Every finding on record at Lhcg Xlii, LLC

. On 07/15/2024 at 12:45 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 the Conditions of Participation for Home Health. On 07/18/2024 at 10:15 AM an exit conference was conducted with Agency Representatives. Preliminary findings of the survey were discussed. .

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on Clinical Record review and staff interview, it was determined the Agency staff did not provide care in accordance with the written Plan of Care (POC) in 1 (#1) of 17 (#1 - #17) Clinical Records reviewed. This failed practice had the potential to affect the quality of care received by all patients currently on census, in that, there was a risk of adverse outcomes, potential to affect the attainment of the patients individual goals and a risk of hospitalizations due to unrecognized signs/symptoms of disease exacerbation. A review of Clinical Record #1, revealed the following: A. Document titled "Certification and Plan of Care" dated 06/17/2024 to 08/15/2024, which showed a Patient with primary diagnosis of "Heart Failure Unspecified." Orders contained in the POC were for Skilled Nurse (SN) to "obtain weight every visit and notify RN/Physician of weight gain or loss of 3 LBS [pounds] within 1 day or 5 LBS within one week." B. Review of SN visit notes dated, 06/22/2024, 06/27/2024, 07/03/2024, and 07/12/2024 showed no evidence of documentation of the Patient's weights having been assessed by the SN. 2. During an interview conducted on 07/18/2024 at 9:30 AM, Agency representatives were provided an opportunity to present additional information. With no additional information presented, Agency Personnel #1 stated "We didn't follow the Care Plan" confirming the Agency staff failed to provide care in accordance with the written Plan of Care for Patient #1. .