Every finding on record at The Good Shepherd Home Health Agency , Inc.

Home Health Care 2000- Lake Charles is in compliance with the federal emergency preparedness requirements.

Recertification Survey

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient's written individualized POC (plan of care) was followed as evidenced by the PT (Physical Therapy) failing to make visits as ordered per POC for patient (#1), the SN (Skilled Nurse) failing to follow the physician’s wound care/treatment orders for patient (#4) and failing to ensure the SN weighed patient (#5) per the POC for 3 (#1 , #4, #5) out 7 sampled patients. Patient 1: Review of the Patient #1’s electronic clinical record revealed the start of care date was 11/03/2022. The patient’s diagnoses included Osteoarthritis of right ankle and foot, Right foot Hallux rigidus, Sciatica, and Pain right foot and left hip. Review of the patient’s POC for the certification period 04/26/2024 to 06/24/2024 revealed an order for “PT (physical therapy) evaluate and treat balance problems.” Review of the patient’s electronic clinical record revealed a patient communication note dated 05/13/2024 read in part, “…chart audit review done cert period 04/26/2024 -06/24/2024, physical therapy not available week of 04/29/2024, and week of 05/06/2024 due to physical therapy not available until week of 05/12/2024 for re-evaluation for physical therapy needs. “ On 05/20/24 at 12:30 p.m., Patient #1 stated that she had not received visits from the physical therapist for the last few weeks. She stated that the therapist did not call to let her know when she was not making the visit. On 05/20/2024 AT 3:30 p.m., S1ADM/DON (Administrator/Director of Nursing) stated that the previous physical therapist resigned on 04/14/2024 and the agency had not obtained a contract for physical therapy services until 05/04/2024. After review of the patient’s visit schedule, S1 ADM/DON confirmed that Patient #1 had not received her PT visits as per her POC for the week of 04/29/2024 and the week of 05/06/2024. 1. Patient #4. Review of the patient’s electronic clinical records revealed the start of care date was 04/25/2024. The patient’s diagnosis included Infection Due to Peritoneal Dialysis Catheter and Diabetes. The certification period reviewed was 04/25/2024 to 06/23/2024. Review of the patient’s POC for certification period 04/25/2024 to 06/23/2024 revealed an order for “SN 2w1, 3w8 (skilled nurse visit two times a week for one week, three visits a week for eight weeks).” Further review of the patient’s POC revealed an order for “…SN to perform… the following wound care daily: Clean abdominal wound with NS (normal saline) and gauze, pack wound with wet to dry and cover with dry dressing…” New wound care orders dated 05/02/2024 revealed, “SN to perform… clean abdominal incision with NS and cover with dry dressing daily.” Review of the patient’s skilled nurse visit notes dated 05/04/2024 and 05/11/2024 revealed, “… Cleansed abdomen with saline and gauze… Pack with moistened gauze, covered with dry gauze and abd (abdominal) pad, secured with tape…” Review of the physician’s orders dated 05/02/2024 revealed the orders changed from packing the wound with wet to dry to cleaning the wound with normal saline and cover with dry dressing. The SN did not follow the wound care/treatment orders on 05/04/2024 and 05/11/2024. On 05/20/2024 at 12:52 p.m., a telephone interview was conducted with S2LPN (Licensed Practical Nurse). S2LPN confirmed she was packing the wound with moistened gauze and covering with dry dressing for the skilled nurse visits conducted on 05/04/2024 and 05/11/2024. On 05/20/2024 at 1:25 p.m., an interview was conducted with S1ADM/DON (Administrator/Director of Nursing). She reviewed the patient’s electronic clinical record and confirmed that S2LPN did not follow the physician’s orders for wound care. 2. Patient #5. Review of the patient's electronic clinical record revealed the start of care date was 12/27/2023. The patient's diagnosis included Heart Failure. The certification period reviewed was 04/25/2024 to 06/23/2024. Review of the patient's POC for certification period 04/25/2024 to 06/23/2024 revealed an order for skilled nurse 1wk9 (skilled nurse visit one time a week for nine weeks). Further review of the patient's POC revealed an order for, "Nurse to… assess weight weekly (patient’s own scale if available). Notify physician with unexplained weight gain of 3 or more pounds in one day and weight gain of 5 lbs (pounds) or more within one week. Nurse to obtain measurements from left and right lower ankle or calf circumference each visit when patient is not able to weigh. Notify RN (Registered Nurse), physician with increase of 3 cm (centimeters)…” Review of the patient's SN visit notes dated 04/26/2024, 05/10/2024, and 05/17/2024 revealed there was no evidence the patient's weight was obtained by the skilled nurse. On 05/20/2024 at 2:10 p.m., a telephone interview was conducted with S3LPN. S3LPN confirmed she did not obtain the patient’s weight and did not measure the patient’s ankles or calf circumference for the skilled nurse visits made on 04/26/2024, 05/10/2024, and on 05/17/2024. On 05/20/2024 at 2:12 p.m., an interview was conducted with S1ADM/DON. S1ADM/DON stated S3LPN should have weighed or measured the patient’s ankles or calf circumference as ordered per the POC.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the physician was informed of patient’s complaint of pain of 8 on pain scale 0-10 for 1 (#4) out of 7 sampled patients. Patient #4. Review of the patient’s electronic clinical records revealed the start of care date was 04/25/2024. The patient’s diagnosis included Infection Due to Peritoneal Dialysis Catheter and Diabetes. The certification period reviewed was 04/25/2024 to 06/23/2024. Review of the patient’s POC for certification period 04/25/2024 to 06/23/2024 revealed an order for “SN 2w1, 3w8 (skilled nurse visit two times a week for one week, three visits a week for eight weeks).” The POC included orders to, “Report to physician pain greater than 7 on 0-10 scale…” Review of the patient’s skilled nurse visit note dated 04/27/2024 revealed under the pain section of the note, the patient’s pain intensity was 8 on a pain scale of 0-10 with 10 being the worst pain. Further review of the patient’s electronic clinical record revealed no evidence the physician was informed of the patient’s pain. On 05/20/2024 at 12:52 p.m., a telephone interview was conducted with S2LPN (Licensed Practical Nurse). S2LPN confirmed she did not recall informing the physician of the patient’s pain intensity of 8. On 05/20/2024 at 1:25 p.m., an interview was conducted with S1ADM/DON (Administrator/Director of Nursing). S1ADM/DON reviewed the patient’s electronic clinical record and confirmed there was no evidence the skilled nurse informed the physician of the patient’s pain.

Recertification Survey A COVID-19 Focused Infection Control Survey was conducted on 7/8/2021. 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: 100 Unduplicated admissions census: 190

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 #2 that an OT (Occupational Therapy) evaluation was done as ordered per the POC (Plan of Care) and; 2. No evidence found for Patient #3 that the physician was notified for CBG (Capillary Blood Glucose) levels that were outside the parameters listed on the POC and; 3. No evidence found for Patient #5 that the skilled nurse assessed the patient's weight weekly as ordered per the POC during the skilled visits on 6/24/2021 and 7/1/2021 and; 4. No evidence found for patient #8 that the skilled nurse visits were made as ordered for the weeks of 5/16/2021, 5/23/2021 and 5/30/2021 per the POC for 4 (#2, #3, #5, #8) out of 8 sampled patients. Findings: 1. Patient #2. Review of the patient's clinical record revealed the start of care date was 6/5/2021. The patient's admitting diagnoses included Trauma Subdural Hemorrhage Without Loss of Consciousness and History of Falling. The certification period reviewed was 6/5/2021 to 8/3/2021. Review of the patient's POC for the certification period 6/5/2021 to 8/3/2021 revealed an order for OT (Occupational Therapy) evaluation and treatment. Review of the patient's clinical record, revealed that there was no evidence that an OT evaluation was done by OT. On 7/7/2021 at 2:08 pm, an interview was conducted with S2DON (Director of Nurses). S2DON stated that the order for an OT evaluation was not sent to OT and she confirmed that the OT evaluation was not done as ordered per the POC. 2. Patient #3. The patient was admitted to the agency on 6/1/2021 with a primary diagnosis of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The certification period reviewed was 6/1/2021 to 7/30/2021. Review of the patient's plan of care revealed an order for nurse to obtain blood glucose level each visit and to notifiy the physician of after meal blood sugars over 200 or under 80. Review of the skilled nursing visit note dated 6/29/2021 revealed a documented non-fasting blood sugar of 244. Further review of the patient's clinical record failed to reveal any evidence that the patient's physican had been notified of the elevated blood sugar as ordered. During an interview on 7/7/21 at 2:55 PM, S1Adm (Administrator) confirmed that the patient's physician should have been notified on 6/29/21 as per the patient's plan of care. 3. Patient #5. Review of the patient's clinical record revealed that the patient's start of care date was 10/21/2020. The patient's admitting diagnoses included Dementia Without Behavioral Disturbance, Hemiplegia Following Cerebral Infarction, and Heart Failure. The certification period reviewed was 6/18/2021 to 8/16/2021. The patient's POC was reviewed and revealed the following order - SN (skilled nurse) 1d1, 1w8 (skill nurse visit for one day, skill nurse visit one time a week for eight weeks.) Further review of the POC revealed an order for the "nurse to observe and assess weight weekly ... notify physician with unexplained weight gain of 3 or more pounds in one day and weight gain of 5 lbs or more within one week ..." Review of the patient's SN visit notes dated 6/24/2021 and 7/1/2021 revealed no evidence that the patient's weight was obtained. On 7/8/2021 at 10:10 am, a telephone interview was conducted with S3LPN (Licensed Practical Nurse). S3LPN confirmed that she made the SN visits on 6/24/2021 and on 7/1/2021 and confirmed that that the patient had a diagnosis of Heart Failure. S3LPN stated that she did not weigh or measure arm or leg circumference on the patient to assess if the patient had weight gain. On 7/8/2021 at 10:15 am, S2DON confirmed that the patient had a diagnosis of Heart Failure and confirmed that the patient's POC had orders for the nurse to weigh the patient weekly. S2DON confirmed that there was no evidence that the patient was weighed weekly or assessed for weight gain as ordered per the POC. 4. Patient #8. The patient was admitted to the agency on 3/5/2021 with a primary diagnosis of Non-pressure Chronic Ulcer of Right Ankle Limited to Breakdown Skin. The certification period reviewed was 5/4/2021 to 7/2/2021. Review of the patient's plan of care revealed an order for nurse to perform wound care every other day except days patient goes to wound care. Review of the patient's clinical record revealed a missed visit note dated 5/17/2021 that stated he will be going to the wound care center tomorrow (5/18/2021). Review of the patient's skilled nurse visits revealed that a visit was made on Wednesday, 5/19/2021 to perform wound care which was the following day after the patient had a wound care clinic appointment. Further review of the patient's skilled nurse notes revealed that visits were conducted on Wednesday, 5/27/2021 and Wednesday, 6/3/2021 which were days immediately following the patient's wound care clinic appointments. During an interview on 7/7/2021 at 1:05 PM with S2DON (Director of Nurses) stated that the patient typically went to the wound care clinic on Tuesdays. She stated that the skilled nurse visits on 5/19/2021, 5/26/2021 and 6/2/2021 occurred one day too soon. She confirmed that the patient went without wound care for 48 hours at a time due to the visits occurring too soon.

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 between ST (Speech Therapy) and the nursing staff to inform the physician concerning the patient's drooling for 1 (patient #2) out of 8 sampled patients. (#2) Findings: Patient #2. Review of the patient's clinical records revealed the start of care date was 6/5/2021. The patient's admitting diagnosis included Trauma Subdural Hemorrhage Without Loss of Consciousness. The certification period reviewed was 6/5/2021 to 8/3/2021. Review of the patient's POC (plan of care) for certification period 6/5/2021 to 8/3/2021 revealed an order for "SN (skilled nurse) 1w8, 1w1 (skilled nurse visit one time a week for eight weeks, one visit a week for one week)." Also, the POC revealed an order for ST (speech therapy) "ST eval and treat". Review of the ST evaluation dated 6/9/2021 revealed an order "ST 3w4 (speech therapy three times a week for four weeks)". Review of the patient's Speech Therapy visit notes dated 6/16/2021 revealed, " ...ST requests nursing to notify physician of patient's drooling." There was no evidence found in the patient's medical record that the physician was notified concerning the patient's drooling. On 7/8/2021 at 10:15 am, an interview was conducted with S2DON (Director of Nurses). S2DON stated that there was no evidence that ST notified the nursing staff concerning the patient's drooling. Also, S2DON confirmed that there was no evidence that the physician was informed of the patient's drooling.