Every finding on record at Lhcg Lxiii, LLC

MEDICARE HOME HEALTH RECERTIFICATION SURVEY The Washington State Department of Health (DOH) in accordance with Medicare Conditions of Participation set forth in 42 Part 484 conducted this health and safety survey. Examination number: X2025-332 Dates Onsite: 06/09/25-06/11/25 This survey was conducted by: Surveyor #1 Surveyor #3 DOH staff found the facility in substantial compliance with all Conditions of Participation except those standard-level deficiencies listed below. DOH recommends recertification based on an acceptable plan of correction. .

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: . Based on document review, record reviews, and interviews, the agency failed to accurately complete the Outcome and Assessment Information Set (OASIS) data for M0102 and M0104 for 8 of 19 patients (Patient #106, Patient #108, Patient #115, Patient #117, Patient #304, Patient #305, Patient #309, and Patient #310). Failure to accurately complete the OASIS data places patients at risk for physical harm due to not receiving services in a timely manner. Findings included: 1. Document review of the agency’s policy titled, “OASIS Data Capture, Transmission, Verification, Display, and Reports,” (Policy No. 7.002 Revised Date: 03/01/21) showed that accuracy of encoded OASIS data to reflect the patient’s status at the time the information is collected. 2. Record review of patient records for Patient #106, Patient #108, Patient #115, Patient #117, Patient #304, Patient #305, Patient #309, and Patient #310 showed: a. Patient #106 was admitted on 04/29/25 with the primary diagnosis of Gastrointestinal Bleed. The referral was completed on 04/24/25 for a Skilled Nursing (SN) initial assessment. Physician orders were received for the M0102 Start of Care (SOC) of 04/29/25. Documentation showed that OASIS M0104 SOC date of 04/24/25 rather than the correct date of M0102 date of 04/29/25. b. Patient #108 was admitted on 05/01/25 with the primary diagnosis of Parkinson’s. The referral was completed on 04/30/25 for a SN initial assessment. Documentation showed the M0102 date of 05/01/25 rather than the correct date of M0104 date of 04/30/25. c. Patient #115 was admitted on 11/30/23 with a primary diagnosis of Diabetes Mellitus. The referral was completed on 11/29/23 for a SN initial assessment. Documentation showed the M0102 date of 11/31/23 rather than the correct date of M0104 date of 11/29/23. d. Patient #117 was admitted on 10/29/24 with a primary diagnosis of Polyneuropathy. The referral was completed on 10/28/24 for a SN initial assessment. Documentation showed the M0102 date of 10/29/24 rather than the correct date of M0104 date of 10/28/24. e. Patient #304 was admitted on 06/04/25 with a primary diagnosis of Parkinson’s Disease without Dyskinesia without mention of fluctuations. The referral was completed on 06/03/25 for a PT initial assessment. Documentation showed the M0102 date of 06/04/25 rather than the correct date of M0104 date of 06/03/25. f. Patient #305 was admitted on 05/02/25 with a primary diagnosis of Acute Pyelonephritis. The referral was completed on 04/30/25 for a SN initial assessment. Documentation showed the M0102 date of 05/02/25 rather than the correct date of M0104 date of 04/30/25. g. Patient #309 was admitted on 04/17/25 with a primary diagnosis of Spinal Stenosis. The referral was completed on 04/03/25 for a PT initial assessment. The record showed a coordination note with an expected start of care (SOC) on 04/10/25. Documentation showed the M0102 date of 04/17/25. The record showed no evidence of a physician-ordered SOC for 04/17/25. h. Patient #310 was admitted on 04/22/25 with a primary diagnosis of Enterocolitis due to Clostridium Difficile. The referral was completed on 04/18/25 for a PT initial assessment. Documentation showed the M0102 date of 04/22/25. The record showed no evidence of a physician-ordered SOC for 04/22/25. 3. On 06/11/25 at 9:00 AM, Surveyor #1 and Surveyor #3 interviewed the agency’s Executive Director (Staff #112) and the agency’s Area Administrator (Staff #113) about lack of accuracy in OASIS Data entry for M0102 and M0104. Both Staff #112 and Staff #113 acknowledged the OASIS data error findings and stated that they were not able to provide documentation as to why the OASIS M0102 and M0104 data were inaccurate. .

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: . Based on document review, record reviews, and interview, the agency failed to conduct the initial assessment visit within the 48 hours of completing the referral and notifying patients or their legal representative of the delayed services for 2 of 19 patients (Patient #309 and Patient #310) Failure to meet this requirement places patients at risk for physical harm due to not receiving services in a timely manner. Findings included: 1. Document review of agency's policy titled, "Initial and Comprehensive Assessment," (Policy No. 4-018.1, Last Revised: 01/23/24) showed the initial assessment will be conducted within 48 hours of the complete referral. 2. Record review of patient records Patient #309 and Patient #310 showed: a. Patient #309’s Start of Care (SOC) date was 04/17/25. The patient was admitted for primary diagnosis of Spinal Stenosis. The agency completed the referral on 04/03/25 for a Physical Therapy (PT) initial assessment, and the SOC for the PT services did not occur until 04/17/25. There was no documentation that the patient or their legal representative were notified of the delayed of the PT services within the 48 hours of the referral date. b. Patient #310’s Start of Care (SOC) date was 04/22/25. The patient was admitted for primary diagnosis of Enterocolitis due to Clostridium Difficile. The agency completed the referral on 04/18/25 for a Physical Therapy (PT) initial assessment, and the SOC for the PT services did not occur until 04/22/25. There was no documentation that the patient or their legal representative were notified of the delayed of the PT services within the 48 hours of the referral date. 3. On 06/11/25 at 9:00 AM, Surveyor #3 interviewed the agency’s Executive Director (Staff #112) and the agency’s Area Administrator (Staff #113) regarding the lack of documentation that the patient or their legal representative were notified of the delayed SOC services. Both Staff #112 and Staff #113 acknowledged the findings and stated that they were not able to provide documentation as to why the services were delayed. .

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 record reviews and interview, the agency failed to complete the comprehensive assessment that included therapy evaluations within five calendar days of the start of care date for 5 of 12 active patients (Patient #106, Patient #115, Patient #117, Patient #305, and Patient #309). Failure to address the patient’s therapy needs timely puts patients a risk of injury and harm. Findings included: 1. Document review of agency’s policy titled, “Patient Assessment, initial and Reassessment,” (Policy No. 2.1.002, Last Revised 09/01/24) showed the comprehensive assessment must be completed within five calendar days of the patient’s start of care. Each patient must receive a patient-specific comprehensive assessment that identifies the patient’s nursing and rehabilitative needs. 2. Record review of the patient’s comprehensive assessment for Patient #106, Patient #115, Patient #117, Patient #305, and Patient #309 showed: a. Patient #106’s referral was completed on 04/24/25 with orders for Skilled Nursing (SN) initial assessment, Physical Therapy (PT) evaluation, and Occupational Therapy (OT) evaluation. The SN assessment was completed on the SOC date of 04/29/25. The PT evaluation was completed on 05/02/25, and the OT evaluation was completed on 05/07/25. There is no documentation to show why the OT evaluations was not completed within 5 days of the start of care. b. Patient #115’s referral was completed on 11/29/23 with orders for SN initial assessment, PT evaluation, and OT evaluation. The SN assessment was completed on the SOC date of 11/30/23. The PT evaluation was completed on 12/04/24, and the OT evaluation was completed on 12/19/24. There is no documentation to show why the OT evaluation was not completed within the 5 days of the start of care. c. Patient #117’s referral was completed on 10/28/24 with orders for SN initial assessment and OT evaluation. The SN assessment was completed on the SOC date of 10/29/24. The OT evaluation was completed on 11/14/24. There is no documentation to show why the OT evaluation was not completed within the 5 days of the start of care. d. Patient #305’s referral was completed on 04/30/25 with orders for a SN initial assessment, PT evaluation, OT evaluation, Speech Therapy evaluation, and MSW evaluation. The SN assessment was completed on the SOC date of 05/02/25. The PT evaluation was completed on 05/15/25, and the MSW evaluation was completed on 05/20/25. The Speech Therapy evaluation was not completed at the time of the survey. There is no documentation to show why PT, MSW and Speech evaluations were not completed within the 5 days of the start of care. e. Patient #309’s referral was completed on 04/03/25 with orders for a PT initial assessment and OT evaluation. The PT assessment was completed on the SOC date of 04/17/25. The OT evaluation was completed on 05/14/25. There is no documentation to show why the OT evaluation was not completed within the 5 days of the start of care. 3. On 06/11/25 at 9:30 AM, Surveyor #1 and Surveyor #3 interviewed the agency’s Executive Director (Staff #112) and the agency’s Area Administrator (Staff #113) regarding the delayed therapy evaluations. Staff #112 and Staff #113 acknowledged the findings and stated that the agency makes every attempt to complete therapy evaluations timely but stated they were not able to provide documentation as to why the therapy services were delayed. .

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 document review, record reviews, and interviews, the agency failed to communicate with the patient’s physician the therapies missed visits resulting in changes to the patient’s plan of care in 2 of 19 patients (Patient #309, and Patient #310. Failure to communicate with the patient’s physician of changes to the plan of care may potentially have a clinical impact on the patient’s wellbeing. Findings included: 1. Document review of the agency’s policy titled, “Coordination of Care, From Admit through Discharge,” (Policy No. 2.1.017, Last Revised 09/01/24) showed that missed visits and changes to scheduled visits the agency will contact the patient, notify the provider, and will document the reason for he missed visit in the patient’s clinical record. 2. Record review of patient records Patient #309 and Patient #310 showed: a. Patient #309 was admitted on 04/17/25. Occupational Therapy (OT) evaluation was ordered on the week of 04/20/25. The OT evaluation did not occur until 05/14/25. There was no documentation as to why the OT evaluation was missed. The record also showed an order for OT visits for 1 visit every week for 5 weeks received on 05/22/25. Patient #309 did not receive an OT visit until 06/02/25. There was no documentation as to why the OT visits were missed from 05/22/25 to 06/02/25. The record also showed that Patient #309 had orders to receive Physical Therapy (PT) visits weekly for 9 weeks. The record showed missed PT visits the weeks of 05/18/25 and 05/25/25. There was no evidence that the physician was notified of any of the PT and OT missed visits for Patient #309. b. Patient #310 was admitted on 04/22/25. PT services with frequency of 1 visit per week for 8 weeks starting 04/22/25. During the Medicare week of 05/25/25 to 05/31/25, the patient received no PT visits. In addition, there was no documentation as to why the PT visit was not made, and no physician notification of the missed visit. 3. On 06/11/25 at 9:30 AM, Surveyor #3 interviewed the agency’s Executive Director (Staff #312) and the agency’s Area Administrator (Staff #313) regarding the lack of documentation and physician notification of the missed visits. Staff #312 and Staff #313 acknowledged the findings and stated they were not able to provide documentation as to why the missed therapies visits occurred and why the patients’ physicians were not notified of the missed visits. .

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: . Based on record review and interview, the agency failed to conduct a Tuberculosis (TB) screening using a Department of Health (DOH)-approved TB risk assessment form for 9 of 10 staff (Staff #101, Staff #102, Staff #103, Staff #104, Staff #105, Staff #106, Staff #107, Staff #109, and Staff #110). Failure to screen staff for TB places staff and patients at risk from TB exposure. Reference: WAC 246-335-525 Personnel, contractor, and volunteer policies. The applicant or licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe: (c) Tuberculosis (TB) infection control program. Key elements include, but are not limited to: (i) Conducting a TB risk assessment for all new employees upon hire. Agencies must use a tuberculosis risk assessment form provided by the department. Based on risk assessment results, determine the agency's responsibility to conduct TB testing of new employees. . Findings included: 1. Document review of the agency’s policy titled, "Staff Screening, New Hire and Annual," (Policy No. 6.002, Last Revised 11/01/24) showed the agency's Washington state specific TB screening program conducts a TB risk assessment for all new employee upon hire and annually. The agency must use the DOH-approved TB risk assessment form provided by the department. 2. Record review of personnel contractor records for Staff #101, Staff #102, Staff #103, Staff #104, Staff #105, Staff #106, Staff #107, Staff #109, and Staff #110. The review showed: a. Staff #101 was hired on 08/28/23. The record failed to contain a complete the [DOH]-approved initial TB risk assessment on the day of hire. b. Staff #102 was hired on 01/05/22. The record failed to contain a completed [DOH]-approved initial TB risk assessment on hire and in 2023 and 2024. c. Staff #103 was hired on 04/09/21. The record failed to contain a completed [DOH]-approved initial TB risk assessment on hire and in 2023 and 2024. d. Staff #104 was hired on 02/27/23. The record failed to contain a completed [DOH]-approved initial TB risk assessment on hire and in 2024. e. Staff #105 was hired on 06/26/23. The record failed to contain a completed [DOH]-approved initial TB risk assessment on hire and in 2024. f. Staff #106 was hired on 09/11/23. The record failed to contain a completed [DOH]-approved initial TB risk assessment in 2024. g. Staff #107 was hired on 07/31/23. The record failed to contain a completed [DOH]-approved initial TB risk assessment on hire and 2024. h. Staff #109 was hired on 06/13/22. The record failed to contain a completed [DOH]-approved initial TB risk assessment on hire and in 2023 and 2024. i. Staff #110 was hired on 07/11/22. The record failed to contain a completed [DOH]-approved initial TB risk assessment on hire. 3. On 06/11/25 at 8:30 AM, Surveyor #1 interviewed the agency’s Area Administrator (Staff #113) and the agency’s Office Manager (Staff #115) about the completion of the DOH-approved TB risk assessment forms for each of the staff. Staff #113 and Staff #115 acknowledged the findings and stated that they were unable to provide updated TB risk assessment forms for each of the staff. .

Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This ELEMENT is not met as evidenced by: . Based on observation and interview, the home health agency failed to implement policies and procedures for removing expired supplies and devices from the patient inventory supply room. Failure of the agency to monitor and ensure that products and devices do not go beyond the manufacturer’s expiration date may put patients at risk of bodily harm. Findings included: 1. On 06/11/25 at 9:30 AM, Surveyor #3 conducted an inspection of the agency’s patient supply room. The observation showed 8 speci-cath kit universal (straight catheters) with a documented expiration date of 03/28/25. 2. On 06/11/25 at 10:00 AM, Surveyor #3 interviewed the Area Administrator (Staff #313) about the expired catheters. Staff #113 stated that the Business Manager and Clinical Managers are responsible for checking the supply room for expired supplies. They stated that this typically happens on a monthly basis. Staff #313 stated that the expired supplies would be removed from the supply room.

MEDICARE HOME HEALTH RECERTIFICATION SURVEY The Washington State Department of Health (DOH) in accordance with Medicare Conditions of Participation set forth in 42 CFR 484, conducted this health and safety survey. Onsite dates: 10/03/22 to 10/07/22 Examination number: X2022-821 The survey was conducted by: Surveyor #1 Surveyor #6 DOH staff found the agency in substantial compliance with all Conditions of Participation except those standard-level deficiencies listed below. DOH recommends recertification based on an acceptable plan of correction. .

Licensing CFR(s): 484.100(b) (b) Standard: Licensing. The HHA, its branches, and all persons furnishing services to patients must be licensed, certified, or registered, as applicable, in accordance with the state licensing authority as meeting those requirements. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to update policies and procedures on criminal background check and disclosure statement consistent with state requirements for contracted staff and failed to conduct criminal background checks using the Washington State Patrol (WSP) for 2 of 4 contracted staff (Staff#104 and Staff #110). Failure to maintain compliance with state requirements on criminal background check and disclosure statements put patients at risk of receiving care from un-vetted or unqualified staff. Reference: Washington Administrative WAC 246-335-525 (6) Personnel, contractor, and volunteer policies. The licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe: (6) Criminal history background checks and disclosure statements for personnel, contractors, volunteers, students, and any other individual associated with the licensee having direct contact with children under sixteen years of age, people with developmental disabilities or vulnerable persons, according to RCW 43.43.830 through 43.43.842 and the following: (a) Criminal history background checks must be processed through the Washington state patrol; (b) Disclosure statements must be approved by the department; and (c) All criminal history background checks and disclosure statements required under this chapter must be renewed within two years from the date of the previous check. Findings included: 1. Document review of the agency policy titled, "Patient Care Contracted Workers Requirement Policy #6.014," (11/01/20 revised date) showed that the contracted companies shall provide a background check that included a criminal history search, but lacks the state requirements to process criminal background checks through the Washington state patrol; and that criminal background checks and disclosure statements must be renewed within two years from the date of the previous check. 2. On 10/07/22, Surveyor #1 reviewed 2 contracted staff files (Staff #104 and Staff #110). The review showed: a. Staff #104 was hired on 07/05/22. The staff record failed to document a WSP background check on hire. b. Staff #110 was hired on 09/23/19. The staff record failed to document a WSP background check on hire and renewed within two years from the date of the previous check. 3. On 10/07/22 at 9:00 AM, Surveyor #1 interviewed the agency’s Executive Director (Staff # 112) on the agency's policies and procedures on criminal background check and disclosure statements and missing WSP background checks for the contracted staff. Staff #112 acknowledged the findings and stated that the agency uses a third party company to do the background checks and that they are currently working with the third party company to ensure background checks and disclosure statements are in compliance with the state requirements.