Every finding on record at Lhcg Xxxiv, LLC

A recertification survey was conducted at Atmore Community Home Care from 5/13/25 to 5/15/25. Atmore Community Home Care was found to be in substantial compliance with the Condition of Participation for Emergency Preparedness.

A recertification survey was conducted at Atmore Community Home Care from 5/13/25 to 5/15/25. Standard level deficiencies were cited and will require a plan of correction.

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 medical record (MR) review, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure the comprehensive assessments were completed within five days of the Start of Care (SOC). This deficient practice affected three of ten MR's reviewed including MR # 2, MR # 5, MR # 3 and had the potential to negatively affect all patients admitted to this agency. Findings include: Agency Policy: Patient Assessment, Initial and Reassessment Policy Number: 2.1.002 Revised: 9/1/24 ...Policy: All patients admitted to the agency will receive an initial assessment...by a staff Registered Nurse, Speech Therapist, Physical Therapist, or Occupational Therapist...OASIS (Outcome and Assessment Information Set) comprehensive assessments are completed at patient admission... Procedure: ...d. Physical Therapist, Speech Therapist, Occupational Therapist, ... may make initial evaluations of the patient status to determine the need for specific therapies. This initial discipline specific evaluation(s) will occur within 5 days from the Start of Care (SOC) date... 3. MR # 3 was admitted on 4/2/25 with diagnoses including Chronic Obstructive Pulmonary Disease with Acute Lower Respiratory Infection, and Acute Bronchitis, Unspecified. Review of the HHC and POC dated 4/2/25 revealed physician's orders for Speech Therapy (ST) one visit a week for one week. Review of a physician order written on 4/11/25 revealed an order to omit the ST Evaluation for week of 4/6/25 and reschedule for week of 4/13/25. This order was written nine days after SOC with no documentation of why the ST Evaluation was rescheduled. An interview was conducted on 5/15/25 at 1:33 PM with EI # 1 who confirmed the agency failed to ensure all comprehensive assessments were completed within five days of SOC. 1. MR # 2 was admitted on 4/3/25 with diagnoses including Type 2 Diabetes Mellitus, Essential (Primary) Hypertension, and Atherosclerosis of Coronary Artery Bypass Graft. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 4/3/25 revealed physician's orders for Physical Therapist (PT) one visit a week for one week and Occupational Therapist (OT) one visit a week for one week. Review of the PT Add-On Evaluation Visit Note Report dated 4/12/25 revealed the PT initial assessment was completed nine days after the SOC. Review of the OT Add-On Evaluation Visit Note Report dated 4/9/25 revealed the OT initial assessment was completed six days after the SOC. An interview was conducted on 5/15/25 at 1:30 PM with Employee Identifier (EI) # 1, Executive Director, who confirmed the agency failed to ensure all comprehensive assessments were completed within five days of the SOC. 2. MR # 5 was admitted on 11/7/24 with diagnoses including Bloodstream Infection Due to Central Venous Catheter, Alzheimer's Disease, and Dementia. Review of the HHC and POC dated 11/7/24 revealed physician's orders for PT one visit per week for one week, two visits per week for two weeks, then one visit per week for two weeks, and OT one visit per week for one week then two visits per week for three weeks. Review of the PT Add-On Evaluation Visit Note Report dated 11/14/24 revealed the PT initial assessment was completed seven days after the SOC. Review of the OT Add-On Evaluation Visit Note Report dated 11/15/24 revealed the OT initial assessment was completed eight days after the SOC. An interview was conducted on 5/15/25 at 1:05 PM with EI # 1 who confirmed the agency failed to ensure the comprehensive assessments were completed within five days from the SOC.

Based on the recertification survey conducted on 9/15/22, Atmore Community Homecare was found to be in substantial compliance with the Conditions of Participation for Emergency Preparedness.

A recertification survey was conducted at Atmore Community Home Care from 9/13/22 to 9/15/22. Standard level deficiencies were cited.

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 Medical Record Review (MR), agency policy, and interview, it was determined the agency failed to ensure staff followed physician orders for wound care. This deficient practice affected one of five patients with wounds including Home Visit (HV) # 3 and had the potential to negatively affect all patients admitted to this agency. Findings include: Agency Policy: Physician Orders Policy Number: 2.1.008 Revised date: 11/01/2021 ...Policy: No medications, treatments, ..., will be administered without the order of a qualifed physician or authorized practitioner,... 1. HV # 2 was admitted on 6/29/2021 and recertified for home care from 8/23/22 to 10/21/22 with diagnoses including Type 2 Diabetes Mellitus, Non Pressure Ulcer of Left Ankle, and Pressure Ulcer of Other Site, Stage 2. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 8/23/22 revealed orders for wound care to diabetic ulcer to left ankle daily ...pack with Iodoform... Review of the physician order dated 8/31/22 revealed orders for wound care to diabetic ulcer of left ankle daily...apply Calcium Alginate to wound bed... Review of the Skiled Nurse(SN) Visit Note Report dated 9/2/22 revealed the SN documented Diabetic Ulcer wound to left ankle was cleansed with normal saline and gauze, patted dry, and packed with Iodoform and covered with gauze. In an interview conducted on 9/15/22 at 12:10 PM, Employee Identifier # 1, Executive Director, confirmed the orders for wound care were not followed and Calcium Alginate should have been applied to the wound, not Iodoform.

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 review of Medical Records (MR), agency procedure, and interviews, it was determined the agency failed to ensure the physician was notified of changes in patient condition. This deficient practice affected two of ten MR reviewed including MR # 5 and MR # 2 and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Coordination of Care, From Admit Through Dishcarge Policy Number: 2.1.017 Revised: 8/1/2019 ...Procedure: ...4. Coordination of care with physician: At admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient's physician. a. When changes occur in the patient's condition or response to treatment... 1. MR # 5 was admitted to the agency on 12/1/2021 with diagnoses including Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, and Essential (Primary) Hypertension. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 12/1/2021 to 1/29/2022 revealed orders for Skilled Nurse (SN) to visit one time a week times one week, two times a week times two weeks, then one time a week times six weeks. Report vital sign falling outside the following established parameters: pain greater than 6 and oxygen saturation less than 90. Review of the SN Visit Note Report (VNR) dated 12/6/2021 revealed the SN documented the wound measurements of the right inguinal surgical incision was 10 cm (centimeters) x 1.5 cm x 0.1 cm. Review of the SN VNR dated 12/13/2021 revealed the SN documented the measurements of the right inguinal surgical incision was 10 cm x 5 cm x 0.2 cm, an increase of 3.5 cm in width. There was no documentation the physician was notified of the increase in wound width. Review of the Phyisian Order dated 12/17/2021 revealed orders for Physical Therapy one time a week times three weeks then two times a week times two weeks. Review of the Physical Therapy Assistant (PTA) VNR dated 12/22/2021 revealed the PTA documented under Vital Sign Alert: Pain level 8, upper limit 6, physician contacted N (no). Under the comments section the PTA documented "soreness to right leg from surgery. Will send communication to MD (medical doctor). There was no documentation the physician was notified of the increase in pain. Review of the SN VNR dated 1/12/22 revealed the SN documented in the narrative section "patient has O2 (oxygen) sat (saturation) down to 88% - 90%. SN instructed patient to obtain pulse oximetry and to use oxygen..." There was no documentation the physician was notified of the low pulse oximetry reading. In an interview conducted on 9/15/22 at 11:35 AM, Employee Identifier (EI) # 1, Executive Director, confirmed there was no documentation the physician was notified of the changes in the patient condition including increase in wound size, increase in pain, and low pulse oximetry reading. 2. MR # 2 was admitted to the agency on 8/6/22 with diagnoses including Acute Bronchitis, Pressure Ulcer fo Sacral Region, and Unspecified Dementia. Review of the HHC and POC dated 8/6/22 revealed orders for the licensed professional to report vital signs falling outside the following established parameters including systolic blood pressure less than 90 and diastolic blood pressure less than 60. Review of the PTA VNR dated 9/2/22 revealed the PTA documented MR # 2's blood pressure was 72/40. There was no documentation the physician was notified of the low blood pressure. In an interview conducted on 9/15/22 at 12:25 PM, EI # 1 confirmed the physician was not notified of the low blood pressure.

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 observations, Agency policy and procedure, Medical Record (MR) review, and interviews it was determined the agency failed to ensure the staff followed agency policy for cleaning of re-useable equipment. This affected one of four home visits (HV) including HV # 3 and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Cleaning of Re-Useable Equipment Policy number: 8.006 Revised date: 6/2/22 Purpose: To assure equipment required for patient care is clean and sanitized to prevent the spread of infections. ...Procedure: 1. Non-critical items which will come in contact with intact patient skin will undergo a low level disinfection between each patient use... 1. HV # 3 was admitted on 6/29/2021 and recertified for home care 8/23/22 to 10/21/22 with diagnoses including Type 2 Diabetes Mellitus, Non Pressure Ulcer of Left Ankle, and Pressure Ulcer of Other Site, Stage 2. A HV was conducted on 9/14/22 at 9:10 AM to observe wound care provided by Employee Identifier (EI) # 4, Licensed Practical Nurse. During the wound dressing change, EI # 4 was observed cutting the dressing from the left ankle with scissors. Then, without cleaning the sissors, EI # 4 used the same scissors to cut a piece of clean dressing material and applied the dressing to the wound bed. EI # 4 failed to clean the scissors after contact with a dirty surface. In an interview conducted on 9/15/22 12:10 PM, EI # 1, Executive Director, confirmed the staff failed to follow the agency policy for cleaning of re-usable equipment.