Louisiana Homecare of Miss-Lou

“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 for 2 (#5 and #6) of 10 (#1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) sampled patients as evidenced by: 1. No evidence was found that Patient #5 was evaluated by a PT, as ordered in the POC, and 2. No evidence was found that Patient #6 was evaluated by a MSW, as ordered in the POC. Findings: Patient #5 Review of the clinical record for Patient #5 revealed a Start of Care date of 06/07/2024. Patient #5 had a primary diagnosis of Chronic Obstructive Pulmonary Disease for the Certification Period from 02/02/2025 to 04/02/2025. Review of the Orders of Discipline and Treatments revealed the following: Physical Therapy to evaluate/assess and develop physical therapy plan of care that will be approved by the physician prior to implementation. Review of Patient #5’s calendar and visit notes revealed no evidence of the patient having been evaluated by a Physical Therapist, as of 03/06/2025. Review of Patient #5’s clinical record and interview with S1 Executive Director on 03/06/2025 at 11:45 a.m. revealed Patient #5 had not been evaluated by a Physical Therapist during this certification period, as ordered, but should have been. Patient #6 Review of the clinical record for Patient #6 revealed a Start of Care date of 02/13/2025. Patient #6 had a primary diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery for the Certification Period from 02/13/2025 to 04/13/2025. Review of the Orders of Discipline and Treatments revealed the following: Medical Social Services to evaluate/assess and develop Social Work Plan of Care that will be approved by the Physician prior to implementation. Review of Patient #6’s calendar and visit notes revealed no evidence of the patient having been evaluated/assessed by a Medical Social Worker, as of 03/06/2025. Review of Patient #6’s clinical record and interview with S1 Executive Director on 03/06/2025 at 11:45 a.m. revealed Patient #6 had not been evaluated by a Medical Social Worker during this certification period as ordered, but should have been.”

“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 patient’s physician was promptly notified when the patient’s pain level was high and outside of the physician ordered parameters for 1 (#5) of 10 (#1, #2, #3, #4, #5, #6, #7, #8, #9 and #10) sampled patients reviewed. Findings: Review on 03/06/2025 of the agency’s policy titled “Pain Assessment” with a last review date of 02/01/2024 revealed in part…A score of 7 or greater on any of the pain assessment tools below is indicative of severe pain, which will require physician/authorized practitioner notification and patient appropriate interventions….Numeric Rating Scale (0-10)…7-10=severe pain. Review of the clinical record for Patient #5 revealed a Start of Care date of 06/07/2024. Patient #5 had a primary diagnosis of Chronic Obstructive Pulmonary Disease for the Certification Period from 02/02/2025 to 04/02/2025. Physician’s orders included the following: SN 1wk9 (once per week for 9 weeks) with 2 prn visits. When vital signs are obtained, licensed professional to report vital signs falling outside the following established parameters…Pain greater than 6. Review of a visit note dated 02/04/2025 by S2 RN revealed Patient #5 reported pain of 10 on a scale of 0-10 at 8:37 a.m. Review of the visit note revealed the patient’s pain was interfering with patient’s activity, patient was unable to ambulate as easy, and pain was not relieved at an acceptable level. The visit note stated actions taken to assist patient with pain relief read “Patient has prescription ibuprofen for severe pain” and “Patient states she will take some today.” Patient #5’s clinical record was reviewed with S1 Executive Director on 03/06/2025 at 11:45 a.m. In an interview at that time, S1 Executive Director confirmed the visit note dated 02/04/2025 and clinical record revealed no documented evidence of S2 RN notifying the physician of Patient #5’s severe pain level, which was above the parameters ordered by the physician. S1 Executive Director confirmed S2 RN should have notified Patient #5’s physician of the patient’s pain level at the time of the visit, but did not.”