Lourdes Home Health

“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 SN (Skilled Nurse) failing to make visits as ordered for 2 (#4 and #12) of 17 sampled patients. Findings: Patient #4 Review of the patient’s electronic clinical record revealed the start of care date was 11/23/2025. The patient’s diagnosis included acute kidney failure. The certification period reviewed was 11/23/2025 to 1/21/2026. Review of the patient’s POC for certification period 11/23/2025 to 1/21/2026 revealed an order for “SN 6wk1,3wk2,1wk6 (skilled nurse visit 6 times a week for one week, 3 times a week for 2 weeks, 1 time a week for 6 weeks)”. Review of the patient’s skilled nurse visit notes for the week of 11/23/2025 to 11/29/2025 revealed he received 4 of 6 skilled nurse visits ordered for that week. Patient #12 Review of the patient’s electronic clinical record revealed the start of care date was 11/11/2025. The patient’s diagnosis included muscle wasting and atrophy. The certification period reviewed was 11/11/2025 to 1/9/2026. Review of the patient’s POC for certification period 11/11/2025 to 1/9/2026 revealed an order for “SN 3wk1,1wk8 (skilled nurse visit 3 times a week for one week, 1 time a week for 8 weeks)”. Review of the patient’s skilled nurse visit notes for the week of 11/11/2025 to 11/15/2025 revealed she received 1 of 3 skilled nurse visits ordered for that week. On 12/03/2025 at 8:45 a.m., an interview and record review was conducted with S1ED (Executive Director). She confirmed that patient #4 had orders for SN visits 6 times a week for week 1, but only received 4 visits that week. She confirmed patient #12 had orders for SN visits 3 times a week for week 1, but only received 1 visit that week.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure Patient #3’s physician was notified of a four-pound weight gain in one day that was noted by the skilled nurse during the skilled nurse visit made on 11/24/2025 for 1 (#3) out of 17 sampled patients. Patient #3. Review of the patient’s electronic clinical record revealed the start of care date was 11/23/2025. The patient’s diagnoses included infection/inflammation reaction due to cardiac valve prosthesis and chronic diastolic congestive heart failure. The certification period reviewed was 11/23/2025 to 01/21/2026. Review of the patient’s POC (Plan of Care) for certification period 11/23/2025 to 01/21/2026 revealed the following order, SN 2wk1, 1wk8, 2 prns for… cardiac complications… (skilled nurse visit two times a week for one week, one visit a week for eight weeks, two visits as needed for cardiac complications). Further review of the POC revealed, “Skilled nurse to obtain weight every visit and notify RN (Registered Nurse)/physician of weight gain of 3 lbs (pounds) within one day or 5 lbs within one week.” Review of the patient’s SN Visit Note dated 11/23/2025 revealed the patient’s weight was 200 pounds. Review of the patient’s SN Visit Note dated 11/24/2025 revealed the patient’s weight was 204 pounds, which was a four-pound weight gain in one day. There was no evidence the SN, which was a RN, notified the physician of the patient’s four-pound weight gain in one day. On 12/02/2025 at 10:52 a.m., a telephone interview was conducted with S2RN. S2RN reviewed Patient #3’s electronic clinical record and she verified the patient had a four pound weight gain in one day. S2RN confirmed she did not notify the patient’s physician of the four pound weight gain. S2RN stated that she should have notified the physician concerning the weight gain. On 12/02/2025 at 1:20 p.m., an interview was conducted with S1ED (Executive Director). S1ED reviewed Patient #3’s clinical record and she confirmed the patient had a four pound weight gain in one day. S1ED confirmed there was no evidence the physician was notified of the patient’s weight gain. Also, S1ED stated that S2RN should have notified the patient’s physician of the weight gain.”