Every finding on record at Southwest Louisiana Hospital Association Inc.

Emergency Preparedness Survey

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to conduct an exercise at least annually to test the emergency plan. Findings: A review of the agency’s emergency preparedness binder failed to reveal documentation that an annual exercise to test the emergency plan had been conducted since January 2024. On 06/04/2025 at 11:20 a.m., during an interview and review of the emergency preparedness binder with S1Director, she confirmed the agency had no documentation of an annual exercise being conducted to test the emergency plan since January 2024. She acknowledged the agency did not participate in any community based, facility based or tabletop exercises nor conduct any drills within the last year.

Recertification Survey

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the patient's written individualized POC (Plan Of Care) was followed as evidenced by the SN (Skilled Nurse) failing to ensure the patient’s blood glucose (sugar) testing was being performed by the patient/caregiver to ensure results were within parameters for 2 (#3, #15) out of 17 (#1-#17) sampled patients. 1. Patient #3. Review of the patient's electronic clinical record revealed the start of care date was 05/20/2025. The patient's diagnoses included aftercare following joint replacement surgery and type II diabetes mellitus. The certification period reviewed was 05/20/2025 to 07/18/2025. Review of the patient's POC (Plan of Care) for certification period 05/20/2025 to 07/18/2025 revealed an order for skilled nurse 2wk1, 0wk1, 1wk1, 0wk6 (skilled nurse visits two times a week for one week, no skill nurse visit for one week, one skill nurse visit for one week, and no skill nurse visits for six weeks). Further review of the patient's POC revealed an order for “Skilled nurse for instructions/reinforcement of diabetic care to include…blood glucose testing…Licensed Professional to report … falling outside the following established parameters… FBS (Fasting Blood Sugar) (greater than) 150 RBS (Random Blood Sugar) 200.” Review of the patient’s SN visit notes dated 05/20/2025 and 05/23/2025 revealed no evidence blood glucose testing was done on the patient for those SN visits. On 06/03/2025 at 3:20 p.m., an interview and record review was conducted with S1Director. S1Director confirmed there was no evidence the patient/caregiver or SN were performing blood glucose testing in order to monitor the patient’s blood glucose to ensure results not falling outside parameters. 2. Patient #15. Review of the patient's electronic clinical record revealed the start of care date was 04/14/2025. The patient's diagnoses included surgical aftercare following surgery on circulatory system and type II diabetes with diabetic peripheral angiopathy without gangrene. The certification period reviewed was 04/15/2025 to 06/13/2025. Review of the patient's POC (Plan of Care) for certification period 04/15/2025 to 06/13/2025 revealed an order for skilled nurse 2wk5, 0wk4, (skilled nurse visits two times a week for five weeks, no skill nurse visits for four weeks). Further review of the patient's POC revealed an order for “Skilled nurse for instructions/reinforcement of diabetic care to include…blood glucose testing…Licensed Professional to report … falling outside the following established parameters… FBS 150 RBS 200.” Review of the patient’s SN visit notes dated 04/15/2025, 04/17/2025, and 04/22/2025 revealed no evidence blood glucose testing was done on the patient for those SN visits. On 06/03/2025 at 10:50 a.m., an interview and record review was conducted with S1Director and S2RN (Registered Nurse). S1Director and S2RN confirmed there was no evidence the patient/caregiver or SN were performing blood glucose testing in order to monitor the patient’s blood glucose to ensure results not falling outside parameters.

HH Agency of Lake Charles Memorial is in compliance with the federal Emergency Preparedness requirements..

Recertification Survey

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the individualized plan of care included: 1. Orders for the skilled nurse to monitor/obtain weights for a patient who was admitted with Heart Disease and Heart Failure (#2, #10, #12) and; 2. Failing to perform diabetic foot assessments and provide diabetic education for 1 (#8) patient with diabetes out of a total of 13 sampled patients. 1. Patient #10: Review of the patient's electronic clinical record revealed start of care date 6/9/2022. The patient's diagnoses included Acute Systolic (Congestive) Heart Failure and Chronic Obstructive Pulmonary Disease. The certification period reviewed was 6/9/2022 to 8/7/2022. Review of the patient's POC (Plan of Care) for certification period 6/9/2022 to 8/7/2022 revealed the following order, SN 1wk9 (skilled nurse visit one time a week for nine weeks). There was no evidence found on the POC for the skilled nurse to monitor/obtain the patient's weight during the skilled visits. Review of the patient’s SN visit notes dated 6/14/2022, 6/21/2022 and 6/28/2022 revealed no evidence that the SN monitored/obtained the patient’s weight. On 7/12/2022 at 1:25 pm, an interview was conducted with S1Adm (Administrator) and after a review of the patient's plan of care, she verified there was no documented evidence on the POC for the skilled nurse to monitor/obtain a weight during the skilled visits. Also, S1Adm stated that she would expect the SN to weigh patients that have a diagnosis of CHF. 1. Patient #12: Review of the patient's electronic clinical record revealed start of care date 6/16/2022. The patient's diagnoses included Systolic (Congestive) Heart Failure, Diabetes, and Chronic Kidney Disease. The certification period reviewed was 6/16/2022 to 8/14/2022. Review of the patient's POC (Plan of Care) for certification period 6/16/2022 to 8/14/2022 revealed the following order, SN 1wk9 (skilled nurse visit one time a week for nine weeks). There was no evidence found on the POC for the skilled nurse to monitor/obtain the patient's weight during the skilled visits. Review of the patient’s SN visit notes dated 6/23/2022, 6/30/2022 and 7/8/2022 revealed no evidence that the SN monitored/obtained the patient’s weight. On 7/12/2022 at 3:30 pm, an interview was conducted with S1Adm (Administrator) and after a review of the patient's plan of care, she verified there was no documented evidence on the POC for the skilled nurse to monitor/obtain a weight during the skilled visits. Also, S1Adm stated that she would expect the SN to weigh patients that have a diagnosis of CHF. 1. Patient #2: Patient #2 was admitted to the agency on 2/1/2022 with diagnoses that included Aftercare Following Surgery on the Circulatory System, Atherosclerotic Heart Disease of Coronary Artery, and Hypertension. The certification period reviewed was 2/1/2022 to 4/1/2022. The patient’s POC was reviewed and an order for SN 2WK4 (skilled nurse twice weekly for 4 weeks) was noted. Further review revealed that Patient #2 had undergone cardiovascular surgery -Coronary Arterial Bypass Graft of 4 arteries (CABGx4) on 1/24/2022 prior to admission to the home health agency. The POC failed to reveal an order for the skilled nurse to conduct weights related the cardiac status. On 7/13/2022 at 11:00 AM, an interview was conducted with S1ADM. She confirmed that Patient #2 had been diagnosed with Coronary Artery Disease and had been admitted to agency for post-surgical care after a CABGX4 had been performed. She confirmed that based on Patient #2’s cardiovascular status, the POC should include that weights be assessed during the SNVs. She reviewed SNVs dated 2/4/22 and 2/23/22 and confirmed that no weights had been assessed as indicated for the patient’s cardiovascular disease. S1ADM reviewed the POC and confirmed that it failed to address Patient #2’s diagnoses of CAD and CABGx4 and it should have. 2. Patient #8 was admitted to the agency on 5/20/2022 with diagnoses that included Chronic Diastolic Congestive Heart Failure (CHF) and Type 2 Diabetes Mellitus (DM). The certification period reviewed was 5/20/2022 to 7/18/2022. The patient's POC was reviewed and an order for SN 1WK9 (skilled nurse visit once weekly for 9 week) was noted. Further review failed to reveal an order for the skilled nurse was to conduct weights related to the diagnosis of CHF, or to conduct Diabetic foot monitoring or education during the skilled nurse visits (SNV). On 7/13/2022 10:00 AM, an interview was conducted with S1ADM. She reviewed Patient #8’s POC and confirmed the diagnoses of Congestive Heart Failure and Type 2 Diabetes Mellitus. She verified that there was no order for the skilled nurse to obtain or monitor the patient’s weights. She stated that all patients with a diagnosis of CHF should be weighed during the SNVs. She further stated that Diabetic foot monitoring and education should be provided to patients diagnosed with Diabetes Mellitus. She reviewed the assessments and stated that during the initial assessment conducted on 5/20/22, the nurse failed to initiate the Diabetic pathway for the POC. She reviewed the SNVs conducted during the certification period (5/20/22, 5/25/22, 6/1/22, 6/2/22, 6/8/22, 6/15/22, 6/22/22, 6/29/22, and 7/6/22) and confirmed that weights, foot assessments, and the appropriate education had not been provided as indicated for the diagnoses of CHF and DM. S1ADM confirmed that the POC failed to address Patient #8’s diagnoses of CHF and DM and it should have.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency’s staff failed to ensure patient’s physician responded timely to communications of concerns identified during skilled nurse visits for 1 (#13) out of 13 sampled patients. Patient #13. Review of the patient's electronic clinical records revealed the start of care date was 6/21/2022. The patient's diagnoses included Diabetes, Kidney Disease and Hypertension. The certification period reviewed was from 6/21/2022 to 8/19/2022. Review of the patient's plan of care (POC) for certification period 6/21/2022 to 8/19/2022 revealed the following order: SN 1wk9 (skilled nurse visit one time a week for nine weeks). Also, the POC revealed that the patient’s medications included Eliquis (blood thinner) 5 mg (milligrams) tablet two times a day. Review of the patient's skilled nurse visit note dated 7/5/2022 revealed, “…Daughter reported … bruising to left hip. Pt declined falls…” Review of the patient’s coordination notes report dated 7/5/2022 revealed that a fax was sent to the patient’s physician. There was no evidence that the physician responded to the fax. On 7/13/2022 at 10:25 am, a telephone interview was conducted with S2LPN (Licensed Practical Nurse). S2LPN stated that she reported the bruise and the fact that the patient was on blood thinners to the supervisor in the agency office. S2LPN stated that a fax was then sent to the physician. S2LPN stated that she did not notify the physician or follow-up with the physician concerning the bruise on 7/5/2022. On 7/13/2022 at 10:45 pm, S1Adm (Administrator) reviewed the patient’s electronic clinical record and confirmed that she could not provide evidence that the physician responded to the fax. Also, S1Adm confirmed that she could not provide evidence that the staff followed-up on the fax that was sent to the physician on 7/5/2022.

Recertification Survey A COVID-19 Focused Infection Control Survey was conducted on 5/5/2021. The facility was found to be in compliance with 42 CFR §484.70 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. Total Census: 123 Unduplicated admissions census: 880

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient's comprehensive assessment included the patient's medical needs as evidenced by no orders found on the plan of care (POC) for 2 (Patient #8 and #12) with the diagnosis of Congestive Heart Failure for the skilled nurse to monitor the patient's weight, to report changes in the patient's weights to the physician and obtain/monitor the weights during the skilled visits out of a total of 17 sampled patients. Findings: 1. Patient #8. The patient was admitted to the agency on 4/6/2021 with the diagnoses that included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Chronic Diastolic (Congestive) Heart Failure. The certification period reviewed was 4/6/2021 to 6/4/2021. The patient's RN OASIS Admission dated 4/6/2021 was reviewed and revealed the patient was discharged from a short-stay acute hospital on 4/5/2021 with the significant past history diagnoses of Congestive Heart Failure (CHF) and Renal Disease. The patient's POC was reviewed and there was no evidence found of an order for the skilled nurse to obtain/ monitor the patient's weight and to report changes in the patient's weights to the physician. The patient's electronic medical records was reviewed and there was no evidence found on the Visit Note Reports dated 4/13/2021, 4/20/2021, 4/27/2021 and on 5/4/2021 that the skilled nurse obtained/monitored a weight during the skilled visit. On 5/5/2021 at 11:10 am, an interview as conducted with S1ADM/DON and after a review of the patient's POC, she verified there was no evidence of an order for the skilled nurse to obtain/monitor the patient's weight and to report changes in the patient's weights to the physician. S1ADM/DON reviewed the patient electronic medical records and verified there was no evidence on the Visit Note Reports dated 4/13/2021, 4/20/2021, 4/27/2021 and on 5/4/2021 that the skilled nurse obtained/monitored the patient's weight during the skilled visit. 2. Patient #12. The patient was admitted to the agency on 2/2/2021 with the diagnoses that included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Atherosclerotic Heart Disease of Native Coronary Artery, Presence of Aortocornary Bypass Graft and Hypertensive Chronic Kidney Disease. The certification period reviewed was 4/3/2021 to 6/1/2021. The patient's POC was reviewed and there was no evidence found of an order for the skilled nurse to obtain/ monitor the patient's weight and to report changes in the patient's weights to the physician. The patient's electronic medical records was reviewed and there was no evidence found on the Visit Note Reports dated 4/5/2021, 4/13/2021, 4/20/2021, 4/27/2021 and on 5/4/2021 that the skilled nurse obtained/monitored the patient's weight during the skilled visit. On 5/5/2021 at 1:31 am, an interview as conducted with S1ADM/DON and after a review of the patient's electronic medical record, verified there was no evidence of an order for the skilled nurse to obtain/monitor the patient's weight and to report changes in the patient's weights to the physician. S1ADM/DON reviewed the patient electronic medical records and verified there was no evidence on the Visit Note Reports dated 4/5/2021, 4/13/2021, 4/20/2021, 4/27/2021 and on 5/4/2021 that the skilled nurse obtained/monitored the patient's weight during the skilled visit.

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 as evidenced by: 1. No evidence found for Patient #15 of a skilled visit made for the week of 2/14/2021 and; 2. No evidence found for Patient #8 that the skilled nurse monitored the blood sugar levels during the skilled visits and; 3. No evidence found for Patient #12 that the skilled nurse monitored the blood sugar level during the skilled visits on 4/5/2021 and 4/27/2021 out of a total of 17 sampled patients. Findings: 1. Patient #15. The patient was admitted to the agency on 1/15/2021 with the diagnoses that included Hypertensive Chronic Kidney Disease, Dehydration and Benign Neoplasm of Meninges. The certification period reviewed was 1/15/2021 to 3/15/2021. The patient's plan of care (POC) was reviewed and the following documentation was found - Frequency/Duration of Visits: SN (Skilled Nurse) 1wk1 (one time a week for one week), 2wk1 (two times a week for one week), 1wk7 (one time a week for seven weeks) and 0wk1 (0 time a week for 1 week). The skilled nurse visits for the certification period was reviewed. There was no evidence found for the week of 2/14/2021 that the skilled nurse made a visit with the patient for that week. On 5/5/2021 at 2:29 pm, an interview was conducted with S1ADM(Administrator)/DON (Director of Nursing) and after a review of the patient's electronic medical records, verified there was no evidence of a skilled visit made for the week of 2/14/2021. 2. Patient #8. The patient was admitted to the agency on 4/6/2021 with the diagnoses that included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Chronic Diastolic (Congestive) Heart Failure. The certification period reviewed was 4/6/2021 to 6/4/2021. The patient's RN OASIS Admission dated 4/6/2021 was reviewed and revealed the patient was discharged from a short-stay acute hospital on 4/5/2021 with the significant past history diagnoses of Congestive Heart Failure (CHF), Endocrine Disease and Renal Disease. The patient's skilled nurse visits dated 4/5/2021, and 4/27/2021 was reviewed and there was no evidence found that the skilled nurses monitored the patient's blood sugar levels during the skilled visits. On 5/5/2021 at 11:10 am, an interview as conducted with S1ADM/DON and the lack of evidence of the skilled nurses monitoring the patient's blood sugars during the skilled visits was discussed. S1ADM/DON stated that the skilled nurses as part of the nursing assessment should have reviewed the patient's blood sugars on each skilled visit. S1ADM/DON verified there was no evidence on the Visit Note Reports dated 4/5/2021 and 4/27/2021 that the skilled nurse monitored the patient's blood sugars during the skilled visits. 3. Patient #12. The patient was admitted to the agency on 2/2/2021 with the diagnoses that included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, and Atherosclerotic Heart Disease of Native Coronary Artery. The certification period reviewed was 4/3/2021 to 6/1/2021. The patient's Client Medication Report was reviewed and revealed the patient was on the following diabetic medications: 1. Glipizide 5 mg .5 tablet daily, Januvia 50 mg 1 tablet every morning and Lantus Solostar U-100 Insulin 100 unit/ml (3ml) Subcutaneous Pen 42 units subcutaneously twice a day. The patient's skilled nurse visits dated 4/6/2021, and 4/27/2021 was reviewed and there was no evidence found that the skilled nurses monitored the patient's blood sugar level for that day during the skilled visits. On 5/5/2021 at 1:31 am, an interview as conducted with S1ADM/DON and after a review of the patient's electronic medical record, she verified there was no evidence found that the skilled nurses monitored the patient's blood sugar level for that day during the skilled visits.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the individualized plan of care included parameters for the reporting of abnormal blood glucose readings and changes in weights for Patient #8 and Patient #12 out of a total of 17 sampled patients. Findings: 1. Patient #8. The patient was admitted to the agency on 4/6/2021 with the diagnoses that included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Chronic Diastolic (Congestive) Heart Failure. The certification period reviewed was 4/6/2021 to 6/4/2021. The patient's RN OASIS Admission dated 4/6/2021 was reviewed and revealed the patient was discharged from a short-stay acute hospital on 4/5/2021 with the significant past history diagnoses of Congestive Heart Failure (CHF), Endocrine Disease and Renal Disease. The patient's POC was reviewed and there was no evidence found of parameters for the skilled nurse to report to the patient's physician of the patient's abnormal blood glucose reading or changes in the patient's weight. On 5/5/2021 at 11:10 am, an interview as conducted with S1ADM/DON and after a review of the patient's plan of care, she verified there was no parameters documented on the POC for the skilled nurse to report the patient's abnormal blood glucose readings or changes in the patient's weight. 2. Patient #12. The patient was admitted to the agency on 2/2/2021 with the diagnoses that included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Atherosclerotic Heart Disease of Native Coronary Artery, Presence of Aortocornary Bypass Graft and Hypertensive Chronic Kidney Disease. The certification period reviewed was 4/3/2021 to 6/1/2021. The patient's Client Medication Report was reviewed and revealed the patient was on the following diabetic medications: 1. Glipizide 5 mg .5 tablet daily, Januvia 50 mg 1 tablet every morning and Lantus Solostar U-100 Insulin 100 unit/ml (3ml) Subcutaneous Pen 42 units subcutaneously twice a day. The patient's POC was reviewed and there was no evidence found of parameters for the skilled nurse to report to the patient's physician of the patient's abnormal blood glucose reading or changes in the patient's weight. On 5/5/2021 at 1:31 am, an interview as conducted with S1ADM/DON and after a review of the patient's electronic medical record, she verified there was no parameters documented on the POC for the skilled nurse to report the patient's abnormal blood glucose readings or changes in the patient's weight.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patient #10's physician was promptly alerted by the skilled nurse that bloody urine was draining from his nephrostomy tube from 4/29/2021 to 5/3/2021, which was 4 days for 1 (#10) out of 17 sampled patients. Findings: Review of patient #10's electronic clinical record revealed that he was admitted to the agency on 9/28/2020. The patient's diagnoses included Chronic Kidney Disease and Diastolic Congestive Heart Failure. The certification period reviewed was 3/27/2021 to 5/25/2021. Review of the patient's Plan Of Care (POC) for certification period 3/27/2021 to 5/25/2021 revealed an order for SN 0wk1, 2wk8, 1wk1 (no skill nurse visit for week one, two visits a week for eight weeks, one visit a week for one week). Review of the skill nurse visit note dated 4/29/2021 revealed, "...Nephrostomy tube is draining bloody urine to GU (genitourinary) bag... Nephrostomy tube is still sutured in place... Patient did not want to seek an ER (emergency room) evaluation... Case communication sent to PCP (primary care physician) and Dr. ____. Review of the patient's clinical record revealed no evidence that the physician responded to the communication and no evidence that the agency staff followed up on the communication that was sent to the physician. Review of the skill nurse visit note dated 5/3/2021 revealed, "... Nephrostomy tube is still draining bloody urine to GU bag..." On 5/5/2021 at 10:30 am, S2RNCS (Registered Nurse Clinical Supervisor) reviewed the patient's clinical record and confirmed that there was no evidence in the record that the physician responded to the communication. Also, S2RNCS confirmed that there was no evidence that a follow-up was done to contact the physician concerning the patient's bloody urine draining from the nephrostomy tube. On 5/5/2021 at 10:36 am, S1Adm/DON (Administrator/Director of Nurses) reviewed the patient's clinical record and confirmed that there was no evidence in the record that the physician responded to the communication. Also, S1Adm/DON confirmed that there was no evidence that a follow-up was done to contact the physician concerning the patient's bloody urine draining from the nephrostomy tube. On 5/5/2021 at 11:05 am, S3RNCS (Registered Nurse Clinical Supervisor) reviewed the patient's clinical record and confirmed that there was no evidence in the record that the physician responded to the communication. Also, S2RNCS confirmed that there was no evidence that a follow-up was done to contact the physician concerning the patient's bloody urine draining from the nephrostomy tube. On 5/5/2021 at 11:47 am, a telephone interview was conducted with S4LPN (Licensed Practical Nurse). S4LPN was the nurse that made the skill nurse visits on 4/29/2021 and on 5/3/2021. S4LPN stated that the patient was draining bloody urine from nephrostomy tube on 4/29/2021. S4LPN stated that the patient's urine was clear on the previous visit. S4LPN stated that the patient's spouse was discussing if the patient wanted to go to ER. S4LPN stated that the patient did not want to go to the ER. S4LPN stated that she sent a communication to the primary care physician and to Dr. ____. S4LPN stated that she did not document in the patient's clinical record she informed the physicians concerning the patient's bloody urine draining from the nephrostomy tube. Also, she stated that she did not have any communication with the patient or his spouse concerning the bloody urine since the skill nurse visit on 4/29/2021 and her next visit with the patient was on 5/3/2021. S4LPN stated that the patient was still having bloody urine draining from the nephrostomy tube on 5/3/2021. Review of the agency's Coordination of Patient Care policy and procedur revealed, "...6. Staff provides the physician with patient information on an ongoing basis regarding: Current condition and changes in condition..."

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide evidence of coordination with the physician concerning new finding of 3 plus pitting edema to the patient's left foot for 1 (patient #1) out of 17 sampled patients. (#1) Findings: Patient #1. Review of the patient's electronic clinical records revealed the start of care date was 3/31/2021. The patient's diagnosis included Bronchiectasis with Acute Exacerbation. The certification period reviewed was 3/31/2021 to 5/29/2021. Review of the patient's POC for certification period 3/31/2021 to 5/29/2021 revealed an order for "SN 1wk1, 2wk1, 1wk7 (skilled nurse visit one time a week for one week, two visits a week for one week, one visit a week for seven weeks)." Review of the patient's skilled nurse visit notes dated 5/3/2021 revealed, " ...Left foot has plus 3 pitting edema... Pt states will see Dr.___ soon." There was no evidence that the physician was notified concerning the patient having 3 plus pitting edema to the left foot. On 5/5/2021 at 10:18 am, S2RNCS (Registered Nurse Clinical Supervisor) reviewed the patient's clinical record and confirmed that the 3 plus pitting edema was new and that the skilled nurse should have informed the physician. S2RNCS confirmed that there was no evidence that the skilled nurse informed the physician.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency's Visit Note Reports failed to have documented evidence the skilled nurse preformed a diabetic foot inspection during the skilled visit on 2 (Patient #8 and Patient #12's) patients out of a total of 17 sampled patients. Findings: 1. Patient #8. The patient was admitted to the agency on 4/6/2021 with the diagnoses that included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Chronic Diastolic (Congestive) Heart Failure. The certification period reviewed was 4/6/2021 to 6/4/2021. The patient's RN OASIS Admission dated 4/6/2021 was reviewed and revealed the patient was discharged from a short-stay acute hospital on 4/5/2021 with the significant past history diagnoses of Congestive Heart Failure (CHF), Endocrine Disease and Renal Disease. The patient's electronic medical records was reviewed and there was no evidence found on the Visit Note Reports dated 4/6/2021, 4/13/2021, 4/20/2021, 4/27/2021 and on 5/4/2021 that the skilled nurse preformed a foot inspection during the skilled visit. On 5/5/2021 at 11:10 am, an interview as conducted with S1ADM/DON and after a review of the patient's electronic medical records, she verified there was no evidence in the above listed Visit Note Reports that the skilled nurse preformed a foot inspection during the skilled visits. 2. Patient #12. The patient was admitted to the agency on 2/2/2021 with the diagnoses that included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Atherosclerotic Heart Disease of Native Coronary Artery, Presence of Aortocornary Bypass Graft and hypertensive Chronic Kidney Disease. The certification period reviewed was 4/3/2021 to 6/1/2021. The patient's Client Medication Report was reviewed and was on the following diabetic medications: 1. Glipizide 5 mg .5 tablet daily, Januvia 50 mg 1 tablet every morning and Lantus Solostar U-100 Insulin 100 unit/ml (3ml) Subcutaneous Pen 42 units subcutaneously twice a day. The patient's electronic medical records were reviewed and there was no evidence found on the Visit Note Reports dated 4/5/2021, 4/13/2021, 4/20/2021, 4/27/2021 and on 5/4/2021 that the skilled nurse preformed a foot inspection during the skilled visit. On 5/5/2021 at 1:31 am, an interview as conducted with S1ADM/DON and after a review of the patient's electronic medical record, she verified there was no evidence in the above listed Visit Note Reports that the skilled nurse preformed a foot inspection during the skilled visits.