Every finding on record at Lhcg Lvii LLC

A recertification survey was completed on 1/8/26. Two deficiencies were 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 interview and record review, of the CMS OASIS Error Detail report, the agency failed to electronically transmit current and accurate data regarding each beneficiary with respect to which information was required to be transmitted within 30 days of completing the assessment of the beneficiary for 2 of 2 focus sample records reviewed (Focus Sample A and B) whose data was transmitted from 1/1/25 through 1/1/26. Findings include: 1. Review of the OASIS Error detail report from 1/1/25 through 1/1/26 revealed seven assessments which pertained to seven different patients, which were submitted more than 30 days after the "M0090" date which was the last date information used to complete the comprehensive assessment and determine the OASIS coding gathered by the assessing clinician. a. The agency failed to ensure OASIS data was transmitted within 30 days of completing the assessment. Review of the OASIS error report for 1/1/25 to 1/1/26 revealed Focused Sample A had an OASIS recertification completed on 11/5/25. The OASIS recertification was not submitted until 12/10/25 or five days after the 30 day submission deadline date. On 1/7/25 a review of the agency's electronic medical record (EMR) system revealed the agency had started the OASIS on 11/5/25. It was locked on 11/20/25 and sent on 12/9/25. 2. Similar findings were found for Focused Sample B. 3. During an interview on 1/6/25 at 8:22 a.m., the administrator stated the issues with the OASIS reports being transmitted late was an internal issue with the agency's quality process. The administrator stated an office quality process was holding the transmission of the completed OASIS past its due date and she was not aware of this new process. During an interview on 1/8/25 at 3:45 p.m., the administrator again stated the quality process was backed up and she was not aware of this new process. The administrator stated she was aware of this process and would fix it going forward.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to coordinate care delivery to meet the patient’s needs for 1 of 4 patient records reviewed who were receiving skilled nursing services related to wound care (Patient #6). Findings include: 1. The clinical record for Patient #6 was reviewed on 01/06/2026. The plan of care with certification period of 11/12/25 to 1/10/26 revealed a start care date of 11/12/25. Patient #6 had the following diagnoses; type 2 diabetes mellitus with hyperglycemia and cataract, chronic obstructive pulmonary disease, age-related osteoporosis and pressure ulcers on both heels. Plan of care orders include skilled nursing (SN) visits once a week for one week, five times a week for 4 weeks, and two as needed visits for wound care. Additionally an updated order was sent on 12/22/25 for an additional five times a week SN visits for wound care for an unspecified number of weeks. a. The agency failed to coordinate care delivery to meet Patient #6's needs, specifically the agency failed to inform the physician of cancelled or missed visits. Records review for Patient #6 done on 1/6/26 revealed 3 missed visits from 11/12/25 to 1/6/26 with no documentation of the reasons for the missed visits and notification of the physician of these missed visits. There was no further documentation as to why these visits were missed or as to why the physician was not notified of the missed visits. During an interview on 1/7/26 at 9:17 a.m., the administrator stated Patient #6 did not want to be seen on holidays. During an interview on 1/8/26 at 8:57 a.m., the licensed practical nurse (LPN), who provided care to Patient #6, stated the patient refused holiday visits. During an interview on 1/8/26 at 8:59 a.m., the administrator stated due to Patient #6 reporting not wanting visits on holiday, she had not documented and reported the missed visit to the physician.

A complaint survey prompted by #CO27392 was completed on 6/16/21. Two 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 interview and record review, the agency failed to ensure all patient medications were reviewed and reconciled to identify new, discontinued, or changed medications as required at the time of admission for 1 of 1 patient records reviewed who was readmitted for exacerbation of a previously healed wound (Patient #2). Findings include: AGENCY POLICY According to the agency policy titled "Admission Process" revised 1/1/21 (in pertinent part); 5. "The admitting clinician will: a. Complete verification of Physician Orders, assessment on all other forms and plan of care." According to the agency's policy titled, "Patient Assessments, Initial, and Reassessment" revised 10/1/18 (in pertinent part); 1. "Upon admission and reassessments, the qualified clinician performs the following assessment activities and collects the following data: a. Current health status, psychosocial, functional, and cognitive status b. Review of all medications 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". 1. During an interview on 6/10/21 beginning at 3:02 p.m., the agency's Divisional Orientation Coordinator (DOC) stated the information the admission nurse inputs into the electronic medical record (EMR) to generate the patient's plan of care was reviewed by the Patient Care Manager (PCM) and any discrepancies or inconsistencies were communicated to the clinician for needed changes. She stated it was the registered nurse (RN)'s responsibility to transfer accurate information (inclusive of the medication list) from the referral document during the comprehensive assessment of the patient. According to the DOC, the clinicians were professionals and responsible for the accuracy of the information they input into the EMR and the RN bore responsibilities for any omissions. 2. The clinical record for Patient #2 was reviewed 6/11/21. The Plan of Care for the certification period, dated 5/26/21 to 7/24/21, revealed a start of care date of 5/26/21; diagnoses included chronic venous hypertension with ulcer of right lower extremity and cellulitis of right lower limb. Plan of Care orders included skilled nurse (SN) visits one time a week for one week, twice weekly for one week, four times a week for one week, twice weekly for one week, three times a week for one week, twice a week for one week and then three times a week for one week to provide skilled assessment and wound care to the right lower extremity. a) Clinical record review showed the agency failed to ensure nursing staff appropriately reconciled the patient's medications as part of the medication review during the comprehensive assessment. Review of a hospital discharge/physician order dated 5/24/21 showed an order for Clindamycin (an antibiotic) HCL 300 mg (milligram) capsule, 300 mg by mouth twice daily for 7 days. This medication was identified as "new". Review of a comprehensive assessment completed on 5/26/21 pertaining to the certification dated 5/26/21 to 7/24/21 showed the assessment was completed by RN #5. Review showed under the section titled "Medication", RN #5 documented all medications were reviewed and reconciled for Patient #2's medication during the assessment. However, review of the plan of care related to the certification period dated 5/26/21 to 7/24/21 failed to include the medication order for Clindamycin 300 mg by mouth twice a day for seven days. Further record review revealed no evidence of a physician's order to discontinue the Clindamycin order dated 5/24/21 and clinical record review failed to show documentation to explain why the medication was missing from the list of medications on the plan of care. Additionally, there was no documentation Patient #2 had completed the antibiotic regimen. Review of a Visit Note Report dated 5/31/21 showed RN #4 documented Patient #2's wound was saturated with yellowish drainage "with redness present to leg up to calf". Further review showed RN #4 documented she then contacted RN #5 to get report about the status of the wound at the time of admission. According to RN #4's documentation, RN #5 stated there was no redness to the wound, the "wound was pink" at the time of the admission. Clinical review showed RN #4's concerns for the wound deterioration, swelling and erythema were then communicated to the physicians responsible for the care of Patient #2 and RN #4 obtained new orders for 2 antibiotics - Amoxicillin and doxycycline. During an interview on 6/16/21 beginning at 8:52 a.m., RN #5 stated during the comprehensive assessment he had asked if Patient #2 was on antibiotic and the patient said no. RN #5 stated he did not remember if the patient had started or completed any antibiotic and added "I should probably not have taken his word for it at the time". RN #5 stated, "unfortunately, I guess I missed it".

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on interview and record review the agency failed to ensure services were provided in accordance with physician's orders for 2 of 3 patients reviewed requiring Home Health Aide (HHA) services (Patients #3 and #7). Findings include: 1. The clinical record for Patient #3 was reviewed on 6/13/21. The Plan of Care for the certification periods dated 4/23/21 to 6/21/21, revealed a start of care date of 4/23/21; diagnoses included rheumatic disorder of mitral, aortic and tricuspid valves, and type 2 diabetes mellitus with hypoglycemia without coma. Plan of Care orders included Skilled Nurse (SN) visits weekly to monitor pain and instruct on other pain control measures and new and changed medications; and physical therapy (PT) visits twice a week for three weeks and then weekly for three weeks to provide therapeutic exercise for restoration of upper extremity functional deficit. a) The agency failed to ensure HHA services were provided as ordered by the physician. Review of a referral order dated 4/21/21 showed the referring physician had ordered home health nursing, physical therapy and shower aide. According to the plan of care dated 4/23/21 to 6/21/21, Patient #3 had poor respiratory status, unsteady gait, physical limitation impacting mobility, and weakness in the lower extremity causing balance or gait disturbances and/or falls. However, the agency failed to provide home health aide services to Patient #3 as ordered by the referring physician. Review of the PT evaluation completed on 4/26/21 showed PT #3 documented Patient #3 needed assistance with bathing due to difficulty using the right upper extremity due to her scapula fracture. PT #3 also documented Patient #3 stated her daughter who lived closed by was helping her. However, clinical record review failed to show evidence the agency had contacted the referring physician HHA service as ordered was not being provided to Patient #3 and why. 2. The clinical record for Patient #7 was reviewed on 6/15/21. The Plan of Care for the certification periods dated 5/29/21 to 7/27/21, revealed a start of care date of 5/29/21; diagnoses included other intra-articular fracture of lower end of left radius, subsequent encounter for closed fracture with routine healing and unspecified fracture of left pubis, subsequent for fracture with routine healing. Plan of Care orders included SN visits weekly for two weeks for skilled assessment and to monitor pain and instruct on other pain control measures and new and changed medications; and PT visits one time a week for one week, twice a week for one week, three times a week for one week, twice a week for one week, and then weekly for three weeks to provide assistance with functional level and instruct on safety and fall risk reduction strategies. a) The agency failed to ensure HHA services were provided as ordered by the physician. Review of a referral order dated 5/29/21 showed the referring physician had ordered home health nursing, physical therapy and nurse aide. According to the plan of care dated 5/29/21 to 7/27/21, Patient #7 had pain impacting mobility, poor respiratory status, unsteady gait, physical limitation, and weakness in the lower extremity causing balance or gait disturbances and/or falls. However, the agency failed to provide home health aide services to Patient #7 as ordered by the referring physician. Clinical record review failed to show evidence the agency had contacted the referring physician HHA service as ordered was not being provided to Patient #7 and why. During an interview on 6/16/21 beginning at 10:12 a.m., the agency's Business Manager was asked to help locate any communication the agency had with Patient #3 and #7's physicians for not providing services as ordered. At 11:51 a.m., when she returned she told the surveyor "I did not find any communication with the physician for not providing home health aide to Patients #3 and #7.