Every finding on record at Lhcg Clxv, LLC

A Recertification survey was conducted at University Home Health Services on December 9, 2024, and concluded on December 11, 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 University Home Health Services on December 9, 2024, and concluded on December 11, 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 214. 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, agency policy “OASIS Data Capture, Transmission, Verification, Display and Reports,” and staff interview, it was determined that the agency failed to electronically transmit Outcome and Assessment Information Set (OASIS) data to CMS system every 30 days. Findings include: Review of the policy titled “OASIS Data Capture, Transmission, Verification, Display and Reports,” last revised 03/01/21, revealed the following: 2. At least monthly, Agency will electronically transmit accurate, completed, encoded and locked OASIS data to the state agency. All OASIS assessments completed must be transmitted within thirty (30) days of M0090 date. Review of CMS report titled “HHA Error Summary by Agency,” with a run date of 9/2023-8/20/24, revealed the agency failed to transmit OASIS data to the CMS system within 30 days. On 12/10/2024 at 1:00 pm, during an in-office interview, the Patient Care Manager (PCM) confirmed awareness of the 30-day OASIS submission time frame requirements not met during the time frame of 9/2023 through 8/20/2024. The PCM explained the agency OASIS reviewing and submission process was undergoing a new process with new staff submitting the information and the staff have not yet reached the goal of getting the OASIS information submitted within the required 30-day timeframe.

At the time of the survey, University Home Health Services in Waynesboro, GA. was in compliance with Emergency Preparedness for Home Health Agencies, as a result of a recertification survey conducted December 15, 2021. A focus infection control survey was completed at the time of the survey. Active census 145.

At the time of the survey, University Home Health in Waynesboro, GA. was in substantial compliance with 42 CFR Part 484, Requirements for Home Health Agencies as a result of a recertification survey conducted on December 15, 2021. A focus infection control survey was completed at the time of the survey. Active census 145. The following deficiencies were cited:

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 home visit observations, clinical record review and staff interview it was determined that the home health agency failed to ensure that the medication profile was updated in to reflect current medications at the time of the comprehensive assessment for two of five sampled patients (P) (P#3 and P#4) observed during home visits. The finding include: A home visit was conducted at the home of P#3 on 12/14/21, at 9:40 a.m. P#3 was admitted to the agency on 11/23/21, with the admitting diagnosis of malignant neoplasm of the prostate. The clinical record was reviewed for certification period 11/23/21 to 1/21/22. Upon review of the medications in the home with Certified Occupational Therapy Assistant (COTA) AA during the visit, it was revealed that P#3 was taking the pain medication hydromorphone 2 milligrams (ml) as directed per the instructions on the prescription bottle. The directions on the label were: “Take 1 to 2 tabs every 4 hours as needed for pain”. However, the agency electronic medical record (EMR) had the medication listed as follows: “hydromorphone 2 mg, 2 tablets every 4 hours as needed”. P#3 also had the over-the-counter antacid medication Tum’s Calcium Carbonate 500 mg in the home. P#3 stated: “I take when I need it.” but did not have a routine frequency. The agency EMR did not have the medication listed. P#3 also had the over-the- counter stool softener medication docusate sodium 50 mg in the home. P#3 stated: “I take two or three pills if I do not have a bowel movement in a couple of days”. The agency EMR did not have the medication listed. In an interview at the home during the visit, COTA AA acknowledged that the medications in the home did not match the medications listed in the agency’s EMR. A home visit was conducted at the home of P#4 on 12/14/21, at 11:30 a.m. P#4 was admitted to the agency on 12/4/21, with the admitting diagnosis of essential primary hypertension. The clinical record was reviewed for certification period 12/4/21 to 2/1/22. Upon review of the medication in the home with physical therapist (PT) BB during the visit, it was revealed that P#4 had the pain medication hydrocodone/ acetaminophen 5mg/325mg present in the home with the following instructions on the label: “Take one every hour only for severe pain”. However, the medication was not listed in the agency’s EMR. The patient stated: “The doctor keeps sending the prescription in, but I don’t take them”. The patient also had the gastrointestinal anti-spasmatic medication dicyclomine in the home with the following instructions on the label: “Take one 10mg tablet three times daily”. However, the agency’s EMR had the medication entered as “dicyclomine 20 mg tablets three times daily”. P#4 stated: “I am taking it like it says to on the bottle”. Additionally, P#4 had the neuropathic pain medication pregabalin 100mg in the home with the following instructions on the label: “Take one capsule three times per day”. However, the agency EMR had the medication listed as “pregabalin 100mg, one capsule three times daily”. P#4 stated “I only take one at bedtime every evening. I don’t take it two or three times a day”. In an interview in the home during the visit, PT BB acknowledged that the medications in the home did not match the medications listed in the agency’s EMR. The agency Clinical Director was informed of these findings in an interview at the agency on 12/15/21, at 11:40 a.m.

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 clinical record reviews and staff interviews it was determined the agency failed to follow the ordered plans of care for visit frequencies and patient teaching regarding disease process for two of thirteen (#7 and #8) sampled patients (P). Findings were: 2. Review of the plan of care for P#8 with a certification period of 10/27/21 to 12/25/21 required the skilled nurse (SN) to provide instruction related to heart failure including but not limited to: signs and symptoms of heart failure, measures to manage heart failure and possible complications of heart failure. The SN visited the patient on 11/22, 12/2, and 12/9/21 however, the clinical record did not show evidence that the SN taught the patient the signs and symptoms of heart failure or measures to effectively manage heart failure complications in the home. The SN failed to follow the ordered plan of care to provide teaching to manage heart failure status. During an interview on 12/15/21 at approximately 11:30 a.m., the Clinical Director and Patient Care Manager did not provide documentation of patient teaching regarding the management heart failure in the home. P#7 was admitted to the agency on 10/4/21, with the admitting diagnosis of cellulitis of right lower limb. The clinical record was reviewed for certification period 10/4/21 to 12/2/21. P#7 had a physician’s order for a skilled nurse (SN) to visit two times per week for eight weeks and then once a week for one week. However, on the week beginning 11/21/21, P#7 received only one SN visit. There was no documentation in the clinical record recording stating the reason P#1 did not receive two visits on the week beginning 11/21/21. The clinical record also lacked documentation of notification to the physician of the missed visit.

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 clinical record reviews and staff interviews, it was determined that the agency staff failed to include orders to cover all pertinent diagnoses and ensure the patients' needs were addressed to include disease specific interventions/treatments were included on the plans of care for four of thirteen (#6, #7, #8 and #9) sampled patients (P). Findings were: 3. Review of the plan of care for patient #6 with a certification period of 11/1/21 to 12/30/21 revealed the patient has a pertinent diagnosis of Type 2 diabetes mellitus. The plan of care instructs the skilled nurse (SN) to teach the patient on blood glucose testing and frequency of blood glucose testing however, the plan of care does not contain a blood glucose monitoring frequency which would instruct the patient in how often to check blood glucose levels and prompt the staff to notify the physician for early intervention and treatment of a diabetic exacerbation. The agency failed to ensure the plan of care was complete and comprehensive for the care and monitoring of the patient's diabetic status. During an interview on 12/15/21 at approximately 11:30 a.m., the Clinical Director and Patient Care Manager acknowledged the plan of care was incomplete and did not include clear instruction for the care of the patient’s diabetic status. 4. Review of the plan of care for P#8 with a certification period of 10/27/21 to 12/25/21 revealed the patient has a primary diagnosis of hypertensive heart disease and chronic kidney disease with heart failure however, the plan of care lacks interventions such as weight monitoring, edema assessments, or abdominal girth measurements to monitor the patient for early complications which would prompt the staff to notify the physician for early intervention and treatment of heart failure complications. The agency failed to ensure the plan of care/treatment was complete and comprehensive for the care and monitoring of the patient's heart failure status. During an interview on 12/15/21 at approximately 11:30 a.m., the Clinical Director and Patient Care Manager acknowledged the plan of care was incomplete and did not include clear instruction for the care of the patient’s heart failure status. P#7 was admitted to the agency on 10/4/21, with the admitting diagnosis of cellulitis of right lower limb. P#7 also had the following comorbid diagnoses: cellulitis of right toe, type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcer of other part of right foot with unspecified severity, acquired absence of right great toe and long-term current use of insulin. The clinical record was reviewed for certification periods 10/4/21 to 12/2/21 and 12/3/21 to 1/31/22. The clinical record revealed the following orders:“Skilled nurse to perform/ instruct/ reinforce patient/ caregiver of wound to sacrum twice daily and as needed for soiling. Cleanse with soap and water, pat dry, apply Calmoseptine ointment.” The order was dated 10/4/21. The order lacked instructions regarding whether to leave the wound open to air or to cover the wound with a particular type of dressing.“Using clean technique daily wound care to RT (right) 2nd toe; cleanse with NS (normal saline), pat dry, apply Band-Aid. Caregiver to provide care in absence of SN (skilled nurse) visit. The order was dated 10/4/21. The order lacked instructions regarding how often the wound care should be performed. “Patient/caregiver to perform blood glucose testing daily”. The order was dated 10/4/21. The order lacked specification of what time to do blood glucose testing in relation to P#7’s meal schedule. “Skilled nurse to cleanse wound to RT great toe amputation site with NS, apply peri wound area with skin prep, fill entire cavity with black foam, cover with transparent drape and apply tubing, apply negative pressure devise at 125mm/hg (millimeters of mercury) continuous. Use the following protocol as an alternative dressing as needed for peri wound maceration/ breakdown, pump failure or other complications.” The order was dated 10/4/21. The order lacked instructions on the protocol to use as an alternative dressing.“Skin tear to RT upper arm using clean technique cleanse with NS, pat dry, apply Vaseline gauze dressing cover with non-adherent, wrap with dry gauze dressing and secured with tape. May change prn (as needed) for soiling or dislodgement.” The order was dated 12/9/21. The order provided a prn frequency for wound care but lacked a routine frequency for the wound care to be provided.P#9 was admitted to the agency on 9/2/21, with the admitted diagnosis of type 2 diabetes mellitus with foot ulcer. P#9 asl had the following co morbid diagnoses: non pressure chronic ulcer to other part of left foot limited to breakdown of skin and long-term use of insulin. The clinical record was reviewed for certification period 11/1/21 to 12/30/21. The clinical record revealed that P#9 was taking two insulins used to lower blood glucose: Levemir and Novolin R. However, the clinical record lacked a physician’s order for the frequency of monitoring blood sugars required for management of both insulins.