Every finding on record at Ltd Group, LLC

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey Abbreviations mg milligrams

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observations, interviews, and record review, the agency failed to ensure each patients’ comprehensive assessment included a review of all medications the patients were currently using. The agency failed to ensure staff reconciled patients’ medications for 2 (#1 and #2) of 3 (#1, #2 and #3) patients reviewed during home visits Review of the Agency’s Policy titled, “Medication List and Monitoring” dated May 2, 2024 revealed the following, in part: Purpose: To Outline a process for ongoing medication monitoring. Policy: The agency will maintain a current, accurate list of all prescription and over the counter medications taken by the patient. Patient #1 Review of the Clinical Record for Patient #1 revealed he began receiving services from the Home Health Agency on 11/07/2024 and had a current Certification Period of 11/07/2024 through 01/05/2025. Patient #1 had diagnoses, which included Chronic Kidney Disease with Heart Failure. A home visit was conducted with Patient #1 on 12/10/2024 at 9:30 a.m. with S3PTA present. Patient #1’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to Patient #1’s Current Medication Profile provided by the Home Health Agency: Fexofenadine 25mg one tablet daily was on the medication profile with a start date of 11/07/2024, which the patient was no longer taking. Nexletol 180mg one tablet daily was on the medication profile with a start date of 11/07/2024, which the patient was no longer taking. Amlodipine 10mg tablet one tablet daily was on the medication profile with start date of 11/07/2024, which the patient was no longer taking. An interview was conducted on 12/10/204 at 9:35 a.m. with Patient #1’s caregiver. She said Patient #1’s doctor changed the Amlodipine 10mg tablet one tablet daily to Amlodipine 5mg one tablet daily three weeks ago. She said Patient #1 stopped taking Fexofenadine 25mg and Nexletol 180mg three months ago. An interview was conducted on 12/10/2024 at 9:40 a.m. with S3PTA. S3PTA confirmed the above medication discrepancies identified during the home visit. S3PTA said medications should be reconciled during every home visit. Patient #2 Review of the Clinical Record for Patient #2 revealed he began receiving services from the Home Health Agency on 07/04/2024 and had a current Certification Period of 11/12/2024 through 12/30/2024. Patient #1 had diagnoses, which included Pulmonary Embolism. A home visit was conducted with Patient #2 on 12/10/2024 at 10:30 a.m. with S2RN present. Patient #2’s medications were reviewed during the home visit. The following medication discrepancy was identified when compared to Patient #2’s Current Medication Profile provided by the Home Health Agency: Eliquis 5mg tablet take one tablet twice a day was on the medication profile with a start date of 07/03/2024, which the patient was no longer taking. An interview was conducted on 12/10/204 at 10:35 a.m. with Patient #2. He said he had been taking Eliquis 10mg twice a day since 11/19/2024 per the doctor’s orders. An interview was conducted on 12/10/2024 at 10:40 a.m. with S2RN. S2RN confirmed the above medication discrepancy identified during the home visit. S2RN said medications should be reconciled during every home visit. An interview was conducted with S1DON on 12/10/2024 at 3:00 p.m. She was notified of the medication discrepancies identified during the home visits for Patient #1 and #2. She said each patients’ medications should be reconciled every discipline visit and staff should review the medication bottles each visit. She verified each patients’ Medication Profile should have reflected what the patient was currently taking.

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 record review and interview, the agency failed to ensure the Physician was notified regarding a change in a patient's condition for 1 (#7) of 7 (#1- #7) patient records reviewed. The agency staff failed to timely communicate Patient #7’s abnormal urine culture result to the Physician. Findings: Review of Patient #7’s Clinical Record revealed she began receiving services with the agency on 12/05/2023 and had a certification period of 12/05/2023 through 02/02/2024. Patient #7 had diagnoses, which included Chronic Kidney Disease. Review of Patient #7’s faxed urine culture result received from the lab on 01/16/2024 revealed she had Escherichia Coli in her urine. Review of Patient #7’s Nurse’s Notes for certification period 12/05/2023 through 02/02/2024 revealed S1DON notified Patient #7’s doctor of the abnormal urine culture result on 01/18/2024. An interview was conducted on 12/09/2024 at 1:00 p.m. with S1DON. She said the agency received Patient #7’s urine culture and sensitivity result on 01/16/2024. She said Patient #7’s doctor was notified 01/18/2024. She said the staff should have ensured Patient #7’s doctor was notified on 01/16/2024 when the results were faxed from the lab to the agency. She said there was no effective process to ensure critical labs were reported to the doctor timely.

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 record review and interviews, the agency failed to provide services that were ordered by the physician as indicated in the Plan of Care for 1 (#2) of 7 (#1 - #7) patients reviewed. The agency failed to ensure the skilled nurse obtained a weight or measured edema if unable to weigh every visit. Review of the agency’s policy titled “Orders for Care”, dated May 01, 2024, revealed the following, in part: Policy: To ensure patient care is provided in accordance with a Physician’s Order. Review of Patient #2’s Clinical Record revealed he began receiving services from the Home Health Agency on 07/04/2024 and had a current Certification Period of 11/12/2024 through 12/30/2024. Patient #1 had diagnoses, which included Pulmonary Embolism and Hypertensive Heart Disease with Heart Failure. Review of Patient #2’s Plan of Care for Certification Period 11/12/2024 through 12/30/2024 revealed Physician Orders which included the following, in part: Skilled Nurse to obtain weight or measure edema if unable to weigh every visit and notify Registered Nurse or the Medical Doctor of weight gain of three pounds in one day/five pounds within one week or significant changes in edema. Review of the Skilled Nurse visit notes for Patient #2 dated 11/06/2024, 11/13/2024 and 11/19/2024, 11/27/2024 and 12/04/2024 revealed no documented weight or measurement of edema. An interview was conducted on 12/10/2024 at 9:30 a.m. with S2RN. She confirmed she provided skilled nurse visits on the dates listed above and did not obtain Patient #2’s weight or measurement of edema. She said she usually just asked the patient what his last weight was from the previous doctor office visit. She confirmed according to Patient #2’s Plan of Care, weights or measurement of edema should have been obtained each nurse visit. An interview was conducted on 12/10/2024 at 3:30 p.m. with S1DON. She confirmed S2RN did not document Patient #2’s weight or measurement of edema each skilled nurse visit. She said S2RN should have obtained Patient #2’s weight or measurement of edema each visit as ordered by the Physician.

The entity is in compliance with the Federal Emergency Preparedness requirements

Recertification Survey Abbreviations: ADM- Administrator DON- Director of Nursing LPN- Licensed Practical Nurse MD- Medical Doctor POC- Plan of Care PT/INR- Prothrombin Time Test/International Normalized Ratio) SN- Skilled Nurse SOC- Start of Care ROC- Resumption of Care

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observations during home visits, interviews, and record review, the agency failed to ensure the patients’ comprehensive assessments included a review of all medications the patients were currently using. The agency failed to ensure therapy and skilled nursing staff reconciled a patient’s medications for 3 (#3, #4, #10) of 10 (#1-#10) sampled patients reviewed. Findings: Policy Titled, “Medication Patient Information and Reconciliation” revealed the following, in part: Procedure: The Registered Nurse shall perform an assessment of the patient’s current medications/herbal remedies to determine whether actual or potential interactions exist between the current medications and herbal remedies, based on the current body of knowledge. This information is documented in the medication reconciliation notes… Any questions or concerns about the patient’s current medications and herbal remedies are directed to the ordering physician… The patient’s medications are reviewed and assessed during each skilled visit. Any changes in medications or changes in the patient’s response to the medications are conveyed to the ordering physician… An interview was held with S2DON on 01/18/2022 at 1:00 p.m. She provided the current medication profiles for sampled patients reviewed. She verified the medications should be reconciled by a skilled professional every visit and if there was a medication change. Patient #3 Review of the clinical record for Patient #3 revealed the patient began receiving services with the agency on 12/01/2021. The patient had diagnoses that included Gastroesophageal Laceration Hemorrhage Syndrome, Hematemesis and Acute Post Hemorrhagic Anemia. Review of the current medication profile for Patient #3 included the following, in part: Warfarin Sodium 3 mg 1 tablet on Mondays and Fridays and 1.5 tabs all other days. Recheck PT/INR on 12/27/2021. A home visit was conducted for Patient #3 on 01/19/2022 at 9:45 a.m. S3LPN was the discipline present in the home for the visit. Patient #3 verbalized he was currently taking Warfarin as part of his medication regimen. He stated he wrote down the last time the frequency and dose was changed. He stated he was currently taking the Coumadin (Warfarin) 3 mg, 1 tablet on Mondays, Wednesdays, Fridays and Saturdays. He stated he was taking Coumadin (Warfarin) 3mg 1.5 tablets on Tuesdays, Thursdays and Sundays. S3LPN reviewed the last MD order obtained regarding the patient’s Warfarin medication order and verified how Patient #3 was currently taking the medication was the most up to date. Patient #4 Review of the clinical record for Patient #4 revealed the patient began receiving services with the agency on 12/02/2021. The patient had diagnoses that included, in part: 4-Part Fracture of the Surgical Neck of the Left Humerus, Parkinson’s Disease and Paroxysmal Atrial Fibrillation. Review of the current medication profile list provided by the agency for Patient #4 revealed the following, in part: Duloxetine (Cymbalta) HCL Oral 30 mg 1 capsule, take 1 capsule by mouth daily Duloxetine HCL Oral 30 mg 1 capsule every evening Duloxetine HCL Oral 60 mg 1 capsule every morning An interview was held with the caregiver for Patient #4 on 01/19/2022 at 11:10 a.m. She stated she would give the patient her daytime medications. She stated the patient’s husband would leave the medications out each day and she would administer them to the patient. She stated she was giving the Cymbalta to the patient once during the day. She then provided a copy of the patient’s medication list and stated the medications listed were the medications the patient was taking along with the dosages. Review of the list provided by the caregiver indicating the patient’s current drug regimen revealed the patient was taking the following medications, in part: Duloxetine 30 mg tablet twice a day Patient #10 Review of the clinical record for Patient #10 revealed her start of care was 03/01/2021 and she had diagnoses, which included the following: Infection Following a Procedure, Sepsis Following a Procedure, Acute Post Hemorrhagic Anemia, Displaced Fracture of the Proximal Phalanx, and Peripheral Vascular Disease. Review of the Patient Medication Profile for Patient #10 revealed the following medications were listed as active medications: Clopidogrel Bisulfate Oral 75mg 1 tablet(s) take one tablet by mouth daily. Clopidogrel Bisulfate Oral 75mg 1 tablet(s) once daily. An interview was held with S2DON on 01/20/2022 at 11:20 a.m. She verified if there was a duplicate medication on the medication profile, she would expect the staff to seek clarification from the MD to ensure the medication regimen was correct. She confirmed any time there was a medication change, she expected to see the medication change reflected on the medication profile. She verified the medication profiles for Patient #3, #4 and #10 did not match the current medications the patients were on and the medication discrepancies required clarification.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on interviews and record review, the agency failed to communicate with the physician to ensure lab work was obtained as ordered for 1 (#4) of 2 (#3, #4) patients reviewed that were prescribed Coumadin. Findings: Review of the clinical record for Patient #4 revealed a SOC (start of care) date of 12/02/2021. The patient had diagnoses that included a 4-art Fracture to the Surgical Neck of the Left Humerus, Parkinson’s Disease and Paroxysmal Atrial Fibrillation. Review of Patient #4’s 485/POC for the certification period of 12/02/2021 – 01/30/2022 revealed the following: SN Interventions: SN to obtain PT/INR per MD orders week of 12/09/2021. Review of the SN missed visit notes for Patient #4 revealed the following documentation for 12/10/2021: Patient’s husband informed SN that patient had MD appointment with orthopedic surgeon about that time. Further review of the SN notes revealed no documentation an attempt was made to implement the MD order to obtain a PT/INR after 12/10/2021. Review of SN notes revealed the patient had shoulder repair surgery on 12/16/2021. The patient’s ROC (Resumption of Care) for the agency was on 12/20/2021. A review of the communication documentation completed on 12/20/2021 for Patient #4 revealed the following, in part: Labs: Need order for INR. Please contact MD to see when these labs should be done. Review of the record on 01/19/2022 for Patient #4 revealed there was no documentation the MD was contacted to verify when the next INR lab should have been obtained. An interview was held with S1ADM on 01/20/2022 at 10:45 a.m. She provided labs that were completed by the orthopedic doctor prior to Patient #4’s procedure on 12/16/2021 and 12/17/2021. She reviewed the communication documentation for Patient #4 and verified there was documentation indicating the MD was to be contacted to clarify for INR orders. She verified there was no other documentation in the record showing an attempt to clarify when the INR was to be obtained or that it had been obtained since 12/20/2021.