Ochsner Home Health of Baton Rouge

“Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This Element is not met as evidenced by: Based on record reviews and interviews, the Provider failed to ensure that 1 (#1) out of 3 (#1, #2, #3) sampled patients were free from neglect as evidenced by: 1. S4PTA and S6OT failed to notify 911 or wait for Patient #1’s caregiver to arrive at the home on 02/26/2025 when Patient #1 had an unwitnessed fall in the home. This deficient practice had the potential to affect all 501 active patients according to the agency’s current census. Findings: Review of the agency’s policy titled “Patient Abuse, Exploitation, And Neglect: Assessment, Identification, and Reporting” dated 11/02/2022 revealed the following, in part: B. Adult Neglect Failure to provide goods and/or services necessary to avoid physical harm, mental anguish, or mental illness. Review of Patient #1’s Clinical Record revealed Patient #1 was admitted to the agency on 02/04/2025, with diagnoses which included Encounter for Surgical Aftercare Following Surgery on the Digestive System and History of Falling. Review of Patient #1’s Plan of Care for Certification Period 02/04/2025 through 04/04/2025 revealed Physician orders for the following care and services, in part: Physical Therapy (PT): 2w2, 1w7 (two times weekly x 2 weeks, then one-time weekly x 7 weeks); and Occupational Therapy (OT): 2w4, 1w2 (two times weekly x 4 weeks, then one-time weekly x 2 weeks). Further review of Patient #1’s Plan of Care dated 02/04/2025 through 04/04/2025 revealed the following, in part: Safety Measures: Fall Precautions. Supporting documentation for Home Health Eligibility: Needs assistance of another person to leave place of residence; requires aid of cane, walker and wheelchair. Easily fatigued, Pain impacting mobility, unsteady gait. Physical limitation or paralysis impacting mobility ability, weakness in lower extremities causing balance or gait disturbances and/or falls. Review of Complaint log form dated 02/26/2025 revealed the following Complaint filed for Patient #1: Complainant: Patient #1’s Daughter Summary of Complaint by S1ED: CG (Caregiver) called to report S4PTA & S6OT left patient on floor. Daughter stated S4PTA called her to tell her patient was on the floor, he could hear her, but all doors & windows were locked, and he couldn’t get in. Review of findings after investigation: S1ED called and spoke with S4PTA and S6OT: S4PTA stated when they arrived at the home the patient was on the floor, they could hear her talking and calling his name. S4PTA and S6OT attempted to enter home, and all doors and windows were locked. S4PTA then called Daughter, no answer; Daughter returned call; S4PTA asked if she was close by or if he needed to call 911 and Daughter stated don’t call 911. S1ED reported S4PTA was told by Patient #1’s Daughter she was in route approximately 20 minutes away. S4PTA and S6OT left the patient’s home. On 03/05/2025 at 9:55 a.m. a home visit and interview were conducted with Patient #1, who was alone in her home. Patient #1 stated she had a fall last week but couldn’t remember the date. Patient #1 stated she has had 4 falls since admission to the agency. Patient #1 stated she was in her kitchen around 9:00 a.m. in her wheelchair, went to the half bathroom in the hall and walked with her cane into the bathroom. She stated she dropped her glasses, leaned over to pick them up, and fell landing hard on her buttocks hitting the back of her head on the wall behind her. She stated S4PTA and S6OT arrived around 10:00 a.m. for therapy. Patient #1 stated her cell phone rang but she could not get to it. Patient #1 stated she heard them outside the back door talking, so she yelled for help. She stated neither S4PTA nor S6OT responded back to her, which irritated her. She said she heard S4PTA calling her daughter, telling her “She has fallen and is on the floor”. She stated S4PTA told her daughter, “I know she’s fallen because she keeps screaming my name”. Patient #1 stated her door was locked and both S4PTA and S6OT were gone when her daughter arrived at the home. Patient #1 stated her daughter had 2 neighbors come assist her up. Patient #1 stated her daughter encouraged her to go to the ER (Emergency Room), but she refused. On 03/03/2025 at 2:40 p.m. a phone interview was conducted with S4PTA. S4PTA verified Patient #1 had a fall last week, but he could not remember the exact date. S4PTA stated he was outside Patient #1’s home, heard a radio playing really loud, and Patient #1 would not answer the door or his phone call. S4PTA stated Patient #1 was not in her recliner like usual, visible through the back door window. S4PTA stated S6OT arrived at Patient #1’s home as he was leaving the home. S4PTA stated he told S6OT there was no answer at the door, but he thought someone was yelling his name. S4PTA stated he tried to call Patient #1’s husband and he didn’t answer, so he called her daughter. He stated the daughter told him there was no way for them to get in the home and she would be there in 20 minutes with the key. S4PTA stated they left because Patient #1 didn’t sound like she was hurting, they tried to get in, and her daughter was on her way. S4PTA stated since there was no way to get in the home and he didn’t know what else to do they left the home. S4PTA stated he and S6OT did not know what the protocol was in this situation. S4PTA confirmed he should have waited at the home and called 911 and did not. On 03/05/2025 at 3:59 p.m., a phone interview was conducted with S6OT. S6OT stated she was assigned to Patient #1 for OT services and saw her last on 02/26/2025. S6OT stated when she arrived at the home, S4PTA was there. S6OT stated S4PTA told her he thought he could hear the patient yelling his name, but he was not sure. S6OT stated she could faintly hear something in the home but could not make out what it was. S6OT stated S4PTA then contacted Patient #1’s daughter, who said she was nearby and on her way to the home within 20 minutes with the key. S6OT stated all doors and windows were locked. S6OT confirmed she and S4PTA should have stayed at the home, and called the fire department when they suspected Patient #1 was on the floor and did not. S6OT confirmed it would be considered neglectful to leave Patient #1’s home when they suspected she had fallen. S6OT stated she and S4PTA decided to leave the home after calling Patient #1’s daughter and did not wait for the daughter to arrive. On 03/05/2025 at 4:00 p.m., an interview was conducted with S1ED. S1ED stated she was first aware of Patient #1’s fall incident on 02/26/2025 when Patient #1’s daughter called to file a complaint. S1ED confirmed S4PTA nor S6OT did not report Patient #1’s fall incident to the agency on 02/26/2025. S1ED stated it was just a poor decision made by S4PTA and S6OT. S1ED then confirmed S4PTA and S6OT should have called the fire department and stayed with Patient #1 until assistance arrived and did not.”

“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 interview, the agency failed to ensure each OASIS (Outcome and Assessment Information Set) was successfully transmitted to the CMS system within 30 days of completion. Findings: Review of the agency’s policy titled, “OASIS Data Capture, Transmission, Verification, Display and Report” with a revision date of 03/01/2021 revealed the following, in part: Purpose: To ensure proper OASIS data capture and transmission to state agencies and to ensure compliance with regulatory guidelines. Procedure: 2. Transmittal of OASIS data a. …All OASIS assessments completed must be transmitted within thirty (30) days of M0090 date. Review of the agency’s OASIS Final Validation Report with a submission date of 08/20/2024 revealed 58 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after the date on the record. Review of the agency’s OASIS Final Validation Report with a submission date of 09/17/2024 revealed 105 records were processed with 9 records receiving a message the record was submitted late due to a submission date of more than 30 days after the date on the record. Review of the agency’s OASIS Final Validation Report with a submission date of 09/24/2024 revealed 130 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after the date on the record. Review of the agency’s OASIS Final Validation Report with a submission date of 10/08/2024 revealed 83 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after the date on the record. An interview was conducted with S3BM on 10/15/2024 at 3:20 p.m. She reviewed the agency’s above listed OASIS validation reports and confirmed the above records were submitted late. An interview was conducted with S4OS on 10/16/2024 at 9:44 a.m. He stated he was responsible for submitting the agency’s OASIS records. He confirmed OASIS records should have been submitted within 30 days of completion.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observations during home visits, interviews, and record reviews, the agency failed to ensure each patients’ comprehensive assessment included a review of all medications the patients were currently using. The agency failed to ensure staff reconciled patients’ medications for 2 (#6 and #9) of 7 (#6, #7, #8, #9, #10, #11 and #12) patients reviewed with home visits. Findings: Review of the Agency’s Policy titled, “Monitoring Medications,” revised on 07/01/2024, revealed the following, in part: Policy: A drug regimen will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode. Purpose: All clinicians participating in the patient’s care are responsible to assist with the maintenance of accurate patient medication information throughout the episode of care. Patient #6 Review of the Clinical Record for Patient #6 revealed she began receiving services from the Home Health Agency on 06/11/2024, with current Certification Period of 10/09/2024 through 12/07/2024. A home visit was conducted with Patient #6 on 10/14/2024 at 4:00 p.m. with S5RN present in the home. Patient #6’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to her Current Medication Profile provided by the Home Health Agency: Abilify 5mg take one tablet daily was present in the home and not on the medication profile. Iron 65mg take one tablet daily was present in the home and not on the medication profile. An interview was conducted with Patient #6 during the home visit. She said she managed her own medications. She said she had been taking Abilify 5mg tablets and Iron 65 mg tablets daily for approximately one year, and was currently taking them. An interview was conducted on 10/14/2024 at 4:15 p.m. with S5RN. S5RN confirmed the above medication discrepancies during the home visit. S5RN said medications should be reconciled during every home visit. Patient #9 Review of the Clinical Record for Patient #9 revealed he began receiving services from the Home Health Agency on 09/24/2024 with current Certification Period of 09/24/2024 through 11/22/2024. A home visit was conducted with Patient #9 on 10/15/2024 at 9:00 a.m. Patient #6’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to his Current Medication Profile provided by the Home Health Agency: Gabapentin 100 mg by mouth at bedtime was present in the home and not on the medication profile. An interview was conducted with Patient #9 during the home visit. He stated he and his wife managed his medications. He stated he had been taking Gabapentin 100 mg before bed time for three months. An interview was conducted with S1ADM on 10/16/2024 at 2:00 p.m. She was notified of the medication discrepancies found during the home visits for Patient #6 and #9. S1ADM stated each patient’s medications should have been reconciled every discipline visit, and staff should have reviewed the medication bottles each visit. S1ADM verified each patients’ Medication Profile should have reflected what the patient was currently taking.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on interviews and record reviews, the agency failed to ensure Home Health Aide Supervisory Visits were conducted every fourteen days for 2 (#6 and #7) of 4 (#6, #7, #12 and #15) patients reviewed with Home Health Aide Services. Findings: Review of the agency’s policy titled, “Home Health Aide Supervision,” dated 05/01/1999, revealed the following, in part: Purpose: To define the processes associated with Home Health Aide Supervision. Policy: The Registered Nurse and/or Qualified Therapist, as appropriate, will supervise the Home Health Aides according to State and Federal Conditions of Participation to ensure the quality and appropriateness of the home health aides’ services. Procedure: Supervisory visits must be conducted at least every 14 days with or without the aide present. Patient #6 Review of Patient #6’s Clinical Record revealed she began receiving services from the agency on 06/11/2024, with prior certification period of 08/10/2024 through 10/07/2024, and current certification period of 10/09/2024 through 12/07/2024. Review of Patient #6’s Physician Ordered discipline frequency revealed she received Home Health Aide visits one time a week for one week, two times a week for two weeks and one time a week for two weeks Review of Patient #6’s Home Health Aide visits revealed she had visits completed on 08/15/2024, 08/19/2024, 08/22/2024, 08/26/2024, 08/29/2024, 09/02/2024, 09/05/2024, 09/27/2024, 09/30/2024, 10/03/2024, and 10/07/2024. Review of Patient #6’s Nursing Visit Notes dated 08/13/2024, 08/15/2024, 08/20/2024, 08/22/2024, 08/27/2024, 08/29/2024, 09/06/2024, 09/10/2024, 09/12/2024, 09/17/2024, 09/19/2024, 09/25/2024, 09/27/2024, 10/01/2024, 10/03/2024, 10/07/2024, and 10/11/2024 revealed no Home Health Aide Supervisory Visits were conducted. An interview was conducted with S2CD on 10/15/2024 at 12:00 p.m. She reviewed Patient #6’s Clinical Record and confirmed Home Health Aide Supervisory Visits had not been conducted every 14 days and should have been. Patient #7 Review of Patient #7’s Clinical Record revealed she began receiving services from the agency on 09/12/2024 with current certification period of 09/12/2024 through 11/10/2024. Review of Patient #7’s Physician Ordered discipline frequency revealed she received Home Health Aide visits twice weekly for four weeks effective 09/15/2024. Review of Patient #7’s Home Health Aide visits revealed she had visits completed on 09/16/2024, 09/20/2024, 09/24/2024, 09/27/2024, 10/01/2024, 10/04/2024, 10/08/2024, and 10/11/2024. Review of Patient #7’s Nursing Visit Notes dated 09/18/2024, 09/25/2024, 10/02/2024, and 10/09/2024 revealed no Home Health Aide Supervisory Visits were conducted. An interview was conducted with S2CD on 10/14/2024 at 10:41 a.m. She reviewed Patient #7’s Clinical Record and confirmed Home Health Aide Supervisory Visits had not been conducted every 14 days and should have been. An interview was conducted on 10/16/2024 at 2:00 p.m. with S1ADM. S1ADM confirmed Home Health Aide Supervisory Visits should have been conducted at least every fourteen days and were not.”