Every finding on record at Lhcg Lvii LLC

A complaint survey, prompted by #CO2789112 was completed on 4/9/26. One deficiency was cited.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled professional services were authorized, delivered, and supervised only by appropriate qualified health care professionals for 1 of 1 patients (Patient #1). Findings include: 1. Review of Patient #1’s record, reviewed on 4/8/26 at 7:54 p.m., revealed a start of care date of 11/20/25. The initial plan of care (POC) covered a certification period of 11/20/25 to 1/28/26. The plan of care included orders which stated the skilled nurse was to evaluate the patient and develop a POC in coordination with the physician. a.The agency failed to ensure skilled professional services were authorized by qualified healthcare professionals. Specifically, the agency did not receive authorization from Patient #1’s primary care physician (PCP) before the delivery of services. Further record review revealed Patient #1’s listed PCP documented as a medical doctor not employed by the agency (PCP #1). According to a coordination note dated 11/19/25, Employee #3 documented they received a verbal agreement from PCP #1’s nurse to start services for Patient #1. A coordination note dated 12/4/25 revealed PCP #1’s nurse contacted the after-hours triage line and stated PCP #1 was not authorized to practice medicine in Colorado, and does not service Patient #1. A second coordination note dated 12/4/25 documented PCP #1 called the agency, and stated they were to be removed from Patient #1’s services due to them not being authorized to provide care to Patient #1. Patient #1 had received care and services from the agency from 11/20/25 to 12/14/25. Patient #1 was then discharged by the agency due to the lack of a payor source. During an interview on 4/8/26 at 12:59 p.m., with the agency administrator/director of nursing (DON), she stated PCP #1 was not a qualified physician able to sign for and provide authorization of orders to be carried out by the agency. She further stated the process, which is to find another provider once notified the provider was not qualified. She stated she was made aware of the issue, but the agency did not take further action to facilitate a physician for Patient #1.

A complaint survey, prompted by #CO2637796 was completed on 11/21/25. Two deficiencies were cited.

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on interviews and record reviews, the agency failed to ensure the patient had the right to be free of neglect for 3 of 4 consumer records reviewed (Patient #1, #3 and #4) (Cross Reference G-580). Findings include: 1. The clinical record for Patient #1 was reviewed on 10/10/25. The plan of care (POC) for the period dated 8/31/25 to 10/29/25 revealed a start of care date of 3/5/25. Diagnoses included Parkinson's, major depressive disorder, dementia with mood disturbance, generalized anxiety disorder, type 2 diabetes, and insomnia. POC orders included skilled nursing (SN) visits once a week for nine weeks for assistance with wound care and education on wound care, and two as needed visits for wound complications. a. The agency failed to ensure Patient #1 was free of neglect. Review of Patient #1's clinical record revealed the Patient was supposed to receive (SN) visits once a week for nine weeks starting the week of 8/31/25. Review of the SN visit notes revealed Patient #1 was seen on 9/4/25 and on 9/10/25, however there were no further visits noted in the Patient's record. Furthermore there was no evidence of communication with the Patient between 9/10/25 and 10/3/25, regarding missed visits or how Patient #1 had his needs met and not be neglected of skilled services during this time period. Further review of the clinical records revealed a note dated 10/3/25. This note was a documented phone conversation between the alternate administrator and the wife of Patient #1. In the note, the alternate administrator apologized to the wife of Patient #1 for missing visits between 9/10/25 and this phone call on 10/3/25. The alternate administrator also inquired about the health of the Patient which per the note was fine. The wife of Patient #1 also relayed to the alternate administrator they would not be needing further care. During an interview on 10/13/25 at 11:54 a.m., the administrator and alternate administrator confirmed that Patient #1 had not been seen since 9/10/25, and had missed three SN visits at the time of discharge on 10/3/25. The administrator and alternate administrator stated they could not argue that Patient #1 was neglected due to not receiving services, not reporting missed visits to the physician and not communicating with the family. The administrator and alternate administrator stated this should not have happened. 2. Similar findings were found for Patients #3 and #4. 3. During an interview on 10/13/25 at 11:54 a.m., the administrator and alternate administrator confirmed that visits were also missed for Patients #3 and #4 and there was no indication how these Patients were kept free of neglect.

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 interviews and record reviews, the agency failed to services were administered only as ordered by a physician or allowed practitioner for 3 of 4 patient records reviewed (Patient #1, #3 and #4) (Cross Reference G-430). Findings include: 1. The clinical record for Patient #1 was reviewed on 10/10/25. The plan of care (POC) for the period dated 8/31/25 to 10/29/25 revealed a start of care date of 3/5/25. Diagnoses included Parkinson's, major depressive disorder, dementia with mood disturbance, generalized anxiety disorder, type 2 diabetes, and insomnia. POC orders included skilled nursing (SN) visits once a week for nine weeks for assistance with wound care and education on wound care, and two as needed visits for wound complications. a. The agency failed to follow the POC by not providing visits and wound care as ordered on the POC to Patient #1. Review of Patient #1's clinical record revealed the Patient was supposed to receive (SN) visits once a week for nine weeks starting the week of 8/31/25. Review of the SN visit notes revealed Patient #1 was seen on 9/4/25 and on 9/10/25, however there were no further visits noted in the Patient records. Furthermore there was no evidence of communication with the Patient between 9/10/25 and 10/3/25, regarding missed visits. Additionally there was no documentation with Patient #1's physician regarding missed visits. Further review of the clinical records revealed a note dated 10/3/25. This note was a documented phone conversation between the alternate administrator and the wife of Patient #1. In the note the alternate administrator apologized to the wife of Patient #1 for missing visits between 9/10/25 and this phone call on 10/3/25. The alternate administrator also inquired about the health of the Patient which per the note was fine. The wife of Patient #1 also relayed to the alternate administrator they would not be needing further care. Review of the clinical record for Patient #1 revealed a discharge date of 9/28/25. During an interview on 10/10/25 at 12:15 p.m., the administrator stated the discharge date was incorrect and it should be 10/3/25, the day the phone call took place and the agency was let go by the family of Patient #1. During an interview on 10/13/25 at 11:54 a.m., the administrator and alternate administrator confirmed that Patient #1 had not been seen since 9/10/25, and had missed three SN visits at the time of discharge on 10/3/25. The administrator stated it was an error in the system and processes of the agency and that no other visits were plotted on the schedule for Patient #1 after 9/10/25. The administrator went on to state if the agency had completed its reports this error would have been found and the Patient would not have missed visits. 2. Similar findings were found for Patients #3 and #4. 3. During an interview on 10/13/25 at 11:54 a.m., the administrator and alternate administrator confirmed that visits were also missed for Patients #3 and #4.

A recertification survey was completed on 9/25/25. 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 Center for Medicaid and Medicare services (CMS) Outcome and Assessment Information Set (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 5 of 5 focused patients record reviewed (Focused Patient A, B, C, D and E) whose data was transmitted from 9/22/24 through 9/22/25. Findings include: 1. Review of the OASIS Error detail report from 11/1/24 through 11/19/24 revealed 75 assessments 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. 2. Review of the OASIS error report for 11/1/24 to 11/19/24 revealed Focused Patient D had her OASIS submitted for the following assessment; A discharge assessment was created on 6/18/25 and transmitted on 9/9/25 or 83 days after the M0090 date. There was no documentation in the record for a reason as to why the OASIS for Focused Patient D had her discharge OASIS submitted more than 53 days after it was due. 3. Similar findings were found for Focused Patient A, B, C and E. 4. During an interview on 9/25/25 at 11:44 a.m., the administrator stated the agency clinicians would go do an assessment, complete it and submit it to the agency quality review staff to review the completed OASIS assessment. The administrator went on to state the quality review staff would send it back to the clinicians to fix any errors after which point the quality review staff would then submit the completed OASIS to CMS. During an email correspondence on 9/25/25 at 12:30 p.m., the business manager reported she could not explain why the OASIS was transmitted after the 30 day deadline for the Focus patient A, B and C. The business manager also stated the reason for not submitting the OASIS for Focus patient D and E was due to it being not scheduled or completely correctly. During an interview on 9/25/25 at 1:19 p.m., the administrator stated things did not work as they were supposed to work and this is the reason why the OASIS were not submitted within the 30 day time period.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure a comprehensive assessment was completed no later than five calendar days after each patient's start of care for 2 of 10 active patients who received physical therapy (PT) records reviewed (Patient #7 and #10). Findings include: 1. The clinical record for Patient #7 was reviewed on 9/23/25. The plan of care for the certification period dated 7/24/25 to 9/21/25, revealed a start of care date of 7/24/25; diagnoses included acute cystitis without hematuria, paroxysmal atrial fibrillation, hypertensive chronic kidney disease and pulmonary hypertension. Plan of care orders included skilled nursing (SN) once a week for one week, two times a week for two weeks, and once a week for six weeks for wound care, skilled teaching to prevent pressure ulcers and monitor pain; PT once a week for one week to perform an assessment and treat; OT once a week for three weeks, to provide therapeutic exercise, establish home exercise program and provide training for bathing techniques. a) The agency failed to ensure the PT completed a comprehensive assessment within five calendar days of Patient #4's start of care date of 7/24/25. Review of a referral dated 7/20/25 revealed Patient #7 was to be evaluated by SN, PT, and OT services for evaluation and treatment. Review of Patient #7's clinical record on 9/23/25 revealed the PT performed a physical therapy assessment on 8/8/25 or 15 days after the start of care. There was no documentation as to why the comprehensive PT evaluation was done 10 days after the date it was due. During an interview on 9/23/25 at 11:53 a.m., the alternate administrator stated the agency had fallen out of the five day window for the PT assessment. The alternate administrator stated the agency should have called and received a delayed assessment order from the physician of Patient #7 but had not done so. Furthermore the alternate administrator stated Patient #7 had been tough to get a hold of but the agency had no documentation of these issues. 2. Similar findings were found for Patient #10. During an interview on 9/25/25 at 1:20 p.m., the administrator stated she did not have a good answer as to why these PT assessments were delayed. The administrator went on to state the agency should have done things differently and some of the issues were miscommunication. The administrator stated the agency did have processes in place but they were not followed.