Family Home Health Agency

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observations, interviews, and record reviews, the agency failed to ensure nursing staff followed accepted standards of practice to prevent the transmission of infections and communicable diseases for 1(#3) of 3 patients observed during home visits. The agency failed to ensure nursing staff performed proper glove changes and hand hygiene during Patient #3’s wound care. Findings: Review of the agency’s revised policy dated 09/01/2022 and titled “Section 4: Infection Control” revealed, in part: Infection Control Program The Infection Control Program will be the responsibility of the Agency’s leaders and will include the following: To comply with current applicable local, state, and regulatory body regulations, including OSHA and CDC guidelines and other applicable regulations. Review of the Centers for Disease Control and prevention (CDC) guidelines at www.cdc.gov Hand Hygiene and Glove use recommendations included, in part: 1. Indications for handwashing and hand antisepsis: C. Decontaminate hands before having direct contact with patients. E. Change gloves during patient care if moving from a contaminated body site to a clean body site. G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled. H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care. Review of Patient #3’s clinical record revealed a start of care date of 03/22/2024, and diagnoses, which included in part, Stage 2 Pressure Ulcer Right Calf and Stage 2 Pressure Ulcer Right Ankle as of 12/18/2025. A home visit was conducted with Patient #3 on 01/06/2026 at 11:40 a.m. with S1ADM. An observation was made of S1ADM performing wound care to Patient #3’s right calf and right ankle Stage 2 pressure ulcer wounds. S1ADM performed hand hygiene, placed clean gloves on and removed the old dressings to the patient’s right calf and right ankle and discarded them in a biohazard bag at bedside. Without removing gloves, performing hand hygiene, or changing gloves, S1ADM touched his pants, pen, measure tape, measured Patient #3’s wounds, and took pictures with his phone. S1ADM returned the measure tape and pen to his bag, then assisted Patient #3s caregiver to turn and position the patient for incontinence care. With the same pair of gloves, S1ADM then touched the patient’s bed rails, bed control, opened a wash cloth packet, and touched the clean bed linens. S1ADM then removed his gloves, performed hand hygiene, and new gloves were applied. S1ADM removed Patient #3’s left foot dressing and discarded the old dressing in the biohazard bag, then assessed the patient’s left foot. Without changing gloves or performing hand hygiene, S1ADM touched his cell phone, unbuttoned Patient #3’s hospital gown at the right shoulder area exposing his dialysis catheter. S1ADM touched his pants, took a picture of the dialysis catheter with his cell phone, and put his cell phone back in pants pocket. Without changing gloves or performing hand hygiene, S1ADM obtained a wound cleanser bottle, clean 4x4 gauze sponges, he cut clean calcium alginate pieces with scissors removed from his bag, and cleaned both pressure ulcer wounds to Patient #3s right calf and right ankle. Without changing gloves or performing hand hygiene, S1ADM applied calcium alginate to both wounds and covered both wounds with non-adherent bordered gauze dressings then returned unused wound supplies, and un-sanitized scissors to his bag, touched the bedrail, biohazard bag, and applied moisturizing cream to Patient #3s bilateral legs. Gloves were removed, without hand hygiene performed. S1ADM reapplied Patient #3’s heel protector boots bilaterally, and vital signs were obtained. An interview was conducted with S1ADM on 01/06/2026 at 1:40 p.m. S1ADM confirmed he should have implemented proper hand hygiene and glove changes when he performed wound care to Patient #3’s wounds. An interview was conducted with S2QA on 01/06/2026 at 2:30 p.m. S2QA confirmed S1ADM should have implemented proper hand hygiene and glove changes when he performed wound care to Patient #3’s wounds.”

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure the Registered Nurse (RN) provided home health agency services in accordance with current clinical practice guidelines as set forth by the Louisiana State Board of Nursing (LSBN) Declaratory Statement for Scope of Practice for Registered Nurses - Wound Care Management and accepted professional standards as set forth by the National Pressure Ulcer Advisory Panel for Prevention and Treatment of Pressure Ulcers for 2 (#3 and #6) of 2 sampled patients reviewed for Pressure Ulcers. This deficient practice was evidenced by failure of the agency to ensure: 1. The RN performed weekly assessments and measurements for Patient #3’s Stage 2 Pressure Ulcers and Patient #6’s Stage 4 Pressure Ulcer; and 2. The RN assessed Patient #3 and #6’s Pressure Ulcers prior to delegating wound care to the Licensed Practical Nurse (LPN). Findings: Review of the agency’s revised policy dated 10/24/2024 and titled “Wound Care Instructions” revealed, in part: Staging Wounds: If a wound is found, a RN has to stage it first. You should not be treating a wound the RN has yet to see and write instructions for. If you find more wounds, the RN should see it first. Instructions: 1. When a wound is noticed, an RN must stage it before you can treat it (LPN). 2. When a wound is noticed take your label or wound care measure tape. You should be writing the wound location, date and take picture. 4. Repeat every visit until wound is healed. Note: LPN’s cannot treat a wound the RN has not staged. Medicare/State Correction Requirements: Below is the information needed to meet the Medicare requirements. This information should be present in the documentation and communication notes by the RN: Description of the wound, in part: 1. Size (Length x Width) 2. Depth 4. Appearance 5. Drainage 6. Undermining 7. Peri-Wound Character Review of the Louisiana State Board of Nursing’s Declaratory Statement Scope of Practice for RNs - Wound Care Management revealed, in part, the following: RNs render care that is directed towards the prevention and the treatment of wounds. Scope of Practice - The State’s Board of Nursing recognizes that assessment, planning, intervention, teaching, evaluation, and supervision are the major responsibilities of the registered nurse who measures, stages wounds, and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by the authorized prescriber. The RN initiates appropriate wound preventative measures, stages wounds, and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by an authorized prescriber. Delegation - In accord with the Law Governing the Practice of Nursing (RS 37:913(14) the RN may delegate select nursing interventions to qualified nursing personnel as set forth in the Board’s rules on delegation (LAC 46:XLVII.3703.). The RN retains the accountability for the total nursing care of the individual. The RN may delegate to a LPN wound care interventions in any situation when the RN has deemed the patients status is stable, the intervention is based on a relatively fixed and limited body of scientific knowledge, can be performed by following a defined nursing procedure with minimal alteration, responses of the individual to the nursing care are predictable and changes in the patient’s clinical condition are predictable. Furthermore, the patient’s medical and nursing orders are not subject to continuous change or complex modification, and appropriate RN supervision is available. 1. Patient #3 Review of the clinical record for Patient #3 revealed he began receiving services from the agency on 03/22/2024 with diagnoses, which included in part, Pressure Ulcer to Right Calf, Stage 2 and Pressure Ulcer to Right Ankle, Stage 2. Review of Patient #3’s Plan of Care for Certification Period dated 11/12/2025 through 01/10/2026 revealed the following, in part: Skilled Nursing Visits (SNV) once weekly for nine weeks; and Skilled Nurse to perform wound care to Right Leg Pressure Ulcer Stage 2 beginning 12/07/2025 and Right Ankle Pressure Ulcer Stage 2 beginning 12/18/2025 as follows: Cleanse wound with wound cleanser, pat dry; apply calcium Alginate over wound bed, apply non-adherent dressing, wrap loosely with rolling gauze, change every 2 days and as needed. Instruct patient/caregiver on changes in POC/wound care. Review of Patient #3’s Skilled Nurse Visit Notes, Physician Orders, and Communication Notes for Certification Period dated 11/12/2025 to 01/10/2026 revealed Patient #3’s Pressure Ulcer to Right Calf identified by S4LPN on 12/05/2025 was not assessed, staged, or measured by the RN the weeks of 12/05/2025, 12/07/2025, 12/14/2025, 12/23/2025, or 01/06/2026. Review of Patient #3’s Skilled Nurse Visit Notes, Physician Orders, and Communication Notes for Certification Period dated 11/12/2025 to 01/10/2026 revealed Patient #3 Pressure Ulcer to Right Ankle identified by S4LPN on 12/18/2025 was not assessed, staged, or measured by the RN the weeks of 12/18/2025, 12/23/2025, or 01/06/2026. An interview was conducted with S1ADM on 01/07/2026 at 8:45 a.m. S1ADM reviewed Patient #3’s clinical record and confirmed his pressure ulcers were not assessed, staged, or measured by a RN on the weeks of 12/05/2025, 12/07/2025, 12/14/2025, 12/23/2025, or 01/06/2026. S1ADM stated he thought the RN should assess and measure wounds every two weeks instead of weekly. An interview was conducted with S2QA on 01/07/2026 at 8:50 a.m. S2QA reviewed Patient #3’s clinical record and confirmed his pressure ulcers were not assessed, staged, or measured by a RN the weeks of 12/05/2025, 12/07/2025, 12/14/2025, 12/23/2025, or 01/06/2026. S2QA stated the agency RN assessed and measured pressure ulcer wounds every two weeks. Patient #6 Review of the clinical record for Patient #6 revealed he began receiving services from the agency on 02/05/2024 with diagnoses, which included in part, Pressure Ulcer of Left Buttock Stage 4, and Cellulitis of Buttock. Review of Patient #6’s Plan of Care for Certification Period dated 03/31/2025 through 05/29/2025 revealed he was to receive skilled nursing services once weekly for nine weeks; and Skilled Nurse to perform/teach pressure ulcer care to the left buttocks. Cleanse with wound cleanser, apply barrier cream twice daily and as needed using clean/aseptic technique. Further review revealed Patient #6 resumed Home Health Services with the agency on 04/14/2025 after a hospitalization on 04/10/2025, and he was to receive skilled nursing services once weekly for 9 weeks for continued wound care. Patient #6 was hospitalized again on 04/30/2025 and was discharged from the agency to Hospice services on 05/20/2025. Review of Patient #6’s Skilled Nurse Visit Notes, Physician Orders, and Communication Notes for Certification Period dated 03/31/2025 through 05/29/2025 revealed Patient #6’s Pressure Ulcer was not assessed, staged, or measured by a RN the weeks of 04/04/2025, 04/10/2025, 04/14/2025, and 04/25/2025. An interview was conducted with S1ADM on 01/08/2026 at 2:00 p.m. S1ADM reviewed Patient #6’s clinical record and confirmed his pressure ulcers were not assessed, staged, or measured by a RN the weeks of 04/04/2025, 04/10/2025, 04/14/2025, and 04/25/2025 and should have been. An interview was conducted with S2QA on 01/07/2025 at 2:05 p.m. S2QA reviewed Patient #6’s clinical record and confirmed his pressure ulcers were not assessed, staged, or measured by a RN the weeks of 04/04/2025, 04/10/2025, 04/14/2025, and 04/25/2025 and should have been. 2. Patient #3 Review of Patient #3’s Skilled Nurse Visit Notes, Physician Orders, and Communication Notes for Certification Period of 11/12/2025 through 01/10/2026 revealed the following 6 LPN visits were conducted without a RN SNV conducted to assess and measure the wounds prior to the LPN performing wound care: 11/14/2025 – LPN SNV conducted; 11/21/2025 – LPN SNV conducted; 11/28/2025 – LPN SNV conducted; 12/05/2025 – LPN SNV conducted; 12/11/2025 – LPN SNV conducted; and 12/18/2025 – LPN SNV conducted. Patient #6 Review of Patient #6’s Skilled Nurse Visit Notes, Physician Orders, and Communication Notes for the Certification Period of 03/31/2025 through 05/29/2025, revealed the following 3 LPN visits were conducted without a RN SNV conducted to assess and measure the wounds prior to the LPN performing wound care: 04/04/2025 – LPN SNV conducted; 04/17/2025 – LPN SNV conducted; and 04/25/2025 – LPN SNV conducted. An interview was conducted with S1ADM on 01/08/2026 at 2:00 p.m. S1ADM reviewed Patient #3 and #6’s clinical records and confirmed their pressure ulcers were not assessed and measured by the RN prior to the LPN’s aforementioned visits to perform their wound care. An interview was conducted with S2QA on 01/08/2025 at 2:05 p.m. S2QA reviewed Patient #3 and #6’s clinical records and confirmed their pressure ulcers were not assessed and measured by the RN prior to the LPN’s aforementioned visits to perform their wound care.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record reviews and interviews, the agency’s Visit Note Report failed to have documented evidence of a newly identified Stage 2 Pressure Ulcer for 1 (#3) of 2 patients reviewed for Pressure Ulcers out of a total of 7 sampled patients. Findings: Review of the agency’s revised policy dated 10/24/2024 and titled “Wound Care Instructions” revealed, in part: You can use either the picture forms or the ruler to label the location and date. Measurements are required for wound care documentation so make sure to record them. Medicare/State Correction Requirements: This information should be present in the documentation and in communication notes by the RN: Description of wound 1. Size (Length x Width) 2. Depth 3. Total Square Centimeters (CM) 4. Appearance 5. Drainage 6. Undermining 7. Peri-Wound Character Review of the clinical record for Patient #3 revealed he began receiving services from the agency on 03/22/2024. Review of Patient #3’s Plan of Care for Certification Period dated 11/12/2025 through 01/10/2026 revealed the following, in part: Skilled Nursing Visits (SNV) once weekly for nine weeks with diagnoses, which included in part, Hypertensive Heart & Chronic Kidney Disease (CKD) With Heart Failure and Stage 5 CKD, Type 2 Diabetes Mellitus with Diabetic CKD, End Stage Renal Disease, and Hemiplegia Following Cerebral Infarction Affecting Right Dominant Side. Review of Patient #3’s Skilled Nurse Visit Notes, Physician Orders, and Communication Notes for Certification Period dated 11/12/2025 to 01/10/2026 revealed there was no documented evidence Patient #3’s Pressure Ulcer to Right Ankle identified by S4LPN on 12/18/2025 was assessed, staged, or measured by a RN on the agency’s Visit Note Report for the weeks of 12/18/2025, 12/23/2025 or 01/06/2026. An interview was conducted with S1ADM on 01/07/2026 at 8:45 a.m. S1ADM reviewed Patient #3’s clinical record and confirmed there was no documented evidence Patient #3’s Pressure Ulcer to Right Ankle was assessed, staged, or measured by a RN on the agency’s Visit Note Report for the weeks of 12/18/2025, 12/23/2025 or 01/06/2026. An interview was conducted with S2QA on 01/07/2025 at 8:50 a.m. S2QA reviewed Patient #3’s clinical record and confirmed there was no documented evidence Patient #3’s Pressure Ulcer to Right Ankle was assessed, staged, or measured by a RN on the agency’s Visit Note Report for the weeks of 12/18/2025, 12/23/2025 or 01/06/2026.”

“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 record reviews and interviews, the agency failed to ensure a Home Health Aide Supervisory Visit was conducted every fourteen days for 1 (#2) patient with Home Health Aide Services, out of a total sample of 7 patients reviewed. This deficient practice had the potential to affect all 12 patients according to the agency’s current census. Findings: Review of the agency’s revised policy dated 09/01/2022 and titled, “Supervision and Evaluation of Staff” revealed the following in part: A Registered Nurse or Therapist will make a supervisory visit to all clients receiving Home Health Aide services at least every 14 days. Review of Patient #2’s clinical record revealed she began receiving services from the agency on 09/03/2025, with prior certification period of 11/02/2025 through 12/31/2025 and current certification period of 01/01/2026 through 03/01/2026. Review of Patient #2’s Physician Ordered discipline frequency revealed she received Home Health Aide visits one time a week for three weeks beginning 12/14/2025, one time a week for two weeks beginning 12/21/2025, and one time a week beginning 01/06/2026. Review of Patient #2’s Home Health Aide visit calendar revealed, in part, she had visits completed on 12/17/2025, 12/26/2025 and 12/29/2025. Review of Patient #2’s Nursing visits revealed visits were completed on 12/22/2025 and 12/30/2025. Further review revealed there was no documented evidence a Home Health Aide Supervisory Visit was conducted on or before 12/31/2025. An interview was conducted with S1ADM on 01/07/2026 at 8:30 a.m. S1ADM stated a Home Health Aide Supervisory Visit should be conducted by a Skilled Nurse every 14 days. S1ADM confirmed a Home Health Aide Supervisory Visit for Patient #2 was not conducted every 14 days and should have been.”