Four Rivers Home Health of Louisiana

The agency failed to develop and maintain an Emergency Preparedness Plan that was reviewed and updated at least every 2 years.

The agency failed to ensure exercises to test the Emergency Plan were conducted at least annually by having a full-scale exercise that is community-based; or an annual individual, facility-based functional exercise and an additional exercise that may include, a second full-scale exercise that is…

The HHA’s (Home Health Agency's) Governing Body failed to ensure an ongoing program for quality improvement and patient safety was implemented and maintained.

The agency failed to ensure the RN re-assessed a patient’s Stage 2 Pressure Ulcer weekly for 1 (Patient #5) of 7 sampled patients: Findings: Review of Patient #5’s Plan of Care dated 01/07/2023 – 03/07/2023 revealed the primary diagnosis was Pressure Ulcer of Sacral Region and secondary diagnosis…

The agency failed to have a governing body (or designated persons so functioning) to assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational…

The agency failed to ensure patients were advised of the state toll free home health telephone hotline number, contact information, hours of operation, and that its purpose is to receive complaints or questions about local home health agencies for 1 (Patient #2) of 3 (Patient #1, Patient #2 and…

The agency failed to ensure the patient’s medication profile accurately listed the correct medications the patient was taking for 1 (Patient #2) of 2 (Patient #1 and Patient #2) medications reviewed during home visits.

The agency failed to ensure the patient's Individualized Plan of Care included all medications and treatments for 1 (Patient #4) of 7 sampled patients.

The agency failed to ensure skilled nursing services ordered by the physician were provided as indicated in the plan of care for 1 (#5) of 7 (#1, #2, #3, #4, #5, #6, and #7) patient records reviewed for services provided per the plan of care and physician orders.

The agency failed to ensure a Registered Nurse (RN), who was familiar with the patient and the patient's Plan of Care, made an onsite visit to the patient's home no less than every 14 days for aide supervisory visits for 1 (Patient #3) of 1 sampled patients with Home Health Aide services.

The agency failed to ensure the POC was reviewed and revised to include the skilled nurse frequency (#3), filling of medi-planner (#2 and #3) and the removal of therapy services (#3) for 2 (#2 and #3) of 10 total sampled patients out of total census of 103 patients.

The agency failed to have documentation of an ongoing program for QAPI and patient safety in the agency.

The agency failed to maintain and utilize quality indicator data to monitor the effectiveness and safety of services and quality of care, and failed to identify opportunities for improvement with the frequency and detail of the data collection approved by the agency's governing body.

The agency failed to ensure that a patient's (#3) electronic medical record contained the correct documentation as reported to S5 Case Manager/RN for 1 (#3) of 10 total sampled patients out of a total of 103 patients.

The agency failed to ensure the clinicians were completing medication reconciliations and updating the records for 2 (#2 and #3) of the 10 total sampled patients out a total census of 103. Findings: 1. Review of patient #2's POC with recertification dates of 01/22/2021 to 03/22/2021 revealed…