bariatric Surgery Status. Review of the Orders of Discipline and Treatments for Patient #12 revealed the following: SN to obtain weight every SNV and notify RN/MD of weight gain or loss of 3lbs within 1 day or 5lbs in 1 week. SN to perform pulse oximetry every SNV on room air to monitor patient’s respiratory status. Review of SN visits conducted on the following dates revealed no documentation of the patient's weight or pulse oximetry: 06/05/2023, 06/12/2023, 06/19/2023, and 06/26/2023. Patient #14 Review of the Clinical Record for Patient #14 revealed she began receiving services from the Home Health Agency on 10/15/2022 and was discharged from the agency on 01/16/2023. Patient #14 had diagnoses, which included Hypertensive Heart Disease with Heart Failure, Acute on Chronic Diastolic Congestive Heart Failure, Obesity, and Acute Embolism and Thrombus Unspecified Deep Veins of Right Lower Extremity. Review of the Orders of Discipline and Treatments for Patient #14 revealed the following: SN to obtain body measurement of bilateral mid-calf circumference every SNV. SN to notify MD of 4 cm or greater increase more than baseline of 57 cm in 1 week. Review of SN visits conducted on the following dates revealed no documentation of the patient's right calf circumference: 01/04/2023 and 01/10/2023. Patient # 17 Review of the Clinical Record for Patient #17 revealed she began receiving services from the Home Health Agency on 09/27/2021 and was discharged from the agency on 01/03/2023. Patient #17 had diagnoses, which included Chronic Diastolic Congestive Heart Failure, Chronic Kidney Disease Stage 5, and Type 2 Diabetes Mellitus with Hyperglycemia. Review of the Orders of Discipline and Treatments for Patient #17 revealed the following: SN to assess lower extremities for presence of lesions on every visit. Review of SN visits for Patient #17 conducted on the following dates revealed no documentation of the patient's lower extremity assessments: 10/11/2022, 11/08/2022, and 12/12/2022. An interview was conducted with S1ED on 07/06/2023 at 3:50 p.m. He stated vital signs were expected to be taken on every patient, on every visit, including pulse oximetry. After reviewing Patient #2, #9, and #12’s record, he verified there was no documentation of the patient's weights for the SN visit dates reviewed. After reviewing Patient #9’s record, he verified there was no documentation of vital signs for the SN visit date reviewed. After reviewing Patient #1, #2, #3, and #14’s record, he verified there was no documentation of the patient’s bilateral calf measurements for the SN visit dates reviewed. After reviewing Patient #4, #5, #9, and #12’s record, he verified there was no documentation of pulse oximetry for the SN visit dates reviewed. After reviewing Patient #1, #11, and #17’s record, he verified there was no documentation of lower extremity assessments for the SN visit dates reviewed. He stated he expected staff to follow physician’s orders and the above findings should have been documented on each SN visit as ordered.

Recertification Survey COVID-19 Focused Infection Control Survey with no related deficiencies cited. Abbreviations: cm centimeter mg milligrams ml milliliters PEG Percutaneous Endoscopic Gastrostomy prn as needed RN Registered Nurse SN Skilled Nurse WOC(ET)/CWCN Wound, Ostomy and Continence (Enterostomal Therapy)/Certified Wound Care 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 observations, record reviews, and interviews, the agency failed to ensure the medication profile accurately reflected all medications patients were using and/or did not reflect medications the patients were no longer using, for 3 (#2, #3, and #4) of 7 (#1-#7) sampled patients reviewed who received home visits. Findings: Review of an agency policy titled "Medication Management", which was provided by S1ADM, revealed, in part, the following: 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. Patient #2 Review of the clinical record revealed a start of care date of 06/14/2021. The patient's primary diagnosis was Mechanical Complication of Internal Left Knee Prosthesis. A review of the Home Health Certification and Plan of Care/485 for the Certification Period of 06/14/2021 to 08/12/2021 revealed orders for Frequency/Duration of Visits which included: SN 2wk2, 1wk1, + 2 prn. On 07/02/2021 at 10:00 a.m., a home visit was conducted in the home of Patient #2 with S2PT. Review of the patient's medications listed on the current medication list provided by the agency revealed orders for the following medication with discrepancies noted: 1. Ativan 0.5 mg tablet- take 1 tablet every 6 hours/prn. There was none of this medication observed in the home. 2. Norvasc 2.5 mg tablet - take 1 tablet daily. There was none of this medication observed in the home. During the home visit, Patient #2 stated she had never taken Ativan or Norvasc and was unsure why these were on her medication list. S2PT stated each visit he asked the patient if any of her medications had changed since the previous visit. He stated the nurse usually checked the patient's medications. An interview was conducted on 07/07/2021 at 3:00 p.m. with S1ADM. He stated all staff were expected to check the patient's medications each visit. He confirmed Patient #2 had Ativan and Norvasc when she was in the hospital and not after she was discharged home. He stated the admitting nurse should have caught this error on Patient #2's initial assessment. Patient #3 Review of the clinical record revealed a start of care date of 03/21/2021. The patient's diagnoses included Type 2 Diabetes Mellitus. A review of the Home Health Certification and Plan of Care/485 for the Certification Period of 05/20/2021 to 07/18/2021 revealed orders for Frequency/Duration of Visits which included: SN effective 05/23/2021 1wk8. A review of the Visit Note Reports for the Certification Period of 05/20/2021 to 07/18/2021 revealed SN visits were conducted on the following dates: 05/26/2021, 06/01/2021, 06/08/2021, 06/17/2021, 06/22/2021, and 07/02/2021. On 07/06/2021 at 2:35 p.m., a home visit was conducted in the home of Patient #3 with S3RN. The patient's daughter was present for the home visit and stated she managed the patient's medicines and was familiar with all the patient's medicine doses and frequencies. Review of the patient's medications listed on the current medication list provided by the agency revealed orders for the following medication with discrepancies noted during the home visit: 1. Novolog Flexpen U-100 Insulin Aspart 100 unit/ml (3 ml) subcutaneous 6 units 2 times daily. The patient's daughter stated the insulin dose changed approximately a month ago to 5 units three times daily before meals. 2. Timolol 0.5% Eye Drops - Ophthalmic (Eye) 1 drop 3 times daily both eyes. The patient's daughter stated the eye drops were given once a day in the morning only. She stated the patient had taken the eye drops once a day for years. 3. Novolin N 8 units with breakfast and 5 units at bedtime. This medication was not listed on the current medication list provided by the agency. The patient's daughter stated the patient had been taking this insulin dose for at least a month. An interview was conducted with S3RN during the home visit. She verified patient medications were to be reconciled during each skilled nurse visit. She verified she had not updated the medication changes in the electronic chart's medication list. Patient #4 Review of the clinical record revealed a start of care date of 06/23/2021. The patient's diagnoses included Age-related Osteoporosis with Current Pathological Fracture of Right Femur. A review of the Home Health Certification and Plan of Care/485 for the Certification Period of 06/24/2021 to 08/22/2021 revealed orders for Frequency/Duration of Visits which included: SN 1wk3. A review of the Visit Note Reports for the Certification Period of 06/24/2021 to 08/22/2021 revealed SN visits were conducted on the following dates: 06/24/2021 and 07/01/2021. On 07/06/2021 at 3:30 p.m., a home visit was conducted in the home of Patient #4. The patient stated she managed her own medicines and was familiar with all the medicine doses and frequencies. Review of the patient's medications listed on the current medication list provided by the agency revealed orders for the following medication discrepancy noted during the home visit: 1. Alendronate 70 mg tablet - oral 1 tablet weekly. This medication was not in the home. The patient verified she had not gotten the prescription for Alendronate filled since she came home from the hospital prior to admission to the agency. An interview was conducted on 07/12/2021 at 11:15 a.m. with S1ADM. He was notified of the medication discrepancies found during home visits with Patients #3 and #4. S1ADM verified medications were to be reviewed during every SN visit and updated accordingly.

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 reviews and interviews, the home health agency failed to ensure care and services were provided in accordance with the written plan of care for 3 (#5, #11, #13) of 17 (#1 - #17) sampled patient records reviewed. The agency failed to ensure the following: 1. Calf measurements were obtained for Patient #5; 2. Skilled nurse visits were conducted 3 times a week the week of 06/20/2021 for Patient #11 per physician's orders; and 3. Skilled nurse visit was done the week of 04/19/2021 for Patient #13. Findings: Patient #5 Review of Patient #5's Home Health Certification and Plan of Care for Certification Period 06/10/2021 to 08/08/2021 revealed diagnoses that included Aftercare following explantation of knee joint prosthesis. Further review of the Plan of Care revealed Patient #5's orders of Discipline and Treatments included the following: Skilled nurse to obtain body measurement of calf. Skilled nurse to notify physician of 3 cm increase. Review of Visit Note Reports for Certification Period 06/10/2021 to 08/08/2021 revealed no documented calf measurements during each skilled nurse visit. On 07/07/2021 at 10:30 a.m., an interview was conducted with S1ADM. After reviewing the clinical record of Patient #5, S1ADM verified there was no documentation by the skilled nurse that calf measurements were obtained. He confirmed the nurse should have obtained calf measurements with each visit. Patient #11 Review of Patient #11's Home Health Certification and Plan of Care for Certification Period 06/15/2021 to 08/13/2021 revealed diagnoses that included Pressure Ulcer of Left Buttock Unstageable. Frequency/Duration of Visits included the following: SN 1wk1, 2wk8. Further review of the electronic record revealed a physician's order, dated 06/18/2021, which stated the following: Skilled nurse to provide wound care to left buttocks 2x/week on clinic weeks and 3x/week on non-clinic weeks using aseptic technique until healed as follows: cleanse with wound cleanser, 4x4 gauze, apply Medihoney to wound bed, cover with Mesalt and secure with bordered foam dressing. Review of Visit Note Reports for Certification Period 06/15/2021 to 08/13/2021 revealed the following for week of 06/20/2021: Skilled nurse visit conducted on 06/21/2021 only. A missed visit note was documented for 06/25/2021. There was no other documented attempt for a skilled nurse visit during the week beginning 06/20/2021 and no documentation of why an additional skilled nurse visit was not attempted. An interview was conducted on 07/12/2021 at 11:38 a.m. with S1ADM. After reviewing the clinical record for Patient #11, S1ADM verified the patient went to a wound care clinic on 06/24/2021. He further verified a missed skilled nurse visit was documented on 06/25/2021, but no other attempt of a skilled nurse visit was documented for the week beginning 06/20/2021. Patient #13 Review of Patient #13's Home Health Certification and Plan of Care for Certification Period 04/19/2021 to 06/17/2021 revealed diagnoses that included Secondary Malignant Neoplasm of Brain. Further review of the Plan of Care revealed the following: Frequency/Duration of visits: SN 2wk2, 1wk7 Home Health Aide visit week of 06/07/2021 Review of Visit Note Reports for Certification Period 04/19/2021 to 06/17/2021 revealed the following: Missed skilled nurse visit the week of 04/19/2021 An interview was conducted on 07/07/2021 at 1:40 p.m. with S1ADM. He verified the order for skilled nurse 2wk2, 1wk7. He confirmed a missed visit by the skilled nurse the week of 04/19/2021.

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 reviews and interviews, 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 2 (#7, #11) of 2 (#7, #11) patients reviewed with pressure ulcers out of a total of 17 sampled patients. Findings: Review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standard, Part. XLVII, Nurses: Practical Nurses and Registered Nurses (As amended through January 2019) Chapter 37. Nursing Practice revealed, in part: The registered nurse is responsible for and accountable to each consumer of nursing care for the quality of nursing care he or she receives, regardless of whether the care is provided solely by the registered nurse or by the registered nurse in conjunction with other licensed or unlicensed assistive personnel. a. The registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. This assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required. i. Any situation where tasks are delegated should meet the following criteria. (a). The person has been adequately trained for the task. (b). The person has demonstrated that the task has been learned. (c). The person can perform the task safely in the given nursing situation. (d). The patient's status is safe for the person to carry out the task. (e). Appropriate supervision is available during the task implementation. (f). The task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all. iv. Contingent upon the registered nurse's evaluation of each patient's condition and also upon the registered nurse's evaluation of the competency of each unlicensed nursing personnel, registered nurses may delegate non-complex tasks to unlicensed nursing personnel. Chapter 39. Legal Standards of Nursing Practice revealed the following in part: §3901. Legal Standards A. The Louisiana State Board of Nursing recognizes that assessment, planning, intervention, evaluation, teaching, and supervision are the major responsibilities of the registered nurse in the practice of nursing. The standards of nursing practice provide a means of determining the quality of care which an individual receives regardless of whether the intervention is provided solely by a registered nurse or by a registered nurse in conjunction with other licensed or unlicensed personnel as provided in LAC 46: XLVII.3703. B. The standards are based on the premise that the registered nurse is responsible for and accountable to the individual for the quality of nursing care he or she receives. Documentation must reflect the quality of care. C. The standards of practice shall: 1. be considered as base line for quality nursing care; 2. be developed in relation to the law governing nursing; 3. apply to the registered nurse practicing in any setting; 4. govern the practice of the licensee at all levels of practice. §3915. Standard Number 7: Professional Performance A. The registered nurse demonstrates the following professional nursing practice behaviors. 1. Evaluates own nursing practice in relation to professional practice standards, relevant state and federal statutes, and relevant administrative rules. 2. Acquires and maintains current knowledge in nursing practice. 3. Considers factors related to safety, effectiveness, and cost in planning and delivering nursing care. 4. Nursing decisions and actions are determined in an ethical manner. 5. Clarifies any order or treatment regimen believed to be inaccurate, or contraindicated by consulting with the appropriate licensed practitioner and by notifying the ordering practitioner when the registered nurse makes the decisions not to administer the medication or treatment. Review of the Louisiana State Board of Nursing Declaratory Statement Scope of Practice for Registered Nurses - Wound Care Management adapted 02/1999 revealed the following in part: Registered nurses render care that is directed towards the prevention and treatment of wounds. Wounds are a common health care challenge that often occur with or result from chronic disorders such as impaired circulation and malnutrition. Nursing care of skin/wound conditions involves the identification, assessment, management, and ongoing evaluation of patients with alterations in skin/tissue integrity, that includes but is not limited to draining wounds, pressure ulcers, and vascular ulcers, and conditions resulting from incontinence, surgical procedures, and/or trauma. Professional organizations, such as the National Pressure Ulcer Advisory Panel Consensus Development Conference, the Wound Ostomy and Continence Nurses Society (formerly International Association of Enterostomal Therapy), and the Agency for Health Care Policy and Research (AHCPR) agree upon the following definitions and clinical presentations of the four stages of pressure ulcers: Stage I: Non-blanchable erythema of intact skin, the heralding lesion of skin ulceration. In individuals with darker skin, discoloration of the skin, warmth, edema, induration, or hardness may also be indicators. Stage II: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. Stage III: Full thickness skin loss involving damage to or necrosis of subcutaneous tissue may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g. tendon, joint capsule). Undermining and sinus tracts may be associated with Stage IV pressure ulcers. 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 is responsible for performing a nursing assessment and physical examination for preventative and restorative nursing and for providing patient/family teaching. Recognizing that the physician must always prescribe wound care, the following roles are defined to delineate the scope of practice for each member of the nursing team members. 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. Contingent upon the RN's evaluation of each patient's condition and also upon the RN's evaluation of competency of each unlicensed assistive personnel (UAP), an RN may delegate non-complex tasks to a UAP. A non-complex task is one that can safely be performed according to exact directions, with no need to alter the standard procedure, and the results are predictable. When the above criteria has been met, the following wound care interventions may be delegated when non-complex: topical application of anti-infective medications, protective ointments, wound cleansers, skin sealants, gauze, transparent films, hydrocolloids, and hydrogels and the cleansing of the skin of a mature, healed PEG tube site with soap and water or 3% hydrogen peroxide. The Board recognizes the responsibility of the employing agency to have written policies and procedures to allow for such delegable interventions, and a written system in place to document competency for each caregiver. 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 WOC(ET)/CWCN 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. Resident #7 Review of the clinical record for Patient #7 revealed a start of care date of 05/07/2021. Review of the plan of care for the current certification period 05/07/2021 - 07/05/2021 revealed a primary diagnosis of Pressure Ulcer of Right ankle, Stage 3. Further review of the plan of care revealed orders for the following Frequency/Duration of Visits: SN 1wk1, 2wk3, 1wk5 Orders of Discipline and Treatment included the following, in part; Skilled nurse to perform wound care to right ankle stage 3 pressure ulcer every other day until healed. Using clean technique, cleanse with wound cleanser, pat dry with gauze, apply honey to wound bed then alginate, cover with foam. Review of the SN visit documentation revealed visits were conducted every other week by an RN. An interview was conducted on 07/02/2021 at 2:30 p.m. with S3RN. She stated a Registered Nurse assessed pressure wounds every other week. An interview was conducted on 07/07/2021 at 3:00 p.m. with S1ADM. He reviewed Patient #7's medical record and verified a Registered Nurse assessed the patient's wound every other week, rather than weekly. Patient #11 Review of the clinical record for Patient #11 revealed a start of care date of 12/17/2020. Review of the plan of care for the current certification period 06/15/2021 - 08/13/2021 revealed a primary diagnosis of Pressure Ulcer of Left Buttock, Unstageable. Further review of the plan of care revealed orders for the following Frequency/Duration of Visits: SN 1wk1, 2wk8. Orders of Discipline and Treatment included the following, in part; Skilled nurse to perform/instruct/reinforce wound care to left buttock 3 times weekly and as needed for soiled/dislodged dressing until healed as follows: cleanse with non-cytotoxic wound cleanser or saline, 4x4 gauze, apply Medihoney to wound bed, then Mesalt. Cover with bordered foam dressing. Review of the SN visit documentation revealed a visit was conducted by S4LPN on 06/28/2021. Further review of the documentation revealed S4LPN identified a new wound to the patient's lower right buttock and staged the wound as a Stage II pressure ulcer. S4LPN also identified another new wound to the patient's lower right buttock and staged that wound as a Stage II pressure ulcer also. Further review of SN visit documentation revealed a Registered Nurse did not make a visit to assess and stage the 2 new wounds on 06/28/2021 or 06/29/2021. The patient was then transferred on 06/30/2021 to a hospital for an inpatient stay. On 07/12/2021 at 11:38 a.m., an interview was conducted with S1ADM. After reviewing the patient's clinical record, he verified a LPN could not stage a pressure ulcer wound. He further verified a RN visit should have been made the day the two new wounds were discovered or, at least, the following day.