Every finding on record at Lhcg Ccxxii, LLC

A Recertification survey was conducted at Archbold Home Health June 15, 2026 and concluded on June 17, 2026. At the time of the survey, the agency was in compliance with 42 CFR Part 418.113, Emergency Preparedness and Covid-19 infection control.

A Recertification survey was conducted at Archbold Home Health June 15, 2026, and concluded on June 17, 2026. At the time of the survey, the agency was not in compliance with Chapter 42 CFR Part 418, Rules and Requirements for Home Health and Hospice Agencies. The census was 296. The following deficiency was cited.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on the Centers for Medicare & Medicaid Services (CMS) Home Health Agency (HHA) Error Summary by agency report, review of policy “Oasis DATA,” and staff interview, it was determined that the agency failed to electronically transmit monthly Outcome and Assessment Information Set (OASIS) data collected to the CMS system every 30 days. Findings included: Review of the policy titled “OASIS Data Capture, Transmission, Verification, Display and Reports” revised date 10/01/2025, revealed that OASIS date items will be collected and transmitted within 30 calendar days of the completion of the OASIS assessment. Review of CMS report titled “HHA Error Summary by Agency,” with report period of 01/01/2025 - 12/31/2025 ran on 06/16/2026 revealed the agency failed to transmit OASIS data to the CMS system within 30 days. An interview was conducted with the Administrator on 06/15/2026 at 1:00 PM. The Administrator confirmed OASIS reports had not been submitted to CMS within 30 days of completing the assessments. The Administrator revealed the agency had errors on some of the initial assessments that were returned for corrections causing them to be untimely OASIS submissions and they are currently working on a process to correct the error.

A recertification survey was conducted at Archbold Home Health Services on June 26, 2023 and concluded on June 28, 2023. At the time of the survey, the agency was in compliance with 42 CFR Part 418.113, Emergency Preparedness and Covid-19 infection control.

A recertification survey was conducted at Archbold Home Health Services on June 26,2023 and concluded on June 28, 2023. At the time of the survey the agency was not in compliance with Chapter 42 CFR Part 418, Rules and Requirements for Home Health and Hospice Agencies. The census was 154. The following deficiencies were cited:

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record reviews, staff interview and review of the agency policy # 2.1.007 titled "Plan of care (POC)" latest revised date 12/01/21, it was determined that the agency failed to ensure the plans of care included specific interventions and orders for all pertinent diagnoses for seven patients (P) (P#1, P#3, P#4 P#6, P#8, P#12, P#16) of 17 sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15, P#16, P#17). 7. Review of the plan of care for patient #16 with admission date 6/13/2022 revealed the patient has a pertinent diagnosis of type 2 diabetes with diabetic peripheral angiopath without gangrene. However, the plan of care lacks specific teaching and assessments of diabetes mellitus; frequency to check the blood sugar, teaching on diabetic complications, such as hyper and/or hypoglycemia and other diabetic complications to be reported to the nurse and to the physician. The agency failed to ensure the plan of care was complete and consistent to include the specific teaching and assessments of diabetes and its complications. The agency failed to ensure that the plan of care/treatment covered all pertinent interventions for the comprehensive care of the patient's diabetic status. An office interview with the Executive Director (ED) was conducted on 6/28/23 at 11:00 a.m. ED acknowledged the plan of care did not have an appropriate intervention for the ongoing assessment of diabetes mellitus, and teaching anticoagulation therapy. The ED also acknowledged that the agency policy# 2.1. 007 titled "Plan of care " was not followed by the agency. 1.Review of the plan of care for patient #1 with the admission date of 5/11/2022, revealed the patient has a pertinent diagnosis of type 2 diabetes mellitus with long term use of insulin and diabetic ketoacidosis without coma. However, the plan of care lacks specific teaching and assessments of diabetes mellitus; frequency to check the blood sugar, teaching on diabetic complications, such as hyper and/or hypoglycemia and other diabetic complications to be reported to the nurse and to the physician. The agency failed to ensure the plan of care was complete and consistent to include the specific teaching and assessments of diabetes and its complications. 2. Review of the plan of care for patient #4 with the admission date of 2/28/2023, revealed the patient has a pertinent diagnosis of type 2 diabetes mellitus with long term use of insulin and diabetes mellitus with chronic kidney disease. However, the plan of care lacks specific teaching and assessments of diabetes mellitus; frequency to check the blood sugar, teaching on diabetic complications, such as hyper and/or hypoglycemia and other diabetic complications to be reported to the nurse and to the physician. The agency failed to ensure the plan of care was complete and consistent to include the specific teaching and assessments of diabetes and its complications. The agency failed to ensure that the plan of care/treatment covered all pertinent interventions for the comprehensive care of the patient's diabetic status. 3. Review of the plan of care for patient #3 with the admission date of 7/15/22, revealed the patient has a pertinent diagnosis of type 2 diabetes mellitus and long-term use of anticoagulant and patient was taking Eliquis 5 milligrams twice daily. However, the plan of care lacked specific teaching and assessments of diabetes mellitus; frequency to check the blood sugar, blood sugar parameters to notify the physician on diabetic complications, such as hyper and/or hypoglycemia and other diabetic complications to be reported to the nurse and to the physician. The plan of care also lacked teaching on anticoagulant therapy and prevention of bleeding caused by anticoagulant medications. The agency failed to ensure the plan of care was complete and consistent to include the specific teaching and assessments of diabetes and anticoagulant complications. The agency failed to ensure that the plan of care/treatment covered all pertinent interventions for the comprehensive care of the patient's diabetic status. 4. Review of the plan of care for patient #8 with the admission date of 5/6/2022, revealed the patient has a pertinent diagnosis of type 2 diabetes mellitus with long term use of insulin and diabetes mellitus with foot ulcer. However, the plan of care lacks specific teaching and assessments of diabetes mellitus; frequency to check the blood sugar, teaching on diabetic complications, such as hyper and/or hypoglycemia and other diabetic complications to be reported to the nurse and to the physician. The agency failed to ensure the plan of care was complete and consistent to include the specific teaching and assessments of diabetes and its complications. The agency failed to ensure that the plan of care/treatment covered all pertinent interventions for the comprehensive care of the patient's diabetic status. 5. Review of the plan of care for patient #12 with the admission date of 4/7/23, revealed the patient has a pertinent diagnosis of type 2 diabetes mellitus with long term use of insulin and diabetes mellitus with hyperglycemia. However, the plan of care lacks specific teaching and assessments of diabetes mellitus; frequency to check the blood sugar, teaching on diabetic complications, such as hyper and/or hypoglycemia and other diabetic complications to be reported to the nurse and to the physician. The agency failed to ensure the plan of care was complete and consistent to include the specific teaching and assessments of diabetes and its complications. The agency failed to ensure that the plan of care/treatment covered all pertinent interventions for the comprehensive care of the patient's diabetic status. 6. Review of the plan of care for patient #6 with the admission date of 6/4/2023, revealed the patient has a pertinent diagnosis of type 2 diabetes mellitus with long term use of insulin. However, the plan of care lacks specific teaching and assessments of diabetes mellitus; frequency to check the blood sugar, blood sugar parameters to notify the physician, teaching on diabetic complications, such as hyper and/or hypoglycemia and other diabetic complications to be reported to the nurse and to the physician. The agency failed to ensure the plan of care was complete and consistent to include the specific teaching and assessments of diabetes and its complications. The agency failed to ensure that the plan of care/treatment covered all pertinent interventions for the comprehensive care of the patient's diabetic status and followed the policy# 2.1. 007 titled "Plan of care". An office interview with the Executive Director (ED) was conducted on 6/28/23 at 11:00 a.m. ED acknowledged the plan of care did not have an appropriate intervention for the ongoing assessment of diabetes mellitus, and teaching anticoagulation therapy. The ED also acknowledged that the agency policy# 2.1. 007 titled "Plan of care " was not followed by the agency.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on observations, record reviews, staff interview and review of agency policy titled "Coordination of Care, From Admit through Discharge" dated 5/1/99, it was determined that the personnel furnishing services failed to maintain liaison to ensure their efforts were coordinated effectively and timely to support the objectives outlined in the plan of care for two patients (P) (P#13, P#15) of 17 sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15, P#16, P#17). 2. Review of the plan of care for P#15 with a recertification period of 5/09/23 to 7/7/23 and a diagnosis of Alzheimer's Disease, Emphysema, Chronic Kidney disease and a Urinary device. The caregiver reports a need for home health aide (HHA) services to assist with providing baths and assisting with activities of daily living (ADLs). Caregiver also reports she has had a trouble finding an aide for a couple of months. States that she herself has been ill and has had difficulty finding an agency that can provide HHA services. The home health agency does not provide social work services as they have not hired a social worker to assist families with community referrals for services. During the home visit observation on 6/27/2023, the surveyor observed the patient in supine position in bed. Caregiver states he is unable to walk and has a history of falling. Patient does not appear to be able to perform ADLs without maximum assistance however, review of the clinical record does not indicate that HHA visits had been offered to the family to assist with the needs of the patient. The clinical record lacked any coordination of care efforts between team members to ensure the patient had the services offered to support the needs of the patient. Review of agency policy titled "Coordination of Care, From Admit through Discharge" dated 5/1/99 indicated patient care is coordinated among various disciplines and services through care planning processing to ensure continuity of care to include: appropriate, timely communication with the patient, caregivers, and staff involved in the patient's care regarding patient needs, goals and care as well as changes in these. The agency failed to coordinate care to meet the identified needs of the patient. An interview at the agency office with the Interim Executive Director on 6/28/23 at 11:00 a.m., the Executive Director confirmed that the clinical record lacked coordination notes regarding the lack of aide services. It was also confirmed the clinical record lacked any coordination amongst team members to provide HHA services to meet the identified needs of the patient. It was also confirmed that the agency does not offer home health aide services (HHA) or master of social work (MSW) services. Review of the plan of care for P#13 with a diagnosis of Alzheimer's Disease revealed a physician's order dated 5/10/23 ordering a Hoyer lift and wheel chair for the patient in the home. During a home visit observation on 6/27/23 at approximately 4:00 p.m., with licensed practical nurse (LPN) BB, the caregiver stated to this surveyor that she was still awaiting a wheel chair and a Hoyer lift to help assist the patient from the bed to the chair. Caregiver stated it has been over a month and the patient still does not have a wheel chair or Hoyer lift. Caregiver reports these items would be very helpful in caring for the patient. LPN BB did not provide any information related to when the wheel chair would be available. Review of the clinical record did not reveal any documentation or coordination of care within the care team to indicate follow- up had been done to ensure the patient received the necessary equipment to aid in the care of the patient. Additionally, the caregiver reports a need for home heath aide (HHA) services to assist with providing baths and assisting with activities of daily living (ADLs). Caregiver also reports she has been calling around trying to find an agency that can provide HHA services but has not been able to find anyone to provide this service. This agency does not provide social work services as they have not hired a social worker to assist families with community referrals for services. During the home visit observation, this surveyor observed the patient sitting in a chair with head down and nonverbal. The patient does not appear to be able to perform ADLs without maximum assistance however, review of the clinical record does not indicate that HHA visits had been offered to the the family to assist with the needs of the patient. The clinical record lacked any coordination of care efforts between team members to ensure the patient had the services offered to support the needs of the patient. Review of agency policy titled "Coordination of Care, From Admit through Discharge" dated 5/1/99 indicated patient care is coordinated among various disciplines and services through care planning processing to ensure continuity of care to include: appropriate, timely communication with the patient, caregivers, and staff involved in the patient's care regarding patient needs, goals and care as well as changes in these. The agency failed to coordinate care to meet the identified needs of the patient. During an interview at the agency office with the Interim Executive Director on 6/28/23 at 11:00 a.m., the Executive Director confirmed that the clinical record lacked coordination notes regarding the lack of medical equipment in the home. It was also confirmed the clinical record lacked any coordination amongst team members to provide HHA services to meet the identified needs of the patient. It was also confirmed that the agency does not offer home health aide services (HHA) or master of social work (MSW) services.