Every finding on record at Stat Home Health Southeast Louisiana, LLC

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 review and interview, the agency failed to ensure all new and existing staff and all 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 for 2 (S7PT and S8OT) of 10 personnel records reviewed. Findings: Review of the agency’s training logs on 04/18/2024 at 4:05 p.m. with S2RDO revealed no documented evidence of initial training, ongoing training every 2 years, and documentation of demonstrated knowledge of emergency procedures for S7PT and S8OT's personnel records reviewed for Emergency Preparedness training. An interview was conducted on 04/18/2024 at 4:10 p.m. with S2RDO. She stated Emergency Preparedness training should be completed upon hire and every 2 years thereafter. She confirmed there was no documentation of Emergency Preparedness training on file for S7PT and S8OT and there should have been.

Recertification Survey Abbreviations mg milligrams

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 CMS system within 30 days of completion. Review of the agency’s undated policy titled, “Reporting of OASIS Information” revealed the following, in part: Policy: The agency will report required data collected for the Outcome and Assessment Information Set items. Procedure: 1. The agency will report electronically all OASIS data collected according to current federal and/or state requirements. 3. Agency will electronically transmit completed, encoded and locked OASIS data for each completed OASIS assessment at least monthly to the system. 4. OASIS data must be transmitted in accordance with the current CMS transmission policy. Review of the agency's OASIS Agency Final Validation Report with a submission date of 06/05/2023 revealed 6 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 06/06/2023 revealed 11 records were processed with 3 of the records receiving messages the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 06/09/2023 revealed 19 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 06/14/2023 revealed 1 record was processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 06/16/2023 revealed 6 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 06/20/2023 revealed 16 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 06/28/2023 revealed 3 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 07/12/2023 revealed 13 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 07/15/2023 revealed 2 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 07/25/2023 revealed 1 record was processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 07/27/2023 revealed 5 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 08/01/2023 revealed 2 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 08/01/2023 revealed 11 records were processed with 3 records receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 08/03/2023 revealed 6 records were processed with 3 records receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 08/16/2023 revealed 12 records were processed with 4 records receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 08/18/2023 revealed 3 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 08/18/2023 revealed 1 record was processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 12/27/2023 revealed 2 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 01/04/2024 revealed 4 records were processed with 2 record receiving messages the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 02/01/2024 revealed 1 record was processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 03/05/2024 revealed 10 records were processed with 5 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. An interview was conducted with S2RDO on 04/18/2024 at 11:00 a.m. She reviewed the above OASIS validation reports and confirmed the records were submitted late, more than 30 days after completion. She confirmed patients’ OASIS should have been submitted within 30 days of completion.

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 review, the agency failed to ensure each patients’ comprehensive assessment included a review of all medications the patients were currently using. The agency failed to ensure skilled nursing staff reconciled patients’ medications for 3 (#1, #2, and #3) of 6 (#1, #2, #3, #4, #6 and #7) patients reviewed with home visits. Patient #3 Review of the Clinical Record for Patient #3 revealed he began receiving services from the Home Health Agency on 01/20/2024 and had a current Certification Period of 03/20/2024 – 05/18/2024. Patient #3 had diagnoses which included Pain Due to Internal Orthopedic Prosthesis Device, Arthritis Due to Other Bacteria, Right Knee and Type II Diabetes Mellitus with Diabetic Polyneuropathy. A home visit was conducted with Patient #3 on 04/17/202 at 2:00 pm. Patient #3’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to Patient #3’s Current Medication Profile provided by the Home Health Agency: Aspirin 325mg tablet take one tablet by mouth two times a day was on the medication profile with a start date of 03/14/2024, and was not present in the home. Colace100mg capsule take one capsule by mouth twice a day was on the medication profile with a start date of 01/20/2024, and was not present in the home. Crestor 20mg tablet take one tablet daily, and was not present in the home. Cyclobenzaprine 10mg tablet take one tablet every eight hours was on the medication profile with a start date of 03/14/2024, and was not present in the home. Miralax 17 gram oral powder packet take one packet daily was on the medication profile with a start date of 01/20/2024, and was not present in the home. An interview was conducted with Patient #3 during the home visit. He stated he managed his own medications. He stated the home health nurses do not check his medications. He confirmed the above listed medications were not in his home. He stated he had not been on the medications listed above for over one month. An interview was conducted with S1ED on 04/18/2024 at 2:35 p.m. He was notified of the medication discrepancies found during the home visits for Patient #1, #2, and #3. He stated each patients’ medications should have been reconciled every discipline visit and staff should review the medication bottles each visit. He verified each patients’ Medication Profile should have reflected what the patient was currently taking. Findings: Review of the Agency’s Policy titled, “Medication Reconciliation” dated January 2024 revealed the following, in part: Policy: The Agency will reconcile patient’s medications at the time of admission and on an ongoing basis in order to identify potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug reactions, duplicate drug therapy and non-compliance with drug therapy. Purpose: Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. The patient’s medication list in the home will also be updated. Patient #1 Review of the Clinical Record for Patient #1 revealed he began receiving services from the Home Health Agency on 03/09/2024 and had a current Certification Period of 03/09/2024 to 05/07/2024. Patient #1 had diagnoses, which included Dysphagia, Lumbago with Sciatica Right Side, Chronic Pain, Arthritis, and Spinal Stenosis Cervical Region. A home visit was conducted with Patient #1 and Patient #1’s daughter on 04/17/2024 at 10:00 a.m. with S3RN present in the home. Patient #1’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to Patient #1’s Current Medication Profile provided by the Home Health Agency: Cyclobenzaprine 5 mg tablet take one tablet two times daily was on the medication profile with a start date of 03/09/2024, and the patient was taking as needed. Gabapentin 400 mg capsule take two capsules three times daily was on the medication profile with a start date of 03/09/2024, and the patient was taking as needed. Indomethacin 75 mg Extended Release capsule take one capsule daily was on the medication profile with a start date of 03/09/2024, and the patient was no longer taking. Melatonin 3 mg capsule take one capsule at bedtime was on the medication profile with a start date of 03/09/2024, and the patient was no longer taking. An interview was conducted with Patient #1’s daughter during the home visit. She stated she managed Patient #1’s medications and administered his medications through his peg tube. She stated in March 2024, Patient #1’s physician stopped all of his medications that had a sedative effect. She stated Cyclobenzaprine was changed to as needed and he had not taken the medication since his home health admit. She stated Gabapentin was changed to as needed for nerve pain prior to his home health admit. She stated the Indomethacin and Melatonin were stopped completely in March 2024. An interview was conducted with S3RN on 04/17/2024 at 10:15 a.m. during the home visit. S3RN confirmed the above medication discrepancies during the home visit. S3RN stated medications should be reconciled during every home visit. Patient #2 Review of the Clinical Record for Patient #2 revealed he began receiving services from the Home Health Agency on 08/25/2023 and had a current Certification Period of 02/21/2024 to 04/20/2024. Patient #2 had diagnoses, which included Acute Combined Systolic and Diastolic Congestive Heart Failure, End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes Mellitus, Other Chronic Pain, Anxiety Disorder, and Orthostatic Hypotension. A home visit was conducted with Patient #2 on 04/17/2024 at 8:00 a.m. with S3RN present in the home. Patient #2’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to Patient #2’s Current Medication Profile provided by the Home Health Agency: Gabapentin 100 mg capsule take one capsule by mouth three times daily was on the medication profile with a start date of 08/24/2023, and was not present in the home. Hydrocodone 10 mg-Acetaminophen 325 mg tablet take one tablet by mouth every six hours for pain was on the medication profile with a start date of 08/24/2023, and was not present in the home. Lexapro 10 mg tablet take one tablet by mouth daily was on the medication profile with a start date of 02/14/2024, and was not present in the home. Protonix 40 mg tablet take one tablet by mouth daily was on the medication profile with a start date of 08/24/2023, and was not present in the home. Senna Plus 8.6 mg-50 mg capsule take one capsule by mouth two times daily was on the medication profile with a start date of 08/24/2023, and was not present in the home. Valium 5 mg tablet take one tablet by mouth every six hours for anxiety was on the medication profile with a start date of 02/14/2024, and was not present in the home. Xanax 0.25 mg tablet take one tablet by mouth two times daily was on the medication profile with a start date of 08/24/2023, and was not present in the home. An interview was conducted with Patient #2 during the home visit. He stated he managed his own medications. He stated the home health nurses never checked his medications. He stated he had not taken Gabapentin in months. He stated he was no longer prescribed Hydrocodone and had not taken the medication in six months. He stated he took Lexapro for the month of February 2024 and then stopped taking it because it wasn’t helping. He stated he was not taking Protonix and confirmed he did not have any in the home. He stated he had stopped taking Senna six months ago. He stated he never filled the prescriptions for Valium and Xanax. An interview was conducted with S3RN on 04/17/2024 at 8:30 a.m. during the home visit. S3RN confirmed the above medication discrepancies during the home visit. S3RN stated medications should be reconciled during every home visit.

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 interviews, the agency failed to ensure services ordered by the Physician were provided as indicated in the Plan of Care as evidenced by: 1. Medical Social Worker (MSW) visits were not conducted as ordered for 1 (Patient #4) of 2 (Patients #4 and #5) patient records reviewed with orders for MSW services; and, 2. Home Health Aide (HHA) visits were not conducted as ordered for 2 (Patients #12 and #17) of 3 (Patients #11, #12, and #17) patient records reviewed with orders for Home Health Aide services. Patient #12 Review of Patient #12’s Clinical Record revealed he was admitted to the agency on 03/08/2024 with diagnoses which included Hemiplegia following Cerebral Infarction affecting Right Dominant Side, Hemiplegia following Cerebral Infarction affecting Left Non Dominant Side, Chronic Obstructive Pulmonary Disease, and Dementia with Mood Disturbance. Review of Patient #12’s Plan of Care for certification period of 03/08/2024 – 05/06/2024 revealed Physician Orders which included the following, in part: HHA effective 03/24/2024 1 time a week for 1 week, 1 every other 2 times a week for 2 weeks, and 1 time a week for 1 week. Review of the Client Calendar Report for Patient #12 revealed no documentation of a HHA visit for the Certification Period 03/08/2024 – 05/06/2024. An interview was conducted on 04/18/2024 at 1:50 p.m. with S2RDO. She reviewed Patient #12’s Clinical Record and confirmed HHA visits were ordered for 1 time a week for 1 week, 1 every other 2 times a week for 2 weeks, and 1 time a week for 1 week effective 03/24/2024 and were not completed. She confirmed the agency did not follow the physician’s orders and should have. Patient #17 Review of Patient #17’s Clinical Record revealed he was admitted to the agency on 11/14/2023 with diagnoses which included Pressure Ulcer of Sacral Region Stage 4, Pressure Ulcer of Right Heel Stage 1, Paraplegia, Chronic Diastolic Congestive Heart Failure, and Obesity. Review of Patient #17’s Plan of Care for Certification Period of 11/14/2023 – 01/12/2024 revealed Physician Orders which included the following, in part: HHA needed for help with patient personal care assistance written on 11/30/2023. Further review of the Clinical Record revealed an additional order for a HHA visit written on 01/08/2024. Review of the Client Calendar Report for Patient #17 revealed no documentation HHA services were provided from 11/30/2023 until discharge on 01/12/2024. An interview was conducted on 04/18/2024 at 12:15 p.m. with S2RDO. She reviewed the physician orders for HHA services dated 11/30/2023 and 01/08/2024 for Patient #17. She confirmed there was no documentation in Patient #17’s Clinical Record why the HHA services were not provided and there should have been. She confirmed the agency did not follow the physician’s orders and should have. An interview was conducted on 04/18/2024 at 2:21 p.m. with S1ED. S1ED verified the aforementioned clinical records failed to include documentation why services were not provided. He confirmed the agency did not follow the physician’s orders for Patients #4, #12, and #17 and should have. Review of the agency’s policy titled “Plan of Care and Physician/Practitioners Orders” dated February 2024 revealed the following, in part: Policy: Skilled nursing and other home health services will be in accordance with a Plan of Care based on the patient’s diagnosis and assessment of immediate and long range needs and resources. Procedure: 3. 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. Patient #4 Review of Patient #4’s Clinical Record revealed she was admitted to the agency on 03/27/2024 with diagnoses which included Polyneuropathy, Alcohol Dependence, Essential Hypertension and History of Transit Ischemic Attacks. Review of Patient #4’s Plan of Care for certification period of 03/27/2024 – 05/25/2024 revealed Physician Orders which included the following, in part: MSW effective 03/31/2024 1 time a week for 1 week. Further review of the Clinical Record revealed an additional order for a MSW visit written on 04/03/2024. Review of the Client Calendar Report for Patient #4 revealed no documentation of a MSW visit for the Certification Period 03/27/2024 – 05/25/2024. There was no documentation of the reason for the missed visit. An interview was conducted on 04/17/2024 at 1:15 p.m. with S2RDO. She reviewed Patient #4’s Clinical Record and confirmed a MSW visit was ordered for 1 time a week for 1 week effective 03/31/2024 and was not completed. She confirmed an additional MSW visit was ordered on 04/03/2024 and was not completed. She said there were no missed visit notes by the MSW and there should have been. She confirmed the order for a MSW visit on 04/03/2024 was denied by the Registered Nurse that approved visits.

Complaint Survey #LA00063007

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on interviews and record review, the agency failed to implement processes for ensuring 3 staff that currently provide care, treatment or services for the agency met the COVID -19 staff vaccination requirement. The facility failed to obtain the medical exemption, religious exemption or temporary delays for 3 direct care staff that are currently employed with the agency and had been providing care to the patients. Review of the facility policy titled "COVID -19 Vaccination Policy" revealed the following, in part: Policy: This policy applies to all staff who provide any care, treatment, or other services for the facility. This includes the following: (1) facility employees, (2) licensed practitioners, (3) trainees and volunteers, and (4) individuals who provide care, treatment or other services for the facility and/or its patients, under contract or by other arrangements. All new employees are required to comply with the vaccination requirements outlined in this policy as a condition of employment. Potential candidates for employment will be notified of this policy before the start of employment. D. Exemption request process: 1. All medical and religious exemption requests require the completion and submission of the applicable COVID -19 exemption from vaccination exemption form. 3. The Administrator or Executive Director is responsible for collecting and submitting exemption request to the Human Resources Department. 4. In the event forms are incomplete or additional information is required, the HR Department will notify the director and employee in writing. 6. The Administrator or Executive Director must maintain all exemption requests and supporting approval or denial documentation. An interview was conducted on 06/03/2022 at 12:00 p.m. with S2OM. She provided a list with the dates of hire and date last worked for the 3 direct care staff with an unsigned exemption form. Of those 3 direct care staff, 3 worked after 03/15/2022. Review of the list revealed the following: S3CNA-Date of Hire-05/16/2022 -Last worked 06/03/2022 S4LPN-Date of Hire-01/03/2022 -Last worked 06/03/2022 S5RN- Date of Hire-05/23/2022 - Last worked 06/03/2022 She verified it was her responsibility for ensuring staff were vaccinated or had a signed exemption form before providing care to the patients. She confirmed S3CNA, S4LPN and S5RN had not been vaccinated or submitted a completed request for exemption until today. She said the 3 employees above provided care to patients today. An interview was conducted on 06/03/2022 at 1:00 p.m. with S4LPN. She said she had been working for the agency since January 2022. She verified she was unvaccinated. She said prior to today, she had not submitted a completed exemption form to the agency for approval. An interview was conducted on 06/03/2022 at 1:15 p.m. with S5RN. She said she had been working for the agency since 05/23/2022. She verified she was unvaccinated. She said prior to today, she had not submitted a completed exemption form to the agency for approval. An interview was conducted on 06/03/2022 at 3:00 p.m. with S1ADM. He said S3CNA, S4LPN and S5RN were currently providing care to patients for the agency. He confirmed these 3 employees were not vaccinated and had not submitted a completed request for exemption prior to providing care to their patients. He said S2OM was responsible for obtaining the exemptions or the vaccination verification for the employees prior to employment. He stated he was not aware that all employees needed to have a completed vaccination series or an exemption by 03/15/2022.

Recertification Survey A COVID-19 Focused Infection Control Survey was conducted on 05/21/2021 per QSO-20-20-ALL. No deficiencies were cited as a result of this survey. Abbreviations: ABD - Abdominal CG - Caregiver HCTZ - Hydrochlorothiazide mg - milligrams MSW - Master of Social Work NSNV - Non-skilled Nurse Visit 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 (Patient #4, #6, and #7) of 7 (Patients #1-#7) sampled patients reviewed who received home visits. Findings: Patient #4 Review of the clinical record revealed a start of care date of 03/05/2021. The patient's primary diagnosis was Hypertensive Heart Disease Without Heart Failure. A review of the Home Health Certification and Plan of Care/485 for the Certification Period of 05/04/2021 to 07/02/2021 revealed orders which included SN 1W9 effective week of 05/04/2021. A current medication profile list was provided by the agency on 05/17/2021. On 05/19/2021 at 12:00 p.m., a home visit was conducted in the home of Patient #4 with S6LPN. Review of the medications listed on the patient's current medication profile list provided by the agency revealed the following discrepancies when compared with medications in the home: 1. Glipizide 5 mg oral 2 times daily. This medication was not in the home. 2. A bottle of Amlodipine Besylate 10 mg with a prescription fill date of 03/02/2021 was observed in the home; instructions stated one tablet by mouth daily. This medication was not listed on the patient's current medication profile list provided by the agency. 3. A bottle of Atorvastatin 80 mg with a prescription fill date of 04/01/2021 was observed in the home; instructions stated one tablet by mouth daily. This medication was not listed on the patient's current medication profile list provided by the agency. 4. A bottle of Gabapentin 100 mg with a prescription fill date of 03/20/2021 was observed in the home; instructions stated 2 tablets by mouth at bedtime. This medication was not listed on the patient's current medication profile list provided by the agency. 5. A bottle of Irbesartan-HCTZ 300-12.5 mg with a prescription fill date of 03/22/2021 was observed in the home; instructions stated one tablet daily. This medication was not listed on the patient's current medication profile list provided by the agency. 6. A bottle of Januvia 100 mg with a prescription fill date of 04/01/2021 was observed in the home; instructions stated one tablet daily. This medication was not listed on the patient's current medication profile list provided by the agency. On 05/19/2021 at 12:20 p.m., an interview was conducted with Patient #4 during the home visit. She provided medications for review during the home visit and stated the medications provided were the only ones she was currently taking. She stated her daughter helped her with her medicines and prepared them in a pill box for her to take each day. On 05/19/2021 at 12:25 p.m., an interview was conducted with S6LPN during the home visit. She verified the patient was currently receiving SN visits once a week. She verified the patient's daughter assisted the patient with medications. She stated she talked with the patient's daughter on 05/18/2021 per phone conversation to review medicines with her prior to the SN visit scheduled for 05/19/2021. She verified no SN visit was conducted in the home on 05/18/2021. A review of SN visit documentation revealed SN visits were conducted with Patient #4 on the following dates during the current Certification Period of 05/04/2021 to present: 05/04/2021 and 05/11/2021. Patient #6 Review of the clinical record revealed a start of care date of 02/04/2021. A review of the Home Health Certification and Plan of Care/485 for the Certification Period of 04/05/2021 to 06/03/2021 revealed a primary diagnosis of Unspecified Dementia without Behavioral Disturbances and orders which included SN 1W9 effective week of 04/05/2021. A current medication profile list was provided by the agency on 05/17/2021. On 05/19/2021 at 10:30 a.m., a home visit was conducted in the home of Patient #6 with S9MSW. Review of the medications listed on the patient's current medication profile list provided by the agency revealed the following discrepancies when compared with medications in the home: 1. Memantine 14 mg 1 capsule daily. This medication was listed as a current medication but was not in the home. 2. Myrbetriq 25 mg 1 tablet at bedtime. This medication was listed as a current medication but was not in the home. 3. A bottle of Tamsulosin 0.4 mg with a prescription fill date of 04/12/2021 was observed in the home; instructions stated one tablet by mouth nightly. This medication was not listed on the patient's current medication profile list provided by the agency. 4. A bottle of Aspirin 81 mg with a prescription fill date of 04/09/2021 was observed in the home; instructions stated one tablet by mouth daily. This medication was not listed on the patient's current medication profile list provided by the agency. On 05/19/2021 at 10:50 a.m., an interview was conducted with Patient #6's daughter during the home visit. She verified she was familiar with the patient's medications and assisted him in taking the medications. She verified the patient had not taken Memantine or Myrbetriq in several weeks. She further verified the patient had been taking Tamsulosin and Aspirin for about a month. A review of SN visit documentation revealed SN visits were conducted with Patient #6 on the following dates during the current Certification Period of 04/05/2021 to present: 04/09/2021, 04/13/2021, 04/19/2021, 05/06/2021, 05/12/2021, and 05/17/2021. Patient #7 Review of the clinical record revealed a start of care date of 11/18/2020. A review of the Home Health Certification and Plan of Care/485 for the Certification Period of 03/25/2021 to 05/23/2021 revealed a primary diagnosis of Type 2 Diabetes Mellitus with Diabetic Neuropathy and orders which included SN effective week of 03/28/2021 1W8. A current medication profile list was provided by the agency on 05/17/2021. On 05/20/2021 at 12:00 p.m., a home visit was conducted in the home of Patient #7 with S7PT. Review of the medications listed on the patient's current medication profile list provided by the agency revealed the following discrepancies when compared with medications in the home: 1. Gabapentin 300 mg 1 capsule 2 times daily. A bottle of the medication with a prescription fill date of 04/14/2021 was observed in the home; instructions noted on the bottle were 1 tablet as needed for pain. 2. Humulin 70/30 Kwikpen 20 units 2 times daily. The patient did not provide the insulin pen but stated she had been taking 20 units twice a day, but started taking 30 units twice a day for the last 2-3 weeks. 3. A bottle of Lisinopril 30 mg with a prescription fill date of 04/14/2021 was observed in the home; instructions stated one tablet by mouth daily. This medication was not listed on the patient's current medication profile list provided by the agency. 4. A bottle of Cyclobenzaprine 5 mg with a prescription fill date of 04/22/2021 was observed in the home; instructions stated one tablet by mouth at bedtime. This medication was not listed on the patient's current medication profile list provided by the agency. 5. A bottle of Hydralazine 50 mg with a prescription fill date of 04/14/2021 was observed in the home; instructions stated one tablet twice a day. This medication was not listed on the patient's current medication profile list provided by the agency. 6. A bottle of Naproxen 500 mg with a prescription fill date of 04/22/2021 was observed in the home; instructions stated one tablet daily. This medication was not listed on the patient's current medication profile list provided by the agency. 7. The following medications listed on the patient's current medication profile list provided by the agency were not in the home: Norvasc 5 mg daily, Protonix 40 mg daily, Robaxin 500 mg 4 times daily, Simvastatin 10 mg at bedtime, Zanaflex 4 mg twice daily, and Zofran ODT 4 mg every 8 hours. On 05/20/2021 at 12:20 p.m., an interview was conducted with Patient #7 during the home visit. She provided medications for review during the home visit and stated the medications provided were the only ones she was currently taking. She stated her niece helped her with her medicines when needed. A review of SN visit documentation revealed SN visits were conducted with Patient #7 on the following dates during the current Certification Period of 03/25/2021 to present: 04/13/2021, 04/28/2021, 05/05/2021, and 05/13/2021. On 05/21/2021 at 1:05 p.m., an interview was conducted with S2DON. She was notified of the medication discrepancies found during the home visits for Patients #4, #6, and #7. She verified the medication profiles were not up to date. S2DON verified nurses should reconcile medications during each SN visit and update the medication profiles 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 review and interview, the agency failed to ensure the patient's written Plan of Care was followed as evidenced by the following: 1. SN visits not conducted as ordered for 1 (Patient #2) of 17 (Patients #1 - #17) sampled patient records reviewed that had orders for SN visits; and 2. MSW visits not conducted as ordered for 1 (Patient #6) of 3 (Patients #6, #10, #14) sampled patient records reviewed that had orders for MSW visits out of a total sample of 17 patients. Findings: Patient #2 Review of the clinical record revealed the patient had a Start of Care date of 04/08/2021. The patient's primary diagnosis was Other Sequelae of Cerebral Infarction. A review of the 485/Plan of Care for the certification period of 04/08/2021 to 06/06/2021 revealed orders that included the following: SN 1W9. Review of the SN notes for the patient revealed no documentation of a SN visit for the week of 04/25/2021. There was no documentation of the reason for the missed visit. Patient #6 Review of the clinical record revealed the patient had a Start of Care date of 02/04/2021. The patient's primary diagnosis for the 485/Plan of Care for the certification period of 04/05/2021 to 06/03/2021 was Unspecified Dementia without Behavioral Disturbances. Further review of the 485/Plan of Care revealed orders that included the following: MSW eval. week of 04/11/2021. Review of the MSW notes for the patient revealed no MSW evaluation was conducted the week of 04/11/2021. There was no documentation of the reason for the missed visit. On 05/12/2021, an order was written for MSW eval. to assess community resource needs and LTC needs. There was no MSW evaluation conducted that week. There was no documentation of the reason for the missed visit. The MSW evaluation was not conducted until 05/19/2021. On 05/21/2021 at 12:40 p.m., an interview was conducted with S2DON. After reviewing the clinical record for Patient #2, she verified there was no documentation of a SN visit conducted the week of 04/25/2021. S2DON further verified there was no documentation of the reason the SN visit was missed. After reviewing the clinical record for Patient #6, S2DON verified the MSW evaluation was not conducted in a timely manner. She verified there was no documentation of the reason for the delayed MSW evaluation.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the total plan of care was signed and dated by the patient's physician in a timely manner for 5 (Patients #2, #3, #12, #13, and #16) of 17 (Patients #1-#17) sampled patient records reviewed. Cross-referenced with State Regulations 9123. Patient Care Standards: C. Plan of Care. The plan of care for each patient must be individualized to address the patient's problems, goals, and required services. 1. The Plan of Care, telephone and/or verbal orders must be signed by the physician within a timely manner, not to exceed 30 days. Findings: Patient #2 Review of the clinical record for Patient #2 revealed a start of care date of 04/08/2021. Review of the plan of care for the certification period 04/08/2021 to 06/06/2021 for the patient revealed a principal diagnosis of Other Sequelae of Cerebral Infarction. Further review of the plan of care for this certification period revealed it was not yet signed by the physician. Review of a Physician's Order dated 04/10/2021 revealed it was not yet signed by the physician. Patient #3 Review of the clinical record for Patient #3 revealed a start of care date of 04/01/2021. Review of the plan of care for the certification period 04/01/2021 to 05/30/2021 for the patient revealed a principal diagnosis of Alzheimer's Disease. Further review of the plan of care for this certification period revealed it was not yet signed by the physician. Review of a Physician's Order dated 04/06/2021 revealed it was not yet signed by the physician. Patient #12 Review of the clinical record for Patient #12 revealed a start of care date of 03/19/2020. Review of the plan of care for the certification period 03/14/2021 to 05/12/2021 for the patient revealed a principal diagnosis of Pressure Ulcer of Left Heel Stage 4. Further review of the plan of care for this certification period revealed the physician signed the order on 04/21/2021, which was not within the required time frame of 30 days. Review of a Physician's Order dated 03/20/2021 revealed it was signed by the physician on 04/21/2021, which was not within the required time frame of 30 days. Patient #13 Review of the clinical record for Patient #13 revealed a start of care date of 12/22/2020. Review of the plan of care for the certification period 12/22/2021 to 02/19/2021 for the patient revealed a principal diagnosis of Type 2 Diabetes Mellitus with Foot Ulcer. Further review of the plan of care for this certification period revealed the physician signed the order on 03/09/2021, which was not within the required time frame of 30 days. Review of a Physician's Order for Resumption of Care dated 12/30/2020 revealed it was signed by the physician on 02/04/2021, which was not within the required time frame of 30 days. Review of a Physician's Order dated 01/25/2021 revealed it was signed by the physician on 03/09/2021, which was not within the required time frame of 30 days. Review of a Physician's Order for Resumption of Care dated 01/27/2021 revealed it was signed by the physician on 03/09/2021, which was not within the required time frame of 30 days. Patient #16 Review of the clinical record for Patient #16 revealed a start of care date of 03/29/2021. Review of the plan of care for the certification period 03/29/2021 to 05/27/2021 for the patient revealed a principal diagnosis of Sepsis, Unspecified Organism. Further review of the plan of care for this certification period revealed the physician had not yet signed the orders. On 05/21/2021 at 1:00 p.m., an interview was conducted with S2DON. After reviewing the clinical records for Patients #2, #3, #12, #13, and #16, S2DON verified the orders were not signed for the patients within the required time frame of 30 days.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to comply with accepted professional standards and principles by failing to have a Registered Nurse assess a patient's wounds, including the size and stage, weekly for 3 of 3 (#11, #12, and #17) 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 responsible 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, periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. Resident #11 Review of the clinical record for Patient #11 revealed a start of care date of 11/19/2019. Review of the plan of care for the current certification period 03/13/2021 - 05/11/2021 revealed diagnoses that included Pressure Ulcer of Right Buttock Stage 4, Pressure Ulcer of Left Buttock Stage 4, and Pressure Ulcer of Sacral Region Stage 4. Further review of the plan of care revealed orders for the following Frequency/Duration of Visits: SN effective 03/14/2021 1W9. Orders of Discipline and Treatment included the following: Skilled Nurse to observe and assess integumentary status to identify changes and intervene to minimize complications. Skilled Nurse to perform/teach pressure ulcer care to left and right ischiums cleanse with wound cleanser apply Promogran. Cover with Calcium Alginate PRN and Mepilex. Sacrum keep covered with Mepilex using clean/aseptic technique 3X/week. CG to perform NSNV. Review of the SN visit documentation revealed visits were conducted on the following dates during this current certification period: 03/17/2021, 03/25/2021, 03/31/2021, 04/08/2021, 04/16/2021, 04/22/2021, 04/30/2021, 05/07/2021, and 05/11/2021. All SN visits were conducted once a week by a Registered Nurse. There was no documentation of a wound assessment or measurements performed on 03/31/2021, 04/16/2021, or 04/22/2021. Resident #12 Review of the clinical record for Patient #12 revealed a start of care date of 03/19/2020. Review of the plan of care for the current certification period 03/14/2021 to 05/12/2021 revealed diagnoses that included Pressure Ulcer of Left Heel Stage 4, Pressure Ulcer of Right Heel Stage 4, and Pressure Ulcer of Sacral Region Stage 4. Further review of the plan of care revealed orders for the following Frequency/Duration of Visits: SN 3WK8, 2WK1. Orders of Discipline and Treatment included the following: Skilled Nurse to observe and assess integumentary status to identify changes and intervene to minimize complications. SN to perform/ teach pressure ulcer care to pressure ulcers using clean/aseptic technique as follows: sacral: cleanse with wound cleanser, pat dry with gauze, apply Bactroban and Aquacel AG, and cover with border foam dressing. Bilateral heels: cleanse with wound cleanser, pat dry with gauze, apply Iodosorb, wrap with kerlix, and secure with tape. Wound care to be performed three times weekly and as needed with soilage/non-intact dressing. Review of the SN visit documentation revealed SN visits were conducted 3x/week as ordered, but there was no documentation of a Registered Nurse assessment of the wounds during the weeks of 04/04/21, 04/18/202, or 05/03/2021. There was no documentation of wound measurements during the Registered Nurse visits for the weeks of 04/11/2021 or 04/25/2021. Patient #17 Review of the clinical record for Patient #17 revealed a start of care date of 02/11/2021. Review of the plan of care for the certification period 02/11/2021 to 04/11/2021 revealed diagnoses that included Pressure Ulcer of Sacral Region Stage 4. Further review of the plan of care revealed orders for the following Frequency/Duration of Visits: SN 1WK1, 1QO2WK2, 1WK6. Orders of Discipline and Treatments included the following: Skilled Nurse to observe and assess integumentary status to identify changes and intervene to minimize complications. SN to perform/ teach pressure ulcer care to sacrum: irrigate with saline cleanse with Dakin's 0.5%, apply triad cream. Cover with ABD pad daily and PRN soilage using clean/aseptic technique. CG to perform on non-skilled nurse days. Review of the SN visit documentation revealed SN visits were conducted on the following dates: 02/11/2021, 02/25/2021, 03/03/2021, 03/10/2021, 03/15/2021, 03/17/2021, 03/19/2021, 03/22/2021, and 03/24/2021. There was no documentation of a Registered Nurse assessment of the wound during the weeks of 02/21/2021 or 03/07/2021. On 05/21/2021 at 1:40 p.m., an interview was conducted with S2DON. After reviewing the clinical records for Patients #11, #12, and #17, she verified a visit was not conducted by a Registered Nurse each week to assess the patients' pressure ulcers. S2DON further verified a Registered Nurse failed to properly assess the patients' pressure ulcers during each visit by not measuring the wound each week. S2DON stated a Registered Nurse should have seen each patient with pressure ulcers at least once a week and performed an appropriate wound assessment, which included measurements of the wounds.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a registered nurse (RN), who was familiar with the patient and the patient's plan of care, made an onsite visit to the patient's home no less than every 14 days for aide supervisory visits for 2 (Patients #2 and #6) of 3 (#2, #3, #6) sampled patients' with Home Health Aide (HHA) Services out of a total sample of 17 patients. Findings: Patient #2 Review of the clinical record revealed Patient #2 was admitted to the agency on 04/08/2021 with a principal diagnosis of Other Sequelae of Cerebral Infarction. Review of the Home Health Certification and Plan of Care/485 for Certification Period of 04/08/2021 to 06/06/2021 revealed orders that included the following: HHA effective week of 04/11/2021 2W3. Review of HHA visit notes revealed documentation of the following HHA visits conducted during the current Certification Period of 04/08/2021 to present: 04/16/2021, 04/20/2021, 04/23/2021, 04/27/2021, and 04/30/2021. Review of SN visit documentation revealed no documentation of a HHA supervisory visit conducted by a registered nurse during the current Certification Period. Patient #6 Review of the clinical record revealed Patient #6 was admitted to the agency on 02/04/2021. Review of the Home Health Certification and Plan of Care/485 for Certification Period of 04/05/2021 to present revealed a primary diagnosis of Unspecified Dementia without Behavioral Disturbances. Review of a Physician's Order dated 04/20/2021 revealed the following: HHA to see patient twice weekly. 2W7. Review of HHA visit notes revealed documentation of the following HHA visits conducted during the current Certification Period of 04/05/2021 to present: 04/21/2021, 04/23/2021, 04/27/2021, 04/30/2021, 05/04/2021, 05/07/2021, 05/12/2021, and 05/14/2021. Review of SN visit documentation revealed an aide supervisory visit was not conducted until 05/12/2021. There was no other documentation of an aide supervisory visit conducted during the current Certification Period. On 05/21/2021 at 12:40 p.m., an interview was conducted with S2DON. After reviewing the clinical records for Patients # 2 and #6, S2DON verified aide supervisory visits were not conducted by a registered nurse every 14 days as required.