Excellent Home Health Care, LLC

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop emergency preparedness policies and procedures which addressed the use of volunteers in an emergency. Findings: Review of the agency’s Emergency Preparedness Plan revealed no documented evidence and the agency presented no documented evidence that the agency had policies and procedures which addressed the use of volunteers in an emergency or emergency staffing strategies. In an interview on 03/08/2024 at 3:50 p.m., S3Registered Nurse indicated the agency did not have a policy or procedure for the use of the volunteers and/or emergency staffing strategies in the event of an emergency. In an interview on 03/08/2024 at 4:30 p.m., S1Administrator acknowledged the agency did not have a policy or procedure for the use of the volunteers and/or emergency staffing strategies in the event of an emergency.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(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 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 §484.80(g), must make an onsite visit to the patient’s home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure the Home Health Aide (HHA) is supervised every 14 days by the registered nurse (RN) for 2(Patient #1 and Patient #7) of 2 patients (Patient #1 and Patient #7) receiving Home Health Aide services in a total sample of 7 patients. Findings: Patient #1 Review of Patient #1’s records revealed an admission date of 12/17/2019 with diagnoses in part; diabetes mellitus type II, neurogenic bladder, and neuropathy. Review Patient #1’s Plan of Care for certification period 01/25/2024 - 03/24/2024 revealed a doctor’s order for home health aide services and skilled nursing once in the first week and four per week for 8 weeks. Further review revealed no documentation of HHA supervisory visits by a registered nurse from 01/25/2024 – 03/07/2024. Patient #7 Review of Patient #7’s records revealed an admission date of 07/23/2023 with diagnoses in part; cerebral stroke, dysarthria, and the presence of a tracheostomy and a percutaneous endoscopic gastrostomy (PEG). Review Patient #7’s Plan of Care for certification period 11/10/2023 - 01/08/2024 revealed a doctor’s order for HHA services and skilled nursing once in the first week; twice per week for next two weeks; and then once per week for the next four weeks. Further review revealed no documentation of HHA supervisory visits by a registered nurse from 11/10/2023 – 01/08/2024. In an interview on 03/07/2024 at 2:22 p.m., S2Director of Nursing (S2DON) indicated the agency did not perform RN supervisory HHA visits every 14 days.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure a registered nurse(RN) assessed and measured pressure ulcers and wounds weekly for 1 (Patient #2) of 2 (Patient #2 and Patient #6) patients records reviewed for pressure ulcers and wounds in a sample of 7 patients. Findings: Review of the Wound Ostomy and Continence Nurses Society’s Guidelines revealed assessment and documentation of wound status, which includes comprehensive clinical data demonstrating evidence of progress in healing or failure to heal. Comprehensive wound assessment includes: dimensions and depth; presence, location and depth of any sinus tracts or undermining areas; status and characteristics of the wound bed; volume, color, and odor of exudates; evidence of infection in surrounding tissues. Further review revealed when recorded over time this information can be used to track the progress of wound healing. Review of the Louisiana State Board of Nursing Declaratory Statement Scope of Practice for Registered Nurses Wound Care Management revealed, in part: the registered nurse may delegate to a LPN (Licensed Practical Nurse) wound care if the RN had deemed the wound stable; and provides appropriate supervision. Review of Patient #2’s Home Health Certification and Plan of Care for certification period of 01/01/2024 to 02/29/2024 and 03/01/2024 to 04/29/2024 revealed Patient #2 was to receive skilled nursing services three times per week for 5 weeks; then once for one week; then two times per week for two weeks. Further review revealed skilled nurse to provide in part, dressing change and wound/pressure ulcer care. Review of Patient #2’s Skilled Nursing Visit Note Reports revealed S4LPN measured wounds weekly form 01/01/2024 to 01/29/2024, and no measured wounds after 01/29/2024. Further review of Patient #2’s Skilled Nursing Visit Note Reports revealed no documentation of any RN visits with wound/pressure ulcer documentation. Review of Patient #2’s RN Recertification Oasis Reports dated 02/02/2024 and 02/29/2024 revealed no documentation of wounds/pressure ulcers, and the provider did not present any documentation related to wounds/pressure ulcers In an interview on 03/08/2024 at 10:00 a.m., S2Director of Nursing (DON) indicated S4LPN measured wounds for all patients in his care, and was not aware that RNs had to measure wounds weekly. S2DON acknowledged the agency did not have any documentation of wound/pressure ulcer measurements or staging by an RN for Patient #2.”