Southeast Louisiana Home Health, LLC

“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 interviews, the agency failed to encode and electronically transmit each completed OASIS (Outcome and Assessment Information Set) as evidenced by failing to ensure the agency successfully completed and transmitted OASIS data within 30 days of completion of the assessment of the beneficiary. Findings: Review of CMS’s (Center for Medicare and Medicaid Services) Standard Regulation Text titled “CFR (Code of Federal Regulations) Section 484.45(a)” revealed: A home health agency 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. Review of the agency’s OASIS Error Report dated 10/01/2023 to 05/03/2024 revealed 36 records with Error code-3330 were submitted more than 30 days after the date of completion on the record, which was late. An interview was conducted on 05/09/2024 at 3:04 p.m. with S4ADON and the agency’s Oasis Error Report dated 10/01/2023-05/02/2024 was reviewed. S4ADON stated she was responsible for submitting all of the agency’s Oasis assessments. S4ADON confirmed the 36 in total Oasis assessments, dated from 10/24/2023-02/07/2024 with Error code-3330 had submissions greater than 30 days from the completion date and were late. An interview was conducted on 05/09/2024 at 4:15 p.m. with S1ADM and the aforementioned Oasis Error Report was reviewed. S1ADM confirmed the 36 in total Oasis assessments, dated from 10/24/2023-02/07/2024 with Error code-3330 had submissions greater than 30 days from the completion date and were late.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observations, interviews and record reviews, the HHA failed to ensure staff followed accepted standards of infection control practices for 2 (#1 and #2) of 7 (#1, #2, #3, #4, #5, #6, and #7) patients observed during home visits. The agency staff failed to: 1. Ensure staff used proper hand hygiene, properly used a bag barrier, and disinfected reusable equipment used during Patient #1’s home visit; and, 2. Practice proper hand hygiene and glove use while providing wound care and PICC (Peripherally Inserted Central Catheter) site care to Patient #2. Findings: Review of the undated Agency’s Infection Control Education/Training Policy included the following, in part: Policy: All employees and contractors who have contact with clients in the client’s residence shall complete in-service training about infection control practices to be used in the home. Special Instructions: 1. Infection control training will include the following information: f. Aseptic technique (if applicable to position and responsibilities). g. Standard precautions: Hand washing techniques. i. Cleaning of equipment and devices: Disinfecting reusable equipment. Review of the undated Agency’s Hand Hygiene Policy included the following, in part: Policy: In an effort to reduce the risk for infection in clients and staff members, through hand washing/hand antisepsis is required for all employees. Special Instructions: 3. Indications for hand washing and hand antisepsis: b. Before and after direct patient care. c. After removing gloves. d. After touching objects that are potentially contaminated. i. When hands are visibly soiled. 1. Review of the clinical record revealed Patient #1 had a SOC date of 04/16/2024. The patient’s current diagnoses included Non-displaced Fracture of Medial Malleolus of Left Tibia, Subsequent Encounter for Routine Healing. A review of the 485/Plan of Care for the certification period of 04/16/2024-06/14/2024 revealed Orders and Treatments which included the following: Skilled Nurse: 1w9 and Home Health Aide: 1w9. A visit was conducted in the home of Patient #1 on 05/07/2024 at 8:33 a.m. with S2LPN present. S2LPN placed his bag on Patient #1’s living room floor, without any barrier between his bag and floor. Without performing hand hygiene, S2LPN retrieved his reusable equipment from his bag, and donned gloves to obtain Patient #1’s vital signs. After vital signs were obtained, S2LPN returned the equipment to his bag without disinfecting or cleaning the reusable blood pressure cuff, pulse oximeter or thermometer. On 05/07/2024 at 8:45 a.m., S5CNA arrived at Patient #1’s home while the home visit with S2LPN was in progress. S5CNA placed her bag on Patient #1’s living room floor without any barrier used between the bag and floor. Without performing hand hygiene, S5CNA retrieved her reusable equipment from her bag. S5CNA performed Patient #1’s vital sign assessment, and returned a blood pressure cuff, thermometer, and pulse oximeter back into her bag without disinfecting or cleaning the reusable equipment. An interview was conducted on 05/07/2024 at 9:15 a.m. with S2LPN. S2LPN confirmed the above observations. S2LPN stated S2LPN and S5CNA should have placed a barrier on the floor between the bag and the floor and did not. S2LPN confirmed S2LPN and S5CNA should have performed hand hygiene prior to patient care, prior to donning gloves, and after doffing gloves, and did not. S2LPN confirmed S2LPN and S5CNA should have cleaned the reusable equipment after use, prior to returning to their bag, and did not. An interview was conducted on 05/09/2024 at 4:15 p.m. with S1ADM. S1ADM confirmed nursing and direct care staff should place a barrier between their bag and other surfaces upon entry into a patient’s home. S1ADM confirmed all staff should perform hand hygiene prior to entering their bag, before and after patient care. S1ADM confirmed all staff should clean all reusable equipment before returning the equipment back into their bag. 2. Review of the clinical record revealed Patient #2 had a SOC date of 04/05/2024. The patient’s current diagnoses included Dislocation of Internal Right Hip Prosthesis, Subsequent Encounter, Streptococcus Group B Causing Diseases Classified Elsewhere, and Sepsis, Unspecified. A review of the 485/Plan of Care for the certification period of 04/05/2024 – 06/03/2024 revealed Orders and Treatments which included the following: Skilled Nurse: 1w1, 3w1, 2w2. On 05/07/2024 at 9:45 a.m., a visit was conducted in the home of Patient #2 with S3RN present. After S3RN was observed obtaining Patient #2’s vital signs, S3RN removed Patient #2’s wound vac dressing from his right hip surgical wound. Without removing soiled gloves or performing hand hygiene, S3RN touched a clean, opened 4x4 gauze packet, and wound cleanser bottle. S3RN sprayed the surgical hip wound, wiped the entire wound with multiple 4x4 gauzes, and reached into the clean 4x4 gauze packet 4 times with soiled gloves. Then without removing soiled gloves or performing hand hygiene, S3RN touched her computer, used her camera to take picture of the wound, placed her computer back down on TV stand, and grabbed the clean, unopened wound vac drape dressing and supplies, and placed scissors on the patient’s bed pad. Then without removing soiled gloves or performing hand hygiene, S3RN opened a skin prep packet, wiped the peri-wound, opened one vac drape package, opened a Calcium Alginate dressing package, cut black foam from the vac drape package with scissors, and applied Calcium Alginate dressing to the surgical wound. S3RN then covered Patient #2’s right hip surgical wound with vac drapes. Then without removing soiled gloves or performing hand hygiene, S3RN applied more vac drape, changed the vac container, touched the wound vac device’s screen to resume vac therapy at 125mmHg continuous, and removed and discarded the soiled gloves. Then without performing hand hygiene, S3RN wiped her hands on her scrub jacket and pants. S3RN reapplied gloves without performing hand hygiene and began to lift Patient #2’s Right PICC dressing. S3RN discarded the soiled gloves, without performing hand hygiene, S3RN opened a sterile Central line dressing kit and donned the sterile gloves within kit. S3RN removed the soiled PICC dressing, and then without removing soiled gloves or performing hand hygiene, S3RN cleaned the PICC insertion site, applied a new biopatch to the PICC insertion site, and covered site with a new dressing. Then S3RN removed her soiled gloves and without performing hand hygiene, reached into her bag, retrieved two lab tubes, 2 small labels, normal saline and heparin syringes, and green caps in preparation to obtain labs. An interview was conducted on 05/07/2024 at 12:20 p.m. with S3RN. S3RN confirmed she had not performed hand hygiene or glove changes during the wound vac dressing change after touching soiled items and before touching clean items and should have. S3RN confirmed she had not performed hand hygiene before or after removing the old PICC dressing and should have. S3RN confirmed she should have performed hand hygiene, donned gloves to remove the old PICC dressing first, and perform hand hygiene before applying new sterile gloves to complete PICC care and did not. S3RN confirmed she should have performed hand hygiene before retrieving supplies from her bag and did not. An interview was conducted on 05/09/2024 at 4:15 p.m. with S1ADM. S1ADM confirmed S3RN should have performed hand hygiene prior to donning gloves, and performed glove changes with hand hygiene before and after cleaning Patient #2’s surgical wound, and before touching clean wound care and other medical supplies. S1ADM confirmed S3RN should have performed hand hygiene before donning gloves to remove Patient #2’s old PICC dressing, before donning sterile gloves to perform PICC line care, and before touching clean supplies.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observations and interviews, the agency failed to provide the patient and his or her caregiver written information regarding the patient’s medication regimen based on results of the medication review conducted for 3 (#3, #4, and #6) of 7 (#1, #2, #3, #4, #5, #6, and #7) patients reviewed with home visits. Findings: Review of the Agency’s undated policy titled “Medication Reconciliation” revealed, in part: Special Instructions: 1. At the time of admission to the home care agency, the admitting professional will document a complete list of medications taken by the client. Documentation of these medications will be listed on a Medication profile. 3. The admission professional will review this medication list with the physician/allowed non-physician practitioner. This will generate a reconciled list of current medications and a copy should be provided to the client. Patient #3 Review of the clinical record revealed Patient #3 had a SOC date of 02/24/2023. The patient’s current diagnoses included Radiculopathy, Lumbar Region, Chronic Pain Syndrome, and Chronic Obstructive Pulmonary Disease, Unspecified. A review of the 485/Plan of Care for the certification period of 04/19/2024-06/17/2024 revealed Orders and Treatments which included the following: Skilled Nurse: 1w8 and Physical Therapy: 2w3. Review of the Skilled Nurse calendar revealed Skilled Nurse visits were completed on 04/25/2024, 04/30/2024, and scheduled for 05/10/2024 and 05/13/2024. Review of the Physical Therapy calendar revealed visits were completed on 04/22/2024, 04/25/2024, 04/29/2024, 05/02/2024, and scheduled for 05/07/2024. A Home Visit was conducted on 05/07/2024 at 11:15 a.m., with Patient #3 and S6PT present. Observation of Patient #3’s home folder, with the patient’s permission, revealed no medication list was available for Patient #3. On 05/07/2024 at 11:20 a.m., an interview was conducted with S6PT. S6PT stated the agency expected all nursing and therapy staff to reconcile a patient’s medications at every visit. S6PT confirmed the aforementioned observation, and stated a reconciled medication list for Patient #3 should have been in the home folder and was not. Patient #4 Review of the clinical record revealed Patient #4 had a SOC date of 04/16/2024. The patient’s current diagnoses included Non-Displaced Fracture of Medial Malleolus of Left Tibia, Subsequent Encounter, Laceration Without Foreign Body of Nose, Subsequent Encounter, and Cervicalgia. A review of the 485/Plan of Care for the certification period of 04/16/2024-06/14/2024 revealed Orders and Treatments which included the following: Skilled Nurse: 1w9 and Physical Therapy: 2w3, 1w1. Review of the Skilled Nurse calendar revealed Skilled Nurse visits were completed on 04/16/2024, 04/23/2024, 04/28/2024, and scheduled 05/07/2024. Review of the Physical Therapy calendar revealed Physical Therapy visits were completed on 04/22/2024, 04/25/2024, 04/29/2024, 5/02/2024, and scheduled 05/07/2024. A Home Visit was completed on 05/07/2024 at 11:30 a.m. with Patient #4, her private sitter, and S2LPN present. Observation of Patient #4’s home folder, with the patient’s permission, revealed no medication list was available for Patient #4. On 05/07/2024 at 11:35 a.m., an interview was conducted with S2LPN. S2LPN stated the agency expected all nursing and therapy staff to reconcile a patient’s medications at every visit. S2LPN confirmed the aforementioned observation and stated a reconciled medication list for Patient #4 should have been in the home folder and was not. Patient #6 Review of the clinical record revealed Patient #6 had a SOC date of 04/20/2024. The patient’s current diagnoses included Fracture Unspecified Part of Neck of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing. A review of the 485/Plan of Care for the certification period of 04/20/2024-06/18/2024 revealed Orders and Treatments which included the following: Skilled Nurse: 1w3, Physical Therapy: 1w1, 2w3, and Occupational Therapy: 1w2, 2w2. Review of the Skilled Nurse calendar revealed Skilled Nurse visits were completed on 04/20/2024, 04/23/2024, 05/01/2024, and scheduled for: 05/07/2024, 05/15/2024, 05/22/2024, 05/29/2024, and 06/05/2024. Review of the Physical Therapy calendar revealed Physical Therapy visits were completed on 04/20/2024, 04/23/2024, 04/25/2024, 04/29/2024, 05/02/2024, and scheduled for 05/06/2024 and 05/09/2024. Review of the Occupational Therapy calendar revealed Occupational Therapy visits were completed on 04/20/2024, 04/24/2024, 05/01/2024, 05/03/2024, and scheduled for 05/08/2024, and 05/10/2024. A Home Visit was completed on 05/08/2024 at 1:30 p.m. with Patient #6 and S7OT present. Observation of Patient #6’s home folder, with the patient’s permission, revealed no medication list was available for Patient #6. On 05/07/2024 at 1:35 p.m., an interview was conducted with S7OT. S7OT stated the agency expected all nursing and therapy staff to reconcile a patient’s medications at every visit. S7OT confirmed the aforementioned observation, and stated a reconciled medication list for Patient #6 should have been in the home folder and was not. On 05/09/2024 at 4:15 p.m., an interview was conducted with S1ADM and the aforementioned observations was reviewed. S1ADM confirmed all nursing and therapy staff should complete medication reconciliation at each home visit, and a reconciled medication list should be provided to all patients and available in the home folder and was not.”