Terrebonne Homecare, Inc.

“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 reviews and interviews, the agency failed to ensure the skilled nurse: 1. Obtained an abdominal girth and/or ankle measurement to monitor for weight fluctuations on a patient who was unable to stand for weights (Patient #5); and, 2. Monitored and assessed a patient’s capillary blood glucose for abnormal findings (Patient #9). This failed practice was identified for 2 (Patient #5 and Patient #9) of 13 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, and Patient #13) sampled patients reviewed for care and services provided per the plan of care. Findings: Patient #5 Review of Patient #5’s home health care certification and plan of care for the certification period of 09/29/2024 through 11/27/2024 revealed Patient #5 had a diagnosis of chronic kidney disease stage 3a (condition in which the kidneys are unable to efficiently filter toxins and fluid) and was to receive skilled nursing services once a week for nine weeks. Further review revealed Patient #5 was to be weighed by the skilled nurse during visits, and obtain abdominal girths and/or ankle measurements on Patient #5 if unable to stand. Review further revealed the skilled nurse was to monitor for fluctuations in weight and report to the physician if necessary. Review of Patient #5’s record revealed Patient #5 had skilled nurse visits on provided, in part, on 10/01/2024, 10/08/2024, 10/19/2024, 10/22/2024, 10/29/2024, and 10/31/2024. Further review revealed no documented evidence, and the agency presented no documented evidence, Patient #5’s weight, abdominal girth, and/or ankle measurements were obtained on the above mentioned dates to monitor for Patient #5’s weight fluctuations as required. In an interview on 11/06/2024 at 11:33 a.m., S2Director of Nursing (DON) indicated the skilled nurse had not obtained Patient #5’s weight, abdominal girth, and/or ankle measurements for the above mentioned dates as required. In an interview on 11/06/2024 at 11:34 a.m., S1Administrator indicated the skilled nurse had not obtained Patient #5’s weight, abdominal girth, and/or ankle measurements for the above mentioned skilled nurse visit dates as required. Patient #9 Review of Patient #9’s home health certification and plan of care for the certification period of 09/01/2024 through 10/30/2024 revealed, in part, Patient #9 had a diagnosis of type II diabetes (condition in which the body does not effectively manage glucose levels in the blood). Further review revealed Patient #9 scheduled to receive skilled nursing services once a week for five weeks, then twice a week for two weeks. Review of Patient #9’s patient care order dated 09/01/2024 revealed, in part, the skilled nurse was to educate Patient #9 on diabetic monitoring, report abnormal findings, and assess Patient #9’s ability to monitor capillary blood glucose levels. Review of Patient #9’s record revealed no documented evidence, and the agency presented no documented evidence, Patient #9’s capillary blood glucose was obtained or assessed for compliance and/or abnormal findings on 10/18/2024. In an interview on 11/06/2024 at 12:00 p.m., S2DON indicated the agency did not have documented evidence Patient #9’s capillary blood glucose was obtained and/or assessed for abnormal findings on 10/18/2024. In an interview on 11/06/2024 at 12:01 p.m., S1Administrator indicated the agency had no further evidence to present which documented the skilled nurse monitored Patient #9’s capillary blood glucose for abnormal findings on 10/18/2024.”

“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 wounds were measured weekly for 2 (Patient #9 and Patient #10) of 4 (Patient #5, Patient #7, Patient #9, and Patient #10) sampled patients reviewed with wounds. 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, odor of exudates, and evidence of infection in the surrounding tissues. Further review revealed when recorded over time this information can be used to track the progress of wound healing. Patient #9 Review of Patient #9’s home health certification and plan of care for the certification period of 09/01/2024 through 10/30/2024 revealed, in part, Patient #9 had a diagnosis of Fournier Gangrene (a rapid spreading life threatening infection of the genitals and perineum) to the left groin. Further review revealed Patient #9 had skilled nursing services once a week for five weeks, and the skilled nurse was to assess Patient #9’s left groin wound status which included signs and symptoms of healing and/or complications. There was no documented evidence, and the agency presented no documented evidence, Patient #9’s left groin wound had measurements obtained the week of 09/08/2024 through 09/14/2024, or for the week of 09/29/2024 through 10/05/2024. In an interview on 11/06/2024 at 12:00 p.m., S2Director of Nursing (DON) indicated the agency did not have any wound care measurements for Patient #9’s left groin wound for the above mentioned time periods. In an interview on 11/06/2024 at 12:01 p.m., S1Administrator indicated the agency had no further documentation to present that wound care measurements of Patient #9’s left groin wound were obtained as required. Patient #10 Review of Patient #10’s home health certification and plan of care for the certification period of 10/01/2023 through 11/29/2023 revealed Patient #10 was to receive skilled nursing services once a week for nine weeks. Review of Patient #10’s record revealed Patient #10 had the following wounds: left heel suspected deep tissue injury (wound which was unable to be staged due to the depth of the wound), a left posterior buttocks gluteal fold (wound to the buttock) stage II (open wound) pressure ulcer, and a posterior medial buttocks/coccyx (area near the tailbone) stage II pressure ulcer. Further review revealed no documented evidence, and the agency presented no documented evidence, Patient #10’s above mentioned wounds were measured from 10/01/2023 through Patient #10’s discharge on 11/20/2023. In an interview on 11/06/2024 at 12:01 p.m., S1Administrator indicated the skilled nurse failed to obtain weekly wound care measurements as required.”

“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 record reviews and interviews, the agency failed to ensure an accurate medication reconciliation was completed for 1 (Patient #1) of 5 (Patient #1, Patient #2, Patient #3, Patient #4, and Patient #5) sampled patients whose medication reconciliation was reviewed during in person home visit observations. Findings: Review of Patient #1’s home health certification and plan of care for the certification period of 08/20/2024 through 10/18/2024 revealed Patient #1 was admitted to the agency on 04/22/2024. Further review revealed Patient #1 was to receive skilled nursing services once a week for nine weeks. Review of Patient #1’s Medication Profile, presented to the surveyor on 10/31/2024 as the most accurate medication profile, revealed Patient #1 was receiving the following medications, in part: - Arfortmoterol (inhaled medication which relaxes the respiratory muscles) 15 microgram (mcg)/2 milliliters (ml) inhalation solution, inhale 15mcg once a day with a start date of 04/29/2024; -Fluticasone (medication used to treat allergies) 50mcg/inhalation nasal spray administer 2 sprays into nostril once a day with a start date of 04/29/2024; - Gabapentin (medication used to treat nerve pain) 100 milligrams (mg) administer 3 capsules once a day at bedtime with a start date of 05/23/2024; -Protonix (medication used to treat acid reflux) Delayed Release (DR) 20mg take one tablet daily with a start date of 05/23/2024; -Revefenacin (medication used to open the airway) 175mcg/3ml inhalation solution administer 3ml twice a day as needed with a start date of 05/23/2024; -Apixaban (medication used to prevent the blood from clotting) 5mg administer one tablet by mouth twice a day with a start date of 06/13/2024; -Balsalazide (medication used to treat inflammation of the colon) 750mg administer one capsule twice a day as needed for diarrhea with a start date of 08/15/2024; -Colestipol (medication used to treat high cholesterol) 1 gram administer 2 tablets twice a day as needed for diarrhea with a start date of 08/15/2024; -Dicyclomine (medication used to treat irritable bowel syndrome) 20mg administer one tablet orally four times a day as needed for diarrhea with a start date of 08/15/2024; -Aldactone (medication used to decrease fluid in the body) 25mg administer one half of a tablet (12.5mg) once a day with a start date of 08/28/2024; and, Further review of Patient #1’s Medication Profile revealed no documented evidence of the following medications had been captured on Patient #1’s medication profile: Vitamin D2, Vitamin K2, Vitamin D3, Cranberry tablet, Alpha Lipoic Acid (supplement which helps with nerve pain), Melatonin (supplement which assists with sleep), Zinc (supplement which helps with wound healing), Vitamin C, Biotin (supplement which helps with hair and nails), and Humalog (insulin, medication used to regulate the amount of glucose in the blood). Observation of Patient #1’s medications on 11/01/2024 at 1:07 p.m. revealed Patient #1 had the following medications in her possession, in part: - Arformoterol 15mcg/2ml administer 15mcg twice a day with a prescription filled date of 10/08/2024; - no evidence of Fluticasone; - Gabapentin 100mg administer 3 capsules at bedtime and one every morning with a prescription filled date of 05/09/2024; - no evidence of protonix; - Revefenacin 175 mcg/3ml administer 3 ml once a day as needed with a prescription filled date of 10/08/2024; -Apixaban 2.5mg one tablet twice a day written on the bottle; -Balsalazide 750mg administer two capsules twice a day as needed for diarrhea with a prescription filled date of 10/01/2024; -no evidence of Colestipol; -Dicyclomine 20mg administer one tablet at bedtime with a filled date of 04/24/2023; -Aldactone 25mg administer one-half tablet (12.5mg) once a day and take an additional dose for edema; - Vitamin D2, 2400 international units (IU) administer one tablet once a day; -Vitamin K2, 100mcg administer one tablet once a day; -Vitamin D3 25mcg administer one tablet one a day; -Cranberry 4200mg tablet administer once tablet once a day; -Alpha Lipoic Acid 600mg two tablets once a day; -Melatonin 10mg administer one tablet at bedtime; -Zinc 50mg administer one tablet once a day; -Vitamin C 500mg administer one tablet once a day; and, -Biotin 10,000 mcg administer one tablet once a day. In an interview on 11/01/2024 at 1:10 p.m., Patient #1 indicated she no longer took Fluticasone, Protonix, and Colestipol. Patient #1 further indicated she was taking the above mentioned medications in per possession per the instructions on the medication labels, and had Humalog 100 units/ml per sliding scale in her insulin pump. Review of Patient #1’s Communication Note dated 10/15/2024 revealed, in part, medications were verified physically in the home with Patient #1 and Patient #1’s daughter. Further review revealed multiple changes were noted to Patient #1’s medications, and the skilled nurse was to update the medication profile. Review revealed no documented evidence of which medication changes were identified. There was no documented evidence, and the agency presented no documented evidence, Patient #1’s medication discrepancies were addressed after the 10/15/2024 skilled nurse visit. In an interview on 11/06/2024 at 12:15 p.m., S2Director of Nursing (DON) indicated the agency did not have any documented evidence the discrepancies identified on Patient #1’s skilled nurse visit dated 10/15/2024 were reconciled.”