Every finding on record at Lhcg Xxxvii, LLC

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 01/05/2022. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program (EP) for this survey.

A recertification survey was conducted on 01/05/2022. The Agency was not in compliance with Standards for Home Health Agencies, 42 CFR, 484, as evidenced by: Abbreviations: E - employee EP - emergency program POC-plan of care Pt - patient PT - physical therapy PTA-physical therapy asisstant # - number

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: Based on document review and staff interview it was determined for 1 of 10 (Pt #2) physical therapy (PT) clinical records reviewed, the home health agency (HHA) failed to ensure the physician was notified of modifications to the plan of care. This has the potential to effect all patients receiving services-current census-871.. Findings include: 1. The HHA policy revision date 8/1/19, titled, "COORDINATION OF CARE, FROM ADMIT THROUGH DISCHARGE" was reviewed on 1/5/22. The policy indicated under "PROCEDURE: 4. Coordination of care with physician: At admission, throughout care...is promoted through routine communication with the patient's physician: ..c. When a missed visit occurs, altering the Plan of Care. 2. The clinical record of Pt #2 was reviewed on 1/3/22. Pt #2 was admitted on 11/29/21 with diagnosis of hypomagnesemia. The PT order written on 12/2/21 indicated PT three times a week for two weeks, two times a week two weeks and one time a week for one week. Documentation indicated the week of 12/12/21 and 12/19/21 only two PT visits were made. There was no documentation the physician was notified of the modification of the plan of care (POC). 3. On 1/4/22 at 11:00 AM, an interview was conducted with the Administrator (E#1). E#1 reviewed Pt #2's clinical record and confirmed the PT visits were missed and the physician was not notified.

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 document review and staff interview, it was determined for 1 of 18 (Pt #11) patient, the Home Health Agency (HHA) failed to ensure the plan or care was followed. This has the potential to affect all patients receiving services from a HHA with a census or 871 patients. 1. The medical record of Pt #11 was reviewed on 01/04/2022 at approximately 2:00 PM. Pt #11's start of care was 12/27/2021, with a diagnosis of "aftercare following surgery on the circulatory system". The "Plan of Care" for certification period 12/27/2021 thru 02/24/2021 indicated the "skilled nurse was to obtain body measurement of right calf every visit". The "Visit Note Report" for 12/29/2021, which was performed by registered nurse (E #5), lacked documentation that body measurements of the right calf was conducted. 2. On 01/04/2022, HHA policy "Plan of Care" effective 12/01/2021 was reviewed. Under "Purpose:" it reads "To ensure that physician/authorized practitioner's orders are followed." 3. On 01/04/2022 at 230 PM, an interview with the Administrator (E#1) was conducted. E #1 confirmed that body measurements were not conducted on 12/29/2021 for Pt #11, and stated "They should have been done."

Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This ELEMENT is not met as evidenced by: Based on document review and staff interview it was determined for1 of 10 (Pt #2) clinical records reviewed the HHA failed to ensure rehabilitative services were provided under the supervision of a PT. This has the potential to effect all patients receiving therapy services. Findings include: 1. The HHA policy, dated, 12/1/21, titled, "PHYSICAL THERAPIST ASSISTANT (PTA) SUPERVISION" was reviewed on 1/5/22. The policy indicated under "PROCEDURE: 3. The PT provides supervision for every patient receiving care by the PTA (physical therapy assistant) to ensure that the patient is receiving satisfactory care. These visits are made according to specific state guidelines outlined below:... Illinois...PT provides on-site supervision every four to six visits, either when the PTA is present or without the PTA. 2. The clinical record of Pt #2 was reviewed on 1/3/22. Pt #2 was admitted for services on 11/29/21 with diagnosis of hypomagnesemia. A PT evaluation was completed on 12/2/21. From 12/6/21 thru 12/29/21, the PTA visited Pt #2 eight times. There was no documentation of a supervisory visit being conducted by the PT. 3. On 1/4/22 at 11:00 AM, an interview was conducted with the administrator (E#1). E#1 reviewed Pt #2's clinical record and confirmed there were no PT supervisory visits completed.