Lasalle Gen Hosp Home Health Agency

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review, observation, and interview, the agency failed to ensure the individualized plan of care included all pertinent diagnoses, all types of services and treatments required, and patient and caregiver education and training for 2 (#1 and #6)) of 7 sampled patients reviewed. Findings: Patient #1 Review of Patient #1’s POC (Plan of Care) revealed a start of care date of 12/18/2024 and a certification period of 10/14/2025 through 12/12/2025. Further review revealed Client #1 diagnoses were Cerebrovascular disease, Hypothyroidism, Age-related Osteoporosis without current pathological fracture, Other specified nutritional anemias, Dermatitis, and Slow transit constipation. Review of the POC revealed no diagnoses of wounds or orders for wound care. In an interview on 12/15/2025 at 11:41 a.m., S1 Director confirmed Patient #1 was receiving wound care and the wound diagnoses and wound care orders were not listed on the POC, but should have been. S1 Director stated the orders did not get carried over to the new POC from the last episode but should have been. During a home visit on 12/15/2025 at 3:15 p.m., wound care was performed by S3 RN to Patient #1’s right shoulder area. At this time, S3 RN confirmed Patient #1 also had wounds to her left hip and sacrum/coccyx area that were being treated weekly by the wound care clinic. In an interview on 12/16/2025 at 2:50 p.m., S3 RN confirmed she recertified Patient #1 and completed the POC but failed to enter the diagnoses and wound care orders for her wounds, but should have. Patient #6 Review of #6’s Home Health Care Certification and Plan of Care (485) for the certification period 04/24/2025 – 06/22/2025 reflected no care interventions, measureable outcomes listed, and no specific patient and caregiver education and training. Staff interview with S1 Director on 12/15/2025 at 3:50 p.m. revealed Patient #6’s nursing interventions were entered into the computer for the nurses’ visits while creating the Plan of Care, but they did not carry over to the 485/doctor’s orders and they should have. Interview on 12/16/2025 at 9:00 a.m. with S1 Director revealed when the assessing nurse generates a Plan of Care/485, the goals, care interventions, and outcomes have to be clicked on to carry over to the 485. S1 Director confirmed Patient #6’s 485/Plan of Care did not have goals, interventions, patient and caregiver education and training, or outcomes, and it should have. She revealed they had failed to click the button to carry them over to the 485. Interview on 05/16/2025 at 2:00 p.m. with S2 RN, revealed she was Patient #6’s home health nurse and that she was the nurse that performed the initial assessment, created the plan of care, and made all the skilled nurse visits, including the discharge visit. She revealed that she had created interventions, goals, outcomes, and patient/caregiver education and training, but must have not clicked to have them added to the 485 and she should have. S2 RN confirmed the interventions, goals, outcomes, and patient/caregiver education and training were on the Plan of Care that she followed in the home, and that the doctor did sign the 485, but she did not realize that the interventions, goals, outcome, and patient/caregiver education and training were not on the signed 485 and they should have been.”

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the revised POC (Plan of Care) reflected current information from the patient’s updated comprehensive assessment for 1 (#1) of 7 sampled patients reviewed. Findings: Review of Patient #1’s POC (Plan of Care) revealed a start of care date of 12/18/2024 and a certification period of 10/14/2025 through 12/12/2025. Further review revealed Client #1 diagnoses were Cerebrovascular disease, Hypothyroidism, Age-related Osteoporosis without current pathological fracture, Other specified nutritional anemias, Dermatitis, and Slow transit constipation. Further review of Patient #1’s POC revealed interventions that included physical therapy and speech language pathology therapy. Review of the visit notes revealed no visits made by physical therapy or speech therapy. In an interview on 12/15/2025 at 11:41 a.m., S1 Director stated Patient #1 last received speech therapy in 05/2025 and physical therapy in 01/2025. S1 Director confirmed the speech and physical therapy orders were carried over from a previous episode by the nurse writing the POC. S1 Director confirmed the nurse should have removed the speech and physical therapy interventions, but had not. In an interview on 12/16/2025 at 2:50 p.m., S3 RN confirmed Patient #1 was no longer receiving physical or speech therapy services. S3 RN stated those were old orders that she should have removed when recertifying the patient, but did not.”