Every finding on record at Lhcg V LLC

This entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey

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 interview and record review, the Home Health provider failed to provide services, in accordance with the plan of care, for 1 (#1) of 10 (#1-#10) patients sampled. Findings: Review of Patient #1’s record revealed an admission date of 09/10/2025 with diagnoses including other ischiorectal abscess, cutaneous abscess of buttock, unspecified Escherichia coli as the cause of diseases classified elsewhere, epilepsy, other problems related to housing and economic circumstances, and problems related to living alone. Review of Patient #1’s Plan of Care (POC) dated 09/10/2025 revealed the orders of discipline and treatments for the patient included the following, in part: …in addition to skilled care, the patient needs the following: Social Work. -Medical Social Services to evaluate/assess and develop social work plan of care that will be approved by the physician prior to implementation. Review of the record revealed no documented evidence that a social worker assessed Patient #1 since she was admitted on 09/10/2025. An interview on 10/01/2025 at 1:50 p.m. with Executive Director confirmed that the provider failed to provide services, in accordance with the plan of care, for Patient #1 by failing to provide a social worker to evaluate/assess and develop a social work plan of care. An interview on 10/02/2025 at 11:05 a.m. with S1Executive Director confirmed that the provider did not have a social worker on contract/direct hire when Patient #1 was admitted to the provider on 09/10/2025.

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 record review, interviews, and observation, the provider failed to ensure treatments are administered only as ordered by a physician or allowed practitioner for 1 (#1) of 1 patients reviewed for wound care. Findings: Review of Patient #1’s record revealed an admission date of 09/10/2025 with diagnoses including other ischiorectal abscess, cutaneous abscess of buttock, and unspecified Escherichia coli as the cause of diseases classified elsewhere. Review of Patient #1’s Plan of Care dated 09/10/2025 revealed the orders of discipline and treatments listed the following, in part: -Start of care clinical summary the patient was recently hospitalized at local hospital for ischiorectal abscess. The patient’s primary focus of care is wound care. Current procedures/treatment which cannot be performed by patient/caregiver due to documented lack of knowledge and or skill: wound assessment and management. Review of Patient #1’s physician order dated 09/23/2025 for skilled nurse to perform wound care to buttocks surgical wound (abscess Incision and Drainage site) daily and as needed for soiling or dislodgement using clean technique as follows: cleanse with wound cleanser and pat dry with gauze, pack with ¼ inch iodoform gauze, apply saline moisted gauze, cover with dry gauze and ½ abdominal pad or foam dressing, and secure with tape if needed due to drainage. Observation on 10/01/2025 at 10:25 a.m. revealed Patient #1’s wound care to left buttock was provided by S2Registered Nurse (RN) as follows: cleaned wound with wound cleanser, patted dry, packed with ¼ inch iodoform gauze, and covered with a dry dressing. An interview on 10/01/2025 at 10:45 a.m. with S2RN confirmed she did not apply saline moistened gauze after packing Patient #1’s wound with iodoform gauze. An interview on 10/01/2025 at 1:50 p.m. with S1Executive Director confirmed that S2RN failed to provide wound care in accordance with the physician’s order written on 09/23/2025 for Patient #1.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on record review and interview, the provider failed to provide services, in accordance with current clinical practice guidelines and accepted professional standards of practice, for 1 (#1) of 10 (#1-#10) patients sampled. Findings: Review of the provider’s Wound Assessment, Documentation, and Photography policy and procedure, revised 09/01/2024, revealed the following, in part: Purpose To ensure the accurate and consistent assessment and documentation of wounds. Policy: Upon initial visit and subsequently as indicated below, all wounds will be assessed with appropriate documentation within the medical record. Unless otherwise ordered by the physician, the qualified clinician as defined above will assess wounds at least: -Weekly for patient receiving negative pressure wound therapy, receiving daily wound care performed by the agency, have an infected wound, or have stage 4 pressure injury with evidence of infection or exposed bone, tendon, or muscle tissue. Reassessments will be documented on the Wound Assessment Tool. -The assessments includes measurement of length, width, and depth, undermining and tunneling, wound bed description, wound edges, exposed tissue types, drainage, and the condition of the periwound. Patient #1 Review of Patient #1’s record revealed an admission date of 09/10/2025 with diagnoses including other ischiorectal abscess, cutaneous abscess of buttock, unspecified Escherichia coli as the cause of diseases classified elsewhere, epilepsy, and problems related to living alone. Review of the Wound Record Report for Patient #1 revealed no documented evidence of a weekly wound assessment that included the wound measurements for Patient #1 for the week of 09/21/2025. An interview on 10/01/2025 at 2:30 p.m. with S1Executive Director confirmed that S2RN failed to document weekly wound assessments including wound measurements, in accordance with the provider’s policy and procedure, for Patient #1 for the week of 09/21/2025.