Every finding on record at Lhcg Xxxvii, LLC

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, and Complaint #104472 / 242178 on 04/17/26. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements and Complaint #104472 / 242178 on 04/17/26. Standard level deficiencies cited. Abbreviations: Pt / Pts = Patient / Patients RN = Registered Nurse SOC = Start of Care

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on clinical records review and staff interview in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to inform patients of the disciplines that will be providing services and the frequency of visits. Findings include: 1. The following clinical records were reviewed between 04/14/26 and 04/16/26. Pt #1 SOC 03/31/26 Pt #2 SOC 04/09/26 Pt #3 SOC 03/12/26 Pt #4 SOC 04/01/26 Pt #5 SOC 04/07/26 Pt #6 SOC 10/18/25 Pt #7 SOC 12/15/25 The clinical records lacked documentation indicating that at the start of care, the Pts. were informed of the frequency and disciplines that will be providing services. 2. During an interview with the Administrator on 04/16/26 at 2:30PM, the Administrator confirmed that the clinical records lacked documentation of patient notification of the disciplines and frequency of visits at the SOC.

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: Based on observation and staff interview, the Agency failed to have a Clinical Manager since March 23, 2026. Findings include: 1. During the survey entrance process, it was observed that Agency had no Clinical Manager present. 2. During an interview with the Administrator on 04/14/26 at 10:00 AM. The Administrator (RN) stated and confirmed that Agency currently has no Clinical Manager, and she is covering both duties. She stated the clinical manager resigned March 23, 2026.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: x = times Q = every # = number WK = week lbs = pounds AM = morning > = greater than SN = Skilled Nurse POC = Plan of care SOC = Start of care PsOC = Plans of Care MD = Medical Doctor RN = Registered Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients MSW = Medical Social Worker ST = Speech Therapy/Therapist PT = Physical Therapy/Therapist PTA = Physical Therapy Assistant OT = Occupational Therapy/Therapist

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: A. Based on observations during home visits and staff interview, it was determined the Agency failed to ensure Pts. were provided with the Administrator’s name and contact information. This was found in 2 of 2 (Pts. #6 and 7) home visits conducted from the branch office. Findings include: 1. Pt. #6. SOC 10/22/22. Primary Diagnosis: Essential (Primary) Hypertension. A home visit was conducted on 1/4/23 at 12:40 PM. During this home visit, the folder provided by the Agency to the Pt. was observed. The folder lacked the name and contact information of the current Executive Director (Administrator). 2. Pt. #7. SOC 9/8/22. Primary Diagnosis: Other Sequelae of Cerebral Infarction. A home visit was conducted on 1/4/23 at 9:30 AM. During this home visit, the folder provided by the Agency to the Pt. was observed. The folder lacked the name and contact information of the current Executive Director. 3. During an interview on 1/5/23 at 11:10 AM with the Executive Director, Regional Vice President, and Performance Improvement Manager, the above findings were confirmed.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: A. Based on a review of clinical records, observation and interview during home visits, and staff interview, it was determined the Agency failed to ensure Pts. were informed and/or participated in the disciplines to provide care/service and the frequency of visits provided by each discipline. This was found in 17 of 17 (Pts. #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17) clinical records reviewed. Findings Include: 1. The following clinical records were reviewed from 1/3/23 at 2:00 PM to 1/4/23 at 3:45 PM: Pt. #1. SOC 12/22/22. Pt. received PT service. Pt. #2. SOC 12/22/22. Pt. received PT and OT services. Pt. #3. SOC 11/2/22. Pt. received SN, PT, OT and Home Health Aide services. Pt. #4. SOC 12/14/22. Pt. received SN, PT and OT services. Pt. #5. SOC 2/18/22. Pt. received SN, PT and OT services. Pt. #6. SOC 10/22/22. Pt. received PT service. Pt. #7. SOC 9/28/22. Pt. received SN, PT and OT services. Pt. #8. SOC 11/17/22. Pt. received SN, PT, OT and MSW services. Pt. #9. SOC 10/2/22. Pt. received SN service. Pt. #10. SOC 12/15/22. Pt. received SN, PT and OT services. Pt. #11. SOC 10/7/22. Pt. received PT service. Pt. #12. SOC 11/17/22. Pt. received SN, PT and ST services. Pt. #13. SOC 9/4/22. Pt. received SN, PT, OT and MSW services. Pt. #14. SOC 12/7/21. Pt. received PT service. Pt. #15. SOC 8/5/22. Pt. received SN, PT and OT services. Pt. #16. SOC 10/11/22. Pt. received SN service. Pt. #17. SOC 11/9/22. Pt. received PT service. The records lacked documentation that at the SOC, the Pt./patient's representative participated or was notified of the discipline(s) to provide care/service and the frequency of those visits, prior to providing Pt. care/services. 2. The following home visits were conducted on 1/4/23 from 9:30 AM to 4:30 PM: Pt. #1. SOC 12/22/22. Pt. #2. SOC 12/22/22. Pt. #3. SOC 11/2/22. Pt. #4. SOC 12/14/22. Pt. #5. SOC 2/18/22. Pt. #6. SOC 10/22/22. Pt. #7. SOC 9/28/22. During the home visits, the patient's admission home folder was observed and lacked documentation of the disciplines to provide care/service and frequency of visits for each discipline. A home visit was conducted with Employee #4 and Pt. #1 on 1/4/23 at 4:00 PM. During the home visit, an interview was conducted, and the Pt. was asked: "Do you know how often the PT is supposed to visit you?" The Pt. replied, "2 to 3 times a week, I think." 3. During interviews with the Regional Vice President, Executive Director and the Office Manager on 1/4/23 at 1:37 PM to 4:08 PM, and 1/5/23 at 10:20 AM and 11:10 AM, it was confirmed the Agency failed to ensure Pts. were informed and/or participated in the disciplines to provide care/service and frequency of visits provided by each discipline.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure Pts. were made aware of their payment source and/or financial responsibility for care and services at the SOC. This was found in 6 of 17 Pts. (Pts. #2, 3, 6, 9, 14, and 17) clinical records reviewed. Findings include: 1. The following records were reviewed between 1/4/23 at 9:50 AM and 1/4/23 at 3:20 PM: Pt. #2. SOC 12/22/22 Pt. #3. SOC 11/2/22 Pt. #6. SOC 10/22/22 Pt. #9. SOC 10/2/22 Pt. #14. SOC 12/7/21 Pt. #17. SOC 11/9/22 The records lacked documentation the above Pts. were notified of their payment source and/or financial responsibility, if any, for agency care and services at the SOC. 2. During interviews on 1/4/23 at 1:37 PM with the Regional Vice President, Executive Director and the Office Manager; and 1/5/23 at 11:10 AM with the Regional Vice President, Executive Director, and Performance Improvement Manager the above findings were confirmed.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: A. Based on a review of the Agency's Pt. admission folder, observation during home visits and staff interview, it was determined the Agency failed to ensure complete information regarding the State Hotline was provided to Pts. This was found in 17 of 17 (Pts. #1, 2, 3, 4, 5, 6, 7, 8, 9, 10,11,12,13,14,15,16 and 17) clinical records reviewed. Findings include: 1. The Agency's Pt. admission folder was reviewed on 1/3/23 at 4:00 PM. The folder contained a section titled, "Home Health Hotline" with information pertaining to the State Hotline. This section lacked the address to forward a written complaint with the Illinois Department of Public Health. 2. The following clinical records were reviewed from 1/3/23 at 2:00 PM to 1/4/23 at 3:45 PM, and lacked the address to forward a written complaint to the Illinois Department of Public Health: Pt. #1. SOC 12/22/22. Pt. #2. SOC 12/22/22. Pt. #3. SOC 11/2/22. Pt. #4. SOC 12/14/22. Pt. #5. SOC 2/18/22. Pt. #6. SOC 10/22/22. Pt. #7. SOC 9/28/22. Pt. #8. SOC 11/17/22. Pt. #9. SOC 10/2/22. Pt. #10. SOC 12/15/22. Pt. #11. SOC 10/7/22. Pt. #12. SOC 11/17/22. Pt. #13. SOC 9/4/22. Pt. #14. SOC 12/7/21. Pt. #15. SOC 8/5/22. Pt. #16. SOC 10/11/22. Pt. #17. SOC 11/9/22. 3. The following home visits were conducted on 1/4/23 from 9:30 AM to 4:30 PM: Pt. #1. SOC 12/22/22. Pt. #2. SOC 12/22/22. Pt. #3. SOC 11/2/22. Pt. #4. SOC 12/14/22. Pt. #5. SOC 2/18/22. Pt. #6. SOC 10/22/22. Pt. #7. SOC 9/28/22. During the home visits, the Pt. admission folders were observed and lacked an address for which the Pt./patient's representative may submit a complaint to the State Hotline in writing. 4. During interviews with the Regional Vice President, Executive Director and the Office Manager on 1/4/23 at 1:37 PM to 4:08 PM; and 1/5/23 at 10:20 AM and 11:10 AM, it was confirmed the Pt. admission folder lacked the address (contact information) for a Pt./patient representative to file a complaint in writing.

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: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure staff provide service/treatment as ordered by the Physician and indicated in the POC. This was found in 6 of 17 (Pts. #9, 13, 14, 6, 7 and 17) clinical records reviewed. 4. Pt. #6. SOC 10/22/22. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 1/4/23 at 10:45 AM. The record contained the PsOC effective 10/22/22 to 12/20/22 and effective 12/21/22, which included the Physician’s order: “…Report vital signs outside the following established parameters…Pain >6.” The record contained the PTA visit notes dated 11/7/22, 11/11/22, and 12/29/22, which included documentation the Pt. reported a pain level of “7” on a 0 to 10 scale, with “0,“ meaning no pain, and “10” meaning the worst possible pain. The record also contained the PTA visit note dated 12/29/22, during which the Pt. reported a pain level of “8.” The record lacked documentation the Physician was notified of the Patient’s pain level on these dates. 5. Pt. #7. SOC 9/28/22. Primary Diagnosis: Other Sequelae of Cerebral Infarction. The clinical record was reviewed on 1/4/23 at 11:30 AM. The record included the POC effective 11/27/22, which included the Physician’s order: “OT 2WK1, 1WK1, 1EVERY2WK6, 1WK1.” The record lacked documentation the Pt. received a 2nd OT visit for week 1 of service, 11/27/22 to 12/2/22, or that the Physician was notified of the missed OT visit. 6. Pt. #17. SOC 11/9/22. Primary Diagnosis: Displaced Fracture of Trochanter Left Femur. The clinical record was reviewed on 1/4/23 at 3:20 PM. The record included the POC effective 11/9/22 to 1/27/23. This POC included the Physician’s order: “PT 1WK1, 2WK4, 1WK3.” The record lacked documentation of a second PT visit for week of 11/20/22 to 11/26/22, or that the Physician was notified of the missed 7. During an interview with the Executive Director, Regional Vice President, and Office Manager on 1/4/23 at 1:37 PM, and with the Clinical Director, Employee #2, and Employee #3 on 1/4/23 at 3:40 PM, the above findings were confirmed. Findings include: 1. Pt. #9. SOC 10/2/22. Primary Diagnosis: Type 2 Diabetes Mellitus with Diabetic Cataract. The clinical record was reviewed on 1/4/23 at 9:50 AM. The record contained the POC for certification period of 10/2/22 to 11/30/22 that required: "Skilled Nurse to obtain weight every week and notify RN/MD of weight gain or loss of 3 lbs over night or 5 lbs within 7 days." The SN provided one time during the week of 12/4/22 to 12/10/22, the SN visit note dated 12/8/22 lacked the patient's weight. 2. Pt. #13. SOC 9/4/22. Primary Diagnosis: Chronic Obstructive Pulmonary Disease with (Acute) Lower Respiratory Infection. The closed clinical record was reviewed on 1/4/23 at 10:45 AM. The record contained the POC effective 9/4/22 that required: "Skilled Nurse to perform pulse oximetry Q visit on room air or with oxygen to monitor patient's respiratory status." The SN visit note dated 10/13/22 lacked a pulse oximetry result/reading. 3. Pt. #14. SOC 12/7/21. Primary Diagnosis: Sacroiliitis, Not Elsewhere Classified. The closed clinical record was reviewed on 1/4/23 at 11:35 AM. The record contained the POC for the certification period of 12/7/21 to 2/4/22 that required, "Frequency/Duration of Visits: PT 2WK5, 1WK4". The record lacked documentation the PT provided any service during the week of 12/19/21 to 12/25/21.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: A. Based on a review of clinical records and staff interviews, it was determined the Agency failed to ensure the Agency assessed the need for Pneumococcal Pneumonia and/or Influenza vaccines. This was found in 14 of 17 (Pts. #2, 4, 5, 6, 7, 8. 9, 11, 12, 13, 14, 15, 16 and 17) clinical records reviewed. Findings include: 1. The following clinical records were reviewed from 1/3/23 to 1/4/23 from 2:55 PM to 1:30 PM: Pt. #2. SOC 12/22/22. Lacked Pneumonia vaccination status. Pt. #4. SOC 12/14/22. Lacked Pneumonia vaccination status. Pt. #5. SOC 02/18/22. Lacked Pneumonia and Influenza vaccination status. Pt. #6. SOC 10/22/22. Lacked Pneumonia and Influenza vaccination status. Pt. #7. SOC 09/28/22. Lacked Pneumonia and Influenza vaccination status. Pt. #8. SOC 11/17/22. Lacked Pneumonia and Influenza vaccination status. Pt. #9. SOC 10/02/22. Lacked Pneumonia and Influenza vaccination status. Pt. #11. SOC 10/07/22. Lacked Pneumonia and Influenza vaccination status. Pt. #12. SOC 11/17/22. Lacked Pneumonia and Influenza vaccination status. Pt. #13. SOC 09/04/22. Lacked Pneumonia vaccination status. Pt. #14. SOC 12/07/21. Lacked Pneumonia vaccination status. Pt. #15. SOC 08/05/22. Lacked Pneumonia and Influenza vaccination status. Pt. #16. SOC 10/11/22. Lacked Pneumonia vaccination status. Pt. #17. SOC 11/09/22. Lacked Pneumonia vaccination status. 2. During the Entrance interview on 1/3/23 at 9:25 AM the Executive Director stated, the RN is required to assess the patient's Influenza and Pneumococcal Pneumonia vaccination status at the SOC, and this information is documented in SOC comprehensive assessment. 3. During interviews on 1/4/23 at 1:37 PM and 1/5/23 at 11:10 AM with the Regional Vice President, Executive Director and the Performance Improvement Manager, the above findings were confirmed.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: A. Based on a review of the Agency's Pt. admission folder, observation during home visits and staff interview, it was determined the Agency failed to provide information regarding the Clinical Director and their contact information. This was found in 5 of 5 (Pts. #1, 2, 3, 4 and 5) home visits conducted from the parent Agency. Findings include: 1. The Agency's Pt. admission folder was reviewed on 1/3/23 at 4:00 PM, and lacked documentation identifying the Clinical Director's name and contact information. 2. The following home visits were conducted on 1/4/23 from 9:30 AM to 4:30 PM: Pt. #1. SOC 12/22/22. Pt. #2. SOC 12/22/22. Pt. #3. SOC 11/2/22. Pt. #4. SOC 12/14/22. Pt. #5. SOC 2/18/22. During the home visits, the Pt. admission folders were observed and lacked the Clinical Director's (Clinical Manager) name and contact information. 3. During interviews with the Regional Vice President, Executive Director and the Office Manager on 1/4/23 at 1:37 PM to 4:08 PM, and 1/5/23 at 10:20 AM, it was confirmed the Agency failed to provide Pts. the Clinical Director's name and contact information.