Every finding on record at Lhcg Xxxiii LLC

An incident investigation (Intake 1084962) was conducted on 04/28/2026. Census: License and Certified Home Health Services: 292. Abbreviations: AA: Area Administrator Adm/DON: Administrator/Director of Nurses/Supervising Nurse APS: Adult Protective Services Area Adm: Area Administrator EMS: Emergency Medical Services LVN: Licensed Vocational Nurse POC: plan of care Pt’s: patients Rehab: rehabilitation RN: Registered Nurse

Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This ELEMENT is not met as evidenced by: Based on record review and interview, when the agency had cause to believe an agency patient had been neglected by agency employees, the agency failed to report the information within 24 hours to the Texas Health and Human Services Commission in one of three records reviewed (Patient 1). This failure placed all patients at an increased risk of abuse, neglect, and exploitation by agency staff and delayed the investigations by the Texas Department of Health and Human Services. Findings included: During pre-survey preparation on 04/22/2026, a review was conducted of the Texas Unified Licensure Information Portal (a database utilized by the state to maintain licensing, demographic information, complaints and self-reported incidents on Home Health and for the State of Texas). Review of the agency information failed to include the agency had submitted a self-reported incident of alleged neglect of Client 1. Record review of agency complaint log on 04/27/2026: The complaint log included one complaint with allegations of neglect of Patient 1 dated 04/16/2026 and processed by the Adm/DON on 04/17/2026. The complaint log did not include the allegation of neglect was reported to the Texas Health and Human Services Commission. The complaint log read in part, “…[Patient 1]… This nurse spoke with pt's [Family Member]... who advised "when my father was in the hospital, they told us that they were going to send my [Patient 1] to anohter (sic) agency because when he was on service with you his wounds becames (sic) infected and his urine backed up inside of him because the bag wasn't changed. They called APS and APS called me and siad (sic) that this is unacceptable… Prevention: discussed complaint & chart review with AA…” During an interview with the Adm/DON and the Area Adm on 04/29/2026 at 12:55 PM, the surveyor reviewed the complaint regarding Patient 1 received by the agency on 04/16/2026 and asked why the agency had not self-reported the allegation of neglect. The Adm/DON stated she did the follow-up for the complaint. The Area Adm stated Patient 1’s wound care clinic called the agency to let the agency know Patient 1 was changing to another home health agency. The agency attempted to gather facts by interviewing family members and obtaining medical records but were unsuccessful. The Area Adm stated without all of the facts, she didn’t think it was reportable and she was waiting to gather all of the facts to determine if it would be reported by the agency. The Area Adm stated that she wondered if agency nurses should have filed a report with Adult Protective Services [Department of Family and Protective Services]. The Adm/DON stated she agreed with the Area Adm’s answer. The surveyor asked who was responsible for self-reporting neglect and why agency policy had not been followed on self-reporting. The Area Adm stated she was responsible for reporting neglect, but she wanted the Adm/DON to be responsible in the future. The Area Adm stated she had dropped the ball on the allegations of neglect of Patient 1. The Adm/DON stated she agreed with the Area Adm’s answer. Agency policy titled, “PATIENT ABUSE, EXPLOITATION,AND NEGLECT: ASSESSMENT, IDENTIFICATION, AND REPORTING… 2.1.005T” with a last reviewed dated of 11/01/2024 read in part, “… This policy and procedure is applicable to ONLY Texas agencies… PURPOSE: To identify, assess and report victims of actual or suspected… neglect… Policy… If an agency has cause to believe that a patient served by the agency has been… neglected… by an agency employee, the agency must report the information immediately, within 24 hours to: The Health and Human Services Commission… Definitions… Neglect Failure to provide one’s self the goods or services, including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caretaker to provide such goods or services… Reportable Conduct: Includes… neglect that causes or may cause death or harm to an individual receiving agency services…”

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a plan of care included all pertinent diagnoses and patient-specific interventions in one of three records reviewed (Patient 1) in that the plan of care did not include wound care orders for a bedsore (pressure ulcer/decubitus ulcer) on the right bottom (buttock); a diagnoses for paraplegia (unable to move legs and lower body), colostomy (surgery to create an opening for the colon/large intestine through the belly), and urinary catheter (tube inserted into the bladder to drain urine) ; and orders for the nurse to assess the colostomy site for infection. These failures placed the patient in jeopardy of harm from agency staff who could not address the types of services needed for appropriate care and placed them at risk of a declining health status and complications. Findings included: Patient 1: Record review of the medical record included a plan of care dated 03/10/2026 to 05/08/2026 with a start of care date of 03/10/2026 that was signed and dated by RN A on 03/09/2026 (the day before the start of care). The physician ordered the nurse to visit the patient three times a week for six weeks, then two times a week for one week, then three times a week for two weeks. The plan of care included a diagnosis of a bedsore on the sacral (sometimes referred to as the coccyx: region of the back at the bottom of the spine) and a bedsore on the right bottom. The plan of care included wound care orders for the bedsore on the sacral area. The record included a start of care visit note signed and dated by RN A on 03/10/2026 that read in part, “… how many times has the patient urinated in the past 24 hours? Patient has an indwelling catheter… Does the patient have a colostomy… Yes… Indicate other musculoskeletal (both muscles and bones) finding… Paraplegic…” The plan of care did not include wound care orders for the bedsore on the right bottom; a diagnosis for paraplegia, colostomy, and urinary catheter; and orders for the nurse to assess the colostomy site for infection. During an interview by Surveyor 1 with RN A on 04/27/2026 at 1:28 PM, the surveyor asked why the plan of care did not include wound care orders for the bedsore on the right bottom; a diagnosis for paraplegia, colostomy, and urinary catheter; and orders for the nurse to assess the colostomy site for infection. RN A stated the wound care orders included in the plan of care for the coccyx/sacral area were the same wound care orders for the wound on the bottom. RN A stated it was an oversight that the items were not included in the plan of care. During an interview by Surveyor 1 with the Adm/DON and Area Adm on 04/28/2026 at 12:45 PM, the surveyor asked why the plan of care did not include wound care orders for the bedsore on the right bottom; a diagnosis for paraplegia, colostomy, and urinary catheter; and orders for the nurse to assess the colostomy site for infection. The Area Adm stated that was a great question. The Adm/DON stated the RN’s who signed the plan of care enters the information onto the plan of care while in the field [patient home] and then the plan of cares are reviewed by different departments in the office. Surveyor 1 asked why agency policy was not followed. The Area Adm stated the staff needed education to make sure everything was included in the plan of cares as required. The Adm/DON stated they needed to focus on the whole patient and not just the patient’s primary problem when the plan of care were developed. Agency policy titled, “Plan of Care… 2.1.007” with a last reviewed date of 03/01/2026 read in part, “… PURPOSE: To assure an appropriate plan of care is developed and revised in a timely manner for each patient… PROCEDURE…The POC includes… Pertinent diagnosis(es)… Patient specific interventions...”