Every finding on record at Lhcg Clxi, LLC

A recertification survey was conducted at Northeast Georgia Home Health on January 22, 2024, and concluded on January 24, 2024. 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 Northeast Georgia Home Health on January 22, 2024, and concluded on January 24, 2024. 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 240. 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, and staff interview, it was determined the agency failed to ensure the patient plan of care (POC), contained complete, concise and clear documentation of all services, including dialysis interventions to monitor dialysis site for infection or bleeding after dialysis procedures, teaching, evaluations, treatments, progress notes, and individualized plan of care to address the patients' needs for one patient (P) (P#7) of 21 sampled patients. The Findings include: Review of the POC for P#7 (certification period of 12/1/2023 to 1/29/2024) revealed P#7 was admitted to home health agency on 12/1/2023, with a diagnosis of end stage renal failure dependence on renal dialysis (a condition where the kidney reaches advanced state of loss of function). The agency failed to address interventions for P#7 on the POC to monitor dialysis site for bleeding, or infection during skilled nurses’ visits after the dialysis procedures (a procedure to remove wasted products and excess fluid from the blood when the kidney stops working). During an interview on 1/23/2024 at 2:46 p.m., with Registered Nurse (RN) BB, revealed RN BB confirmed that the agency failed to addressed interventions and failed to notify physician for not following the POC for P#7. No Policy was provided during the survey and upon exit.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review, staff interview, and review of agency policy, it was determined that the home health agency physician failed to sign patient plan of care (POC) within 30 days for five patients (P) (P#1, P#4, P#6, P#8, P#9), of 21 sampled patients. Specifically, the POC was signed late for three patients (P#1, P#4, P#9) and failed to sign the POC for two patients (P#4, P#9). The Findings include: Review of the agency policy titled “Physician Orders”, revised 10/01/23, Policy Number: 2.1.008 reveals the following: Procedure: 4. The Plan of Care (POC), telephone and or verbal orders must be signed and dated by the physician or authorized practitioner within a timely manner per state regulation: STATE Timeliness of Physician Signature Georgia 30 days 1. Review of clinical record of P#1 revealed P#1 was admitted to the home health agency on 10/27/2023.The physician signed the POC on 11/29/2023. 2. Review of clinical record of P#4 revealed P#4 was admitted to the home health agency on 11/1/2023. The physician failed to sign the POC. 3. Review of clinical record of P#6 revealed P#6 was admitted to the home health agency on 12/14/2023. The physician signed the POC on 1/19/2024. 4. Review of clinical record of P#8 revealed P#8 was admitted to the home health agency on 12/6/2023. The physician signed the POC on 1/8/2024. 5. Review of clinical record of P#9 revealed a patient was admitted to the home health agency on 12/3/2023. The physician failed to sign the POC. On 1/23/2024 at 3:25 p.m., an interview was conducted with the Clinical Manager (CM) who acknowledged that physicians failed to sign P#1, and P#9 POCS, also signed P#5, P#6, and P#8 POCS late. CM stated it is a struggle for one of their physicians.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record reviews, and staff interview, it was determined the agency failed to obtain patient weight, calf measurement, and document findings as ordered for five patients (P) (P#1, P#3, P#4, P#5, P#6) of 21 sampled patients. The Findings include: 1. Review of the plan of care (POC) for P#1 (certification period of 10/27/23 to 12/25/23) revealed P#1 admitted to the home health agency on 10/27/2023, with a diagnosis of heart failure (when the heart muscle doesn't pump blood as well as it should), required the skilled nurse (SN) to assess and instruct patient/caregiver on precautions to monitor and document daily weight, calf measurements each visit, and report gain of two to three pounds daily, or five pounds in one week. Visit notes for P#1 failed to reveal weight and calf measurements on 11/7/2023, 11/22/2023, and 12/1/2023 2. Review of the POC for P#3 (certification period of 12/8/23 to 2/5/24), revealed P#3 was admitted to the home health agency on 12/8/2023 with a diagnosis of heart failure and required the SN to assess and instruct patient/caregiver on precautions to monitor and document daily weight, calf measurements each visit, and report gain of two to three pounds daily, or five pounds in one week. Visit notes for P#3 failed to reveal weight and calf measurements on 12/9/2023, and 1/11/2024. 3. Review of the POC for P#4 (certification period of 12/31/23 to 2/28/24) revealed P#4 was , admitted to the home health agency on 11/1/2023, with a diagnosis of congestive heart failure and required the SN to assess and instruct patient/caregiver on precautions to monitor and document daily weight, calf measurements each visit, and report gain of two to three pounds daily, or five pounds in one week. Visit notes for P#4 failed to reveal weight and calf measurements on 11/7/2023, and 11/15/2023. 4. Review of the POC for P#5 (certification period of 12/15/23 to 2/12/24) was admitted to the home health agency on 12/15/2023 with a diagnosis of heart failure and required the SN to assess and instruct patient/caregiver on precautions to monitor and document daily weight, calf measurement each visit, and report gain of two to three pounds daily, or five pounds in one week. Visit notes for P#5 failed to reveal weight and calf measurements on 1/5/2024, and 1/10/2024. 5. Review of the POC for P#6 (certification period of 12/14/23 to 2/11/24) was admitted to the home health agency on 12/14/2023 with a diagnosis of congestive heart failure and required the SN to assess and instruct patient/caregiver on precautions to monitor and document daily weight, calf measurements each visit, and report gain of two to three pounds daily, or five pounds in one week. Visit notes for P#6 failed to reveal weight, and calf measurements on 12/22/2023, and 12/26/2023. On 1/23/2024 at 4:02 p.m., an interview was conducted with Licensed Practical Nurse (LPN) BB. LPN BB revealed the patient scale broke, or they did not have a scale and she was not aware it needed to be documented in the nursing notes or notify a physician. No policy was available during the survey or upon exit.

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 record reviews, and staff interview, it was determined the agency failed to notify physician for weights not completed for five patients (P) (P#1, P#3, P#4, P#5, P#6) of 21 sampled patients. The Findings include: 1. Review of the plan of care (POC) for P#1 (certification period of 10/27/23 to 12/25/23) required the skilled nurse (SN) to assess and instruct patient/caregiver on precautions to monitor and document daily weight for a patient diagnosed of heart failure (when the heart muscle doesn't pump blood as well as it should). The agency failed to notify the physician that the SN was unable to weigh the patient. 2. Review of the POC for P#3 (certification period of 12/8/23 to 2/5/24) required the SN to assess and instruct patient/caregiver on precautions to monitor and document daily weight for a patient diagnosed of congestive heart failure. The agency failed to notify the physician that the SN was unable to weigh the patient. 3. Review of the POC for P#4 (certification period of 12/31/23 to 2/28/24) required the SN to assess and instruct patient/caregiver on precautions to monitor and document daily weight for a patient diagnosed of congestive heart failure. The agency failed to notify the physician that the SN was unable to weigh the patient. 4. Review of the POC for P#5 (certification period of 12/15/23 to 2/12/24) required the SN to assess and instruct patient/caregiver on precautions to monitor and document daily weight for a patient diagnosed of congestive heart failure. The agency failed to notify the physician that the SN was unable to weigh the patient. 5. Review of the POC for P#6 (certification period of 12/14/23 to 2/11/24) required the SN to assess and instruct patient/caregiver on precautions to monitor and document daily weight for a patient diagnosed of congestive heart failure. The agency failed to notify the physician that the SN was unable to weigh the patient. On 1/22/24 at 4:47 p.m., an interview was conducted with Licensed Practical Nurse (LPN) DD who revealed that the scale was broke for P#4, P#5, and P#6, and she forgot to notify the physician. No policy was available during the survey and upon exit.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must 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 plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on observation, record review, staff interview, and review of agency policy, it was determined that the agency physician failed to sign plan of care (POC) for five patients (P) (P#1, P#4, P#6, P#8, and P#9) of 21 sampled patients. Findings include: Review of the agency policy titled “Physician Orders”, revised 10/01/23, Policy Number: 2.1.008 reveals the following: Procedure: 4. The Plan of Care (POC), telephone and or verbal orders must be signed and dated by the physician or authorized practitioner within a timely manner per state regulation: STATE Timeliness of Physician Signature Georgia 30 days The governing body failed to have POC signed by physician and failed to have POC signed by physician in a timely manner. 1. Review of clinical record of P#1 revealed P#1 was admitted to the home health agency on 10/27/2023. The physician signed the POC on 11/29/2023. 2. Review of record for P#4 revealed P#4 was admitted to the home health agency on 11/1/2023. The physician failed to sign the POC. 3. Review of record for P#5 revealed P#5 was admitted to the home health agency on 12/15/2023. The physician signed the POC on 1/16/2024. 4. Review of clinical record for P#6 revealed P#6 was admitted to the home health agency on 12/14/2023. The physician signed the POC on 1/19/2024. 5. Review of clinical record for P#9 revealed a patient was admitted to the home health agency on 12/3/2023. The physician failed to sign the POC. On 1/23/24 at 3:30 p.m., an interview was conducted with clinical manager (CM) who revealed the agency has problems with one physician that does not sign the patients verbal order plan of care in a timely manner.

At the time of the survey, Northeast Georgia Home Health Gainesville, Georgia. was in compliance with 42 CFR Part 484.22 Emergency Preparedness for Home Health Agencies as a result of a partial extended recertification survey conducted on April 28, 2021. A Focus Infection Control Survey was completed at the time of the survey. No deficiencies were cited.

At the time of the survey, Northeast Georgia Home Health Gainesville, Georgia was in substantial compliance with 42 CFR Part 484, Requirements for Home Health Agencies as a result of a partial extended recertification survey conducted on April 28, 2021. Census 183. 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 observations, clinical record reviews and staff interviews, it was determined the agency failed to ensure the patients' individualized plan of care included all of the required elements to address the patients' needs for 12 of 17 sampled Patients (P) #1, #3, #4, #5, #6, #7 , #10, #11, #13, #14, #15, and #17. Findings Include: 1. Review of the plan of care/treatment for P#6 with a recertification period of 4/1/21 to 5/30/21 revealed the patient has a pertinent diagnosis of diabetes mellitus type 2. The skilled nurse (SN) was required to notify the physician of fasting blood sugar (FBS) parameters of less than 60 or above 325. However, the plan of care/treatment lacked orders for the frequency of blood glucose monitoring to instruct the patient on how often to monitor blood glucose levels to monitor for early complications. Furthermore, the plan of care lacked instructions on diabetic home management to include foot care, diet management , diabetic diet, and skin care. The agency failed to ensure the plan of care/treatment covered all pertinent interventions for the comprehensive care of the patient's diabetic status. 2. Review of the plan of care/treatment for P #7 with a recertification period of 3/17/21 to 5/15/21 revealed the patient has a pertinent diagnosis of diabetes mellitus type 2. The skilled nurse (SN) was required to notify the physician of fasting blood sugar (FBS) parameters of less than 60 or above 300. The plan of care/treatment lacked orders for the frequency of blood glucose monitoring to instruct the patient on how often to monitor blood glucose levels to monitor for early complications. Furthermore, the plan of care lacked instructions on diabetic home management to include foot care, diet management , diabetic diet, and skin care . 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. During a home observation on 4/26/21 at 1:40 p.m., P#7 stated blood sugars are monitored four times a day, patient provided the surveyor with blood sugar log that patient maintains on daily basis. 3. Review of the plan of care/treatment for P#10 with a recertification period of 3/27/21 to 5/25/21 revealed the patient has a pertinent diagnosis of diabetes mellitus type 2. The skilled nurse (SN) was required to notify the physician of fasting blood sugar (FBS) parameters of less than 60 or above 300. The plan of care/treatment lacked orders for the frequency of blood glucose monitoring to instruct the patient on how often to monitor blood glucose levels to monitor for early complications. Furthermore, the plan of care lacked instructions on diabetic home management to include foot care, diet management, diabetic diet, and skin care Additionally, the plan of care revealed the patient has diagnosis of atrial fibrillation with long term use of anticoagulant (Aspirin low dose 81 mg daily) therapy. However, the plan of care lacked patient specific orders to assess and monitor anticoagulant therapy. 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 anticoagulant therapy. The agency staff failed to include orders to monitor the patient's diabetic status with a specified frequency to monitor the patient's blood sugar and assess and monitor the anticoagulant therapy on the plan of care. 4. Review of the plan of care/treatment for P#11 with a recertification period of 3/17/21 to 5/15/21 revealed the patient has a pertinent diagnosis of diabetes mellitus type 2 with foot ulcer. The skilled nurse (SN) was required to notify the physician of fasting blood sugar (FBS) parameters of less than 60 or above 250. The plan of care/treatment lacked orders for the frequency of blood glucose monitoring to instruct the patient on how often to monitor blood glucose levels to monitor for early complications. Furthermore, the plan of care lacked instructions of diabetic home management to include foot care, diet management, diabetic diet, wound healing, and skin care . 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/treatment for P #13 with a certification period of 12/15/20 to 2/12/21 revealed the patient has a pertinent diagnosis of atrial fibrillation with long term use of anticoagulant therapy (Eliquis 5 mg two times daily). However, the plan of care lacked patient specific orders to assess and monitor anticoagulant therapy. The agency staff failed to include orders to assess and monitor the patient's anti-coagulant therapy on the plan of care. The agency failed to ensure that the plan of care/treatment covered all pertinent interventions for the comprehensive care of the patient's anticoagulant therapy. 6. Review of the plan of care/treatment for P#14 with a recertification period of 6/23/20 to 8/21/20 revealed a principal diagnosis of chronic diastolic congestive heart failure (CHF). However, the plan of care/treatment does not specify interventions for monitoring for heart failure exacerbation (i.e., edema assessments , weight assessments or abdominal girth measurements) to evaluate the patient for complications and to alert the physician of potential complications. The agency failed to ensure the patient's plan of care/treatment addressed all of the pertinent interventions for the comprehensive care of the patient. 7. Review of the plan of care/treatment for P#15 with a certification period of 12/27/20 to 2/24/21 revealed the patient has a pertinent diagnosis of atrial fibrillation with long term use of anticoagulant therapy (Eliquis 5 mg two times daily). However, the plan of care lacked patient specific orders to assess and monitor anticoagulant therapy. The agency staff failed to include orders to assess and monitor the patient's anti-coagulant therapy on the plan of care. The agency failed to ensure that the plan of care/treatment covered all pertinent interventions for the comprehensive care of the patient's anticoagulant therapy. During an interview on 4/28/21 at 12:00 p.m., the Clinical Manager (CM) provided no evidence that the plan of care included orders to teach and monitor patient's cardiac status and its complications. CM also confirmed the plan of care/treatment lacked interventions for monitoring for CHF. 8. Review of the plan of care/treatment for P#17 (closed record) with a certification period of 9/14/20 to 11/12/20 revealed the patient has a diagnosis of pulmonary embolism with long term use of anticoagulant therapy (Eliquis 5 mg two times daily). However, the plan of care lacked patient specific orders to assess and monitor anticoagulant therapy. The agency staff failed to include orders to assess and monitor the patient's anti-coagulant therapy on the plan of care. The agency failed to ensure that the plan of care/treatment covered all pertinent interventions for the comprehensive care of the patient's anticoagulant therapy. 9. Review of the plan of care/treatment for P#5 with a recertification period of 3/5/21 to 5/3/21 revealed an incomplete Foley catheter order which reads as follows: Skilled nurse for insertion of Foley catheter maintenance with catheter # 18 French 10 cc Balloon indwelling catheter using aseptic technique. Change every 3 weeks and as needed for dislodgement or blockage. The order was not complete as it did not specify what type and the amount of fluid to instill into the balloon. The plan of care lacks specific interventions to monitor the patient's foley catheter. The agency failed to obtain a complete and accurate order for the care and maintenance of the catheter. The agency failed to ensure the plan of care/treatment covered all pertinent interventions for the comprehensive care of the patient's foley catheter management. During an interview on 4/27/21 at 11:00 a.m., the Clinical Manager (CM) acknowledged the agency failed to ensure the plan of care has accurate and complete foley catheter order for the care and maintenance of the catheter. 10. Review of the plan of care/treatment for P#1 with a certification period of 4/6/21 to 6/4/21 revealed the patient has a pertinent diagnosis of Lymphedema with long term use of anticoagulant therapy (Eliquis 2.5 mg one time daily). However, the plan of care lacked patient specific orders to assess and monitor anticoagulant therapy. The agency staff failed to include orders to assess and monitor the patient's anti-coagulant therapy on the plan of care. The agency failed to ensure that the plan of care/treatment covered all pertinent interventions for the comprehensive care of the patient's anticoagulant therapy. During an interview on 4/28/21 at 10:30 a.m with clinical manager, the surveyor was provided initial assessment visit note which stated that the patient is taking care of her lymphedema. 11. Review of the plan of care/treatment for P#3 with a certification period of 4/23/21 to 6/21/21 revealed the patient has a pertinent diagnosis of Unspecified Diastolic Congestive Heart Failure. However, the plan of care lacked patient specific orders to assess and monitor complications of Congestive Heart Failure. The agency staff failed to include orders to assess and monitor the patient's weight or blood oxygen level on the plan of care. The agency failed to ensure that the plan of care/treatment covered all pertinent interventions for the comprehensive care of the patient's Unspecified Diastolic Congestive Heart Failure. 12. .Review of Plan of Care/treatment for P#4 with a certification period of 3/20/21 to 5/18/21 revealed the patient has a pertinent diagnosis of diabetes mellitus type 2. The plan of care/treatment lacked orders for the frequency of blood glucose monitoring to instruct the patient on how often to monitor blood glucose levels to monitor for early complications. The plan of care revealed that patient has a long-term use of anticoagulant therapy (Aspirin low dose 81 mg daily). However, the plan of care lacked patient specific orders to assess and monitor anticoagulant therapy. 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 anticoagulant therapy. During an interview on 4/27/21 at 9:15 a.m., the Clinical Manager (CM) confirmed the plan of care/treatment lacked a blood glucose monitoring frequency and teaching on diabetic management and anticoagulant therapy complications. The CM stated staff are providing education during each visit to instruct the patient on how often to monitor blood glucose levels and when to notify the SN of high blood sugars and providing instructions on anticoagulant therapy and cardiac complications. During an interview on 4/28/21 at 12:00 p.m., with the Administrator and the clinical manager (CM) they did not provided evidence that the plan of care included orders to monitor the patient's diabetic status, to specify the frequency to monitor the patient's blood sugars, assessment and intervention to monitor patient's anticoagulant therapy, interventions to monitor CHF complications, and complete foley catheter orders. The Clinical Manager (CM) stated that the plan of care should contain the frequencies to monitor blood glucose parameters and the teaching of diabetic management , CHF management anticoagulant therapy and its complications and complete foley catheter orders.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, it was determined that the agency staff failed to ensure treatments were administered only as ordered by the physician for 1 of 17 Patient's (P) #5 who receive home health services. Findings Include: Review of the skilled nurse (SN) visit note dated 4/15/21 and 4/20/21 for P#5 with a recertification period of 3/5/21 to 5/3/21 revealed the SN performed foley catheter change as follows: 18 french 10 cc balloon catheter inserted. Balloon inflated with 10 cc sterile water . Catheter secured with Stat lock , returned 30 cc urine. Tube secured and proper drainage bag placement. Patient tolerated procedure without complications. However, the review of the plan of care/treatment revealed an incomplete foley catheter order which reads as follows: Skilled nurse for insertion of foley catheter maintenance with catheter # 18 French 10 cc Balloon indwelling catheter using aseptic technique. Change every 3 weeks and as needed for dislodgement or blockage. The foley catheter order was not complete as it did not specify the type and the amount of fluid to instill into the balloon. The plan of care lacks specific interventions to monitor the P#5's foley catheter. The agency failed to obtain a complete and accurate order for the care and maintenance of the catheter. The clinical record lacked an order for this intervention. The agency failed to ensure this procedure was administered only as ordered by a physician. During an interview on 4/27/21 at 11:00 a.m., the Clinical Manager (CM) confirmed the catheterization was performed without a complete physician's order. The CM stated that the SN had obtained a verbal order , however it was not documented in the visit note and in the plan of care.