Lourdes at Home Chha

Skilled professional services were not provided to all patients of the agency as evidenced by the failure to ensure: - that the home health agency ensured a registered nurse assessed and supervised the care provided by licensed practical nurses (see G 726) - patients were assessed by all…

In 4 of 19 records, (patients #4, 10, 11 and, 13) the agency failed to provide services that were written in an individualized Plan of Care to address the total needs of the patients.

Evidence as follows: The QAPI Meeting minutes dated 02/22, 06/13, 07/25, 08/29, and 09/26/24 included audit results for multiple focused audits including: - diabetes - central line monitoring - drug regimen review - congestive heart failure - pain monitoring - wound assessment Wound assessment…

The agency failed to track all adverse events, analyze their causes, and implement preventative actions, which contributed to the extended, condition level survey.

The skilled nurse failed to follow accepted standards of infection control practices.

In 3 of 4 of records for patients receiving home health aide services (patients #2, 6, and 12) the skilled nurse failed to develop complete and accurate aide written instructions.

In 7 of 19 records, (patients #1, 3, 5, 9, 11, 12, and 15) the agency failed to develop complete and accurate plans of care that were individualized to address the total needs of the patients.

In 3 of 19 records (patients #2, 7, and 10), the agency failed to perform care in accordance with the orders of a physician or allowed practitioner that establishes and periodically reviews the plan of care.

For 2 of 19 records (Patients #10 and 11) the Skilled Nurse failed to communicate with the physician when changes in the patient's condition occurred.

In 1 of 19 records, (patient #1), the agency failed to ensure care was coordinated to meet the patient's needs.

In 1 of 19 records, (patient #16) the agency failed to provide ongoing interdisciplinary assessment to meet the needs of the patients.

In 4 of 19 records, (patients #3, 7, 9, and 10) the agency failed to educate patients and caregivers.

In 2 of 19 records, (patients 3 and 4), the agency failed to communicate with the patient's health care provider related to the current plan of care.

In 4 of 19 records (patients #5, 9, 13, and 15), the agency failed to supervise, monitor, and evaluate the provision of treatment by the Licensed Practical Nurses.

This condition was not met as evidenced by: Failure to ensure comprehensive assessments were complete and accurately identified the current and ongoing needs of the patient.

This condition was not met as evidenced by: - Failure to develop comprehensive plans of care which address each patient's individual needs.

The Governing Authority failed to ensure an agency-wide data driven QAPI program was in place to identify systemic issues in patient care.

For 8 of 18 records (Patients # 1, 3, 4, 7, 10, 12, 15, and 18), the agency failed to ensure comprehensive assessments were of sufficient scope to ensure all patient needs were identified.

In 6 of 20 patient records (Patients # 1, 3, 4, 6, 8, and 15) the agency failed to provide services as ordered by the physician.

The QAPI Program failed to address the scope of the program as follows: - the QAPI committee failed to identify and address all areas identified as less than 79 % compliant, - failed to develop and implement appropriate action plans for non-compliant areas identified below 79%, - failed to review…

The agency failed to adequately review records of patients with adverse events, analyze their causes and implement preventive actions and failed to identify deficient practice for 2 of 5 records (Patients # 15 and 17).

During 3 of 5 home visits (Patients # 2, 3 and 6), the nurse failed to follow accepted standards of infection control practices.

The 11/16/21 HHA care plan failed to include the Hoyer lift and the patient’s transfer status.

In 3 of 17 records (Patient # 3, 4, and 6), agency staff failed to perform complete and accurate medication reviews.

In 2 out of 3 records (Patients # 4 and 9), the agency failed to conduct an assessment visit within 48 hours of return home from a hospital stay.

Based record reviews and interviews with the Administrator, Director of Patient Services (DPS), Safety Coordinator, Home Care Manager and agency staff, it was determined in 9 of 20 records (Patients # 1, 3, 4, 5, 6, 9, 11,12 and 17) agency staff failed to develop individualized plans of care that…

For 1 of 17 records (Patient # 3), the Skilled Nurse (SN) failed to consult with the physician when changes in the patient's condition occurred.

In 6 of 20 records (Patients # 3, 7, 10, 11, 17 and 19) the agency failed to ensure: - significant information is consistently being exchanged between individuals responsible for developing and implementing the plan of care - the registered nurses (RNs) and physical therapist (PTs) have a clear…

In 2 of 3 records, the agency failed to ensure assessments were of sufficient scope to ensure all patient needs were identified.

The agency failed to identify concerns voiced regarding patient care, investigate the concerns, and develop a plan to resolve the concerns.

In 3 of 17 records (Patients # 1, 2, and 6), agency staff failed to perform complete and accurate medication reviews.

In 7 out of 17 records (Patients # 2, 4, 5, 8, 10, 14, and 16) the agency failed to develop individualized plans of care that were complete, accurate, and addressed the total needs of the patients.

In 2 of 17 records (Patients #1 and 17) the agency failed to ensure the patient's plan of care was effectively coordinated: This was evidenced by: HV 1. Patient #1 was admitted to the agency on 09/16/18 with diagnoses of cellulitis to the right lower leg following a fall, diabetes, and congestive…