Every finding on record at Lhcg Xlii, LLC

On 09/15/2025 at 12:15 PM, an entrance conference was conducted with Agency Representatives. The Agency was informed the purpose of the visit was to conduct a Medicare Recertification survey for compliance with 42 CFR Part 484 Conditions of Participation for Home Health Agencies. On 09/19/2025 at 9:00 AM, an exit conference was conducted with Agency Representatives. Preliminary findings of the survey were discussed.

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 review of Clinical Records and staff interview, the Agency did not ensure a Skilled Nurse (SN) conducted a review of all medications in 1 (#1) of 17 (#1-#17) Clinical Records reviewed. The Agency's noncompliance, if not corrected could result in harm for all current patients on census by inhibiting the SN and Physician's ability to make informed decisions regarding the patient's medication regimen related to potential adverse effects, drug reactions, significant side effects or drug interactions. Review of Clinical Record #1 Revealed: A Document titled Home Health Certification and Plan of Care with certification dates between 08/14/2025 through 10/12/2025 listing a primary diagnosis of Urinary Tract Infection B. A Client Medication Report with printed date of 09/18/2025 showing a medication order of "Gentamicin/Tobramycin 480 mg (milligrams). Instructions: Dissolve medication in 1 liter of sterile water and administer as flush to foley catheter (urinary tube from bladder to drainage bag outside the body) twice daily. When administered hold (clamp off the drainage tube) for two hours before draining." When this report is viewed on a computer screen via the EMR (electronic medical record) instead of a printed paper copy, the medication Gentamicin/Tobramycin is highlighted in blue. At the bottom of the screen, the program explains "medications highlighted in blue are not checked for interactions." C Staff Member #1 was asked on 09/18/25 at 5:05 PM if there was documentation showing the gentamicin/tobramycin had been checked for interactions. Staff #1 stated "No."

. On 10/10/2022 at 10:50 AM, an entrance conference was conducted with Agency Representatives. The Agency was informed the purpose of the visit was to conduct a Medicare Recertification survey for compliance with the Conditions of Participation for Home Health. On 10/13/2022 at 10:30 AM an exit conference was conducted with Agency Representatives. Preliminary findings of the survey were discussed. .

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 review of Clinical Records, and staff interviews, the Agency did not ensure a Skilled Nurse (SN) conducted a review of all medications in 3 (#3, #7, and #13) of 17 (#1 through #17) Clinical Records reviewed. The Agency's noncompliance, if not corrected could result in harm for all 307 patients currently on census by inhibiting the SN and Physician's ability to make informed decisions regarding the patients medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. Review of Clinical Record #3 revealed the following: A. Document titled "Client Medication Report" (report used by Agency to record Patient's medications). A drug "Ferrous Sulfate" (an over the counter (OTC) iron supplement) was highlighted in blue indicating the medication was not checked for interactions by the Agency's electronic medical record system. 2. Review of the Clinical Record #7 revealed the following: A. Document titled "Client Medication Report" which showed Oxygen (02) was highlighted in blue indicating the 02 was not automatically checked for interactions by the Agency's electronic medical record system. 3. Review of the Clinical Record #13 revealed the following: A. Document titled "Client Medication Report" which showed Nigella Saliva Oil (an OTC supplement that is used for it's benefits for obesity, diabetes, and high blood pressure). Tumeric ( a supplemental spice) was listed as being used by Patient #13. Both these substances were highlighted in blue indicating they were not checked for interactions by the Agency's electronic medical record system. 4. During an interview on10/13/22 at 9:30 A.M., Agency Personnel were provided an opportunity to present additional documentation With no additional documentation presented, Agency Personnel #1 confirmed all medications in the patients home were not checked for potential adverse effects, drug reactions, significant side effects or significant drug interactions for patients #3, #7, and #13.

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 Clinical Record review and staff interview, it was determined the Agency staff did not follow the Attending Physician orders contained in the Plan of Care (POC) for 1(#10) of 17 (#1 - #17) Clinical Records reviewed. This failed practice, if not corrected had the potential of increased risk of hospitalizations due to disease exacerbation for all 307 patients on current census.. Review of Clinical Record # 10 revealed the following: A. Document titled "Home Health Certification and Plan of Care (POC)" dated 9/24/22 to 11/22/22 which contained orders for Skilled Nurse (SN) to "obtain weight every SN visit and notify RN/MD (Registered Nurse/Medical Doctor) of weight gain or loss of 5 lbs within 7 days". SN nursing notes dated 9/30/22 and 10/5/22 showed no evidence the SN obtained weights for these two SN visits. 2. During an interview on 10/13/22 at 9:30 A.M., Agency Representatives were provided an opportunity to present additional documentation. With no additional documentation presented, Agency Personnel #1 confirmed the Agency staff failed to provide interventions as ordered in the individualized POC for Patient #10.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on Clinical Record review and Agency staff interview it was determined the Skilled Nurse (SN) failed to alert the Physician of relevant assessment findings which may have necessitated an alteration in the Plan of Care (POC) in 1 (#11) of 17 (#1 - #17) Clinical Records reviewed. This failed practice had the potential to affect all current patients on census in that Physicians may be unaware of new assessment findings resulting in missed opportunities for revision of patient goals / interventions and prevention of hospitalizations. Review of Clinical Record #11 for certification period 8/23/22 to 10/21/22 revealed the following: A. Document titled "Visit Note Report" dated 9/9/22, showed the Skilled Nurse (SN) found new findings that Patient #11 had adverse lung sounds. The SN documented the new findings of "Crackles' and "Rales" in both left and right lobes of the lungs. There was no evidience the SN notified the physician of these new findings: 2. During an interview on 10/13/22 at 9:30 AM, Agency Representatives were provided an opportunity to present additional documentation. With no additional documentation presented, Agency Personnel #1 confirmed the SN failed to notify the Physician of the adverse lung sounds that were heard during the SN assessment of Patient #11.. .

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on Clinical Record review and staff interviews it was determined the Agency did not coordinate care to assure identification of patient needs, communication of assessment findings in 1 (#8) of 17 (#1 - #17) Clinical Records reviewed. This deficient practice, if continued, had the potential to result in harm, risk of adverse outcome, or hospitalization due to the lack of coordination of care by the Agency staff. A review of Clinical Record #8 revealed the following: A. Document titled "Home Health Certfiication and Plan of Care (POC)" dated 9/12/22 to 11/10/22, showed a diagnosis of "Type 2 Diabetes Mellitus with Foot Ulcer", and interventions for "Patient/Caregiver to perform blood glucose (sugar) testing PRN (as needed) X (times) 5 for symptoms of Hypoglycemia (Low blood sugar or Hyperglycemia (high blood sugar). B. The POC stated "facility (Assisted Living Facility where Patient #8 resided), checks Patient's CBG (Blood sugar readings) 3 times weekly and PRN." C. There was no evidence in Patient #8 Clinical Record that the Skilled Nurse reviewed any readings of blood glucose findings or coordinated those findings with other staff members involved in the Patient's care or the Physician. D. Review of a document titled "Visit Note Report," the Skilled Nurse (SN) documented "Patient [#8] tested positive for COVID, (COVID -19 virus) 9/30/22." There was no evidence that this finding was coordinated with any of the other disciplines involved in this case or Patient #8's Physician responsible for care. 2. During an interview on 10/13/22 at 09:30 AM, Agency Personnel were given an opportunity to provide additional documentation. With no additional documentation provided, Agency Personnel #1 confirmed the Skilled Nurse (SN) failed to follow up with the physician or the Assisted Living Facility for reading of blood sugars for Patient 8, and confirmed no coordination was done regarding Patient #8 reports of testing positive for COVID-19.