Every finding on record at Lhcg Cxcvii, LLC

Based on record review and interview, the agency failed to ensure an infection control and prevention plan was followed for all employees to ensure protection from communicable diseases for 3 of 10 employees. (MSW-1, RN-1, CNA-3, and MD-1) Findings include: 1. A revised 11/01/21 policy number 10.011 titled INFECTION CONTROL PLAN provided by the Executive Director (AS-1) on 6/7/2022 at 1:52 p.m. The policy indicated, but was not limited to, "PURPOSE: To enhance the safety and quality of patient care being provided by the agency ..." 2. A revised 6/1/2022 policy number 6.002 titled STAFF SCREENING, NEW HIRE, AND ANNUAL was provided by AS-1 on 6/7/2022 at 12:53 p.m. The policy indicated, but was not limited to, "PURPOSE: To establish a process to ensure appropriate staff screening prior to hire and annually thereafter ...PROCEDURE: ...B. TST Screening: (New Hire) New hires having no history of a positive (reactive) response to the TST are administered an initial TST. 1. If a new hire has documentation of a negative TST administered within the last 12 months, the director or designee will administer an initial TST and document results on the Employee Tuberculosis Screening Form. The previously documented test result, in conjunction with a TST administered by the director or designee, will demonstrate compliance with the 2-step method as per CDC guidelines. 2. If a new hire has no documentation of a TST, or the documentation is greater than 12 months, the director or designee will administer a second TST within 1-3 weeks from the initial TST (2-step method). Both results are documented on the Employee Tuberculosis Screening Form ..." 3. A 1/09/2017 policy number 3.004 titled PERSONNEL FILES was provided by AS-1 on 6/7/2022 at 1:43 p.m. The policy indicated, but was not limited to, "...2. The following items will be maintained in a medical file that is kept separate from the personnel file: a. TB test results..." 4. On 6/7/2022 at 10:55 a.m. the complete personnel record for employee MSW-1, hire date 11/29/2021, was provided by the Business Office Manager and Intake Coordinator (OS-1). The record evidenced documentation of only one Tuberculin Skin Test (TST). It failed to evidence the required TST 2-step method on an Employee Tuberculosis Form for new hires to the agency per agency policy. 5. On 6/7/2022 at 10:55 a.m. the complete personnel record for employee Registered Nurse Case Manager (RN-1), hire date 3/14/2022, was provided by the Business Office Manager and Intake Coordinator (OS-1). The record evidenced documentation of only one Tuberculin Skin Test (TST). It failed to evidence the required TST 2-step method on an Employee Tuberculosis Form for new hires to the agency per agency policy. 6. On 6/7/2022 at 10:55 a.m. the complete personnel record for employee Certified Nursing Assistant (CNA-3), hire date 1/10/2022, was provided by the Business Office Manager and Intake Coordinator (OS-1). The record evidenced documentation of only one Tuberculin Skin Test (TST). It failed to evidence the required TST 2-step method on an Employee Tuberculosis Form for new hires to the agency per agency policy. 7. On 6/7/2022 at 10:55 a.m. the complete personnel record for employee Medical Director (MD-1), hire date 8/1/2021, was provided by the Business Office Manager and Intake Coordinator (OS-1). It failed to evidence the required TST screening for employees of the agency per agency policy. 8. During an interview with OS-1 on 6/7/2022 at 12:03 p.m. it was indicated that all new hires to the agency should have a 2 step TST per policy. OS-1 indicated that older employees should have at least one or annual risk assessments, but MD-1 sometimes was difficult to get requirements from to maintain compliance.

Based on observation, record review, and interview, the agency failed to follow infection control standards of practice for 1 of 3 home visit observations. (Patient 6) Findings include: 1. A revised 11/01/21 policy numbers 10.011titled Infection Control Plan was provided by the Executive Director (AS-1) on 6/7/2022 at 1:52 p.m. The policy indicated, but was not limited to, "PURPOSE: To enhance the safety and quality of patient care being provided by the agency ..." 2. A 2017 Elsevier Clinical eLearning Lesson titled Personal Hygiene: Bathing and Perineal Care training protocol for Home Health Aides was provided by AS-2 on 6/7/22 at 1:46 p.m. The procedure/training protocol indicated, but was not limited to, "Introduction hygiene promotes comfort, safety, and health. The skin is the body's first line of defense against disease ...31. Clean the rectal area. Clean from the scrotum (front or top) to the anus (back or bottom). Rinse and dry well. 32. Remove the waterproof underpad. 33. Remove and discard the gloves. Practice hygiene. Put on clean gloves ..." 3. During a home visit on 12/9/2021 at 8:00 a.m. CNA-3 was observed giving a bed bath to patient 6. The hospice aide failed to change gloves after cleaning the patient's buttocks and anus then remove the underpad with new gloves and practice hand hygiene. CNA-3 failed to change gloves according to the procedure/training protocol of the Aide's competency checks. 4. During an interview on 6/2/2022 at 3:40 p.m. AS-1 indicated CNA-3 should have changed gloves after washing and drying patient 6's bottom and removing the underpad before moving forward with any other activity involving the patient.

Based on record review and interview, the agency failed to ensure staff competency was completed for 1 of 10 records reviewed. (CNA-3) Findings include: 1. A 1/09/2017 policy number 3.004 titled PERSONNEL FILES was provided by AS-1 on 6/7/2022 at 1:43 p.m. The policy indicated, but was not limited to, "...1. The Office Manager or designee will develop, keep and maintain the following items in personnel files at the clinical setting: ...f. Competency Assessments..." 2. A 10/01/2020 policy number 8.005 titled EMPLOYEE EDUCATION AND DEVELOPMENT was provided by AS-1 on 6/7/2022 at 12:24 p.m. The policy indicated, but was not limited to, "PURPOSE: To provide direction and guidance that will assure continuing education and development opportunities for all employees of LHC Group. To establish and maintain a mechanism for documenting completion of required training for regulating agencies ..." 3. On 6/7/2022 at 10:55 a.m. the complete personnel record for employee Certified Nursing Assistant (CNA-3), hire date 1/10/2022, was provided by the Business Office Manager and Intake Coordinator (OS-1). The record failed to evidence documentation of skills checks and an exam to demonstrate the aide's competency. 4. During an interview on 6/8/2022 at 10:01 a.m. AS-2 indicated CNA-3 had a preceptor who was doing skills check. That preceptor left the agency and didn't leave the competency check completed with the executive director. AS-1 indicated CNA-3 also had taken the competency exam but had yet to pass it in ITRAIN. AS-1 stated AS-2 was going to do skills checkoff that day and told OS-1 to get CNA-3 to complete competency exam immediately.

Based on record review and interview, the agency failed to ensure all staff had completed the required orientation to hospice philosophy for 2 of 10 records review. (MSW-1 and MD-1) Findings include: 1. A 10/01/2020 policy number 8.005 titled EMPLOYEE EDUCATION AND DEVELOPMENT was provided by AS-1 on 6/7/2022 at 12:24 p.m. The policy indicated, but was not limited to, "PURPOSE: To provide direction and guidance that will assure continuing education and development opportunities for all employees of LHC Group. To establish and maintain a mechanism for documenting completion of required training for regulating agencies ..." 2. A 08/01/18 policy number 8.012 titled MEDICAL DIRECTORS/ASSOCIATE MEDICAL DIRECTORS was provided by AS-1 on 6/7/2022 at 12:24 p.m. The policy indicated, but was not limited to, " ...PROCEDURE: ...7. All Medical Directors and Associate Medical Directors providing services under contract arrangement with the hospice provider, in addition to a signed and executed contract, must have the following: ...h. Signed Medical Director/Associate Medical Director Attestation indicating review of "Hospice Philosophy for Medical Directors", "Hospice Medical Director Guide", and the hospice provider policies and procedures. i. Initial and annual competency assessment/contract review ...". 3. A 2017 ITRAIN titled Hospice (Outpatient): 2022 Annual Mandatory Training was provided by AS-1 on 6/7/2022 at 12:53 p.m. The training indicated, but was not limited to, "EMPLOYEES (Non-Contractor) ALL Roles (Est Total 2.5 hrs) Code of Conduct & Ethics Attestation, Ethics, Compliance, HIPAA, *Introduction to Hospice Eligibility and Documentation, Fire Safety, HS Policy 15.022-Emergency Preparedness Plan ...Infection Control, Tuberculosis, & Bloodborne Pathogens ...CONTRACTORS ...Medical Directors (Contract Only) Complete Compliance training once they reach 120 hours of service for the year." 4. On 6/7/2022 at 10:55 a.m. the complete personnel record for employee MSW-1, hire date 11/29/2021, was provided by the Business Office Manager and Intake Coordinator (OS-1). It failed to evidence the required orientation to hospice per agency policy. 5. On 6/7/2022 at 10:55 a.m. the complete personnel record for employee Medical Director (MD-1), hire date 8/1/2021, was provided by the Business Office Manager and Intake Coordinator (OS-1). It failed to evidence the required orientation to hospice required per agency policy. 6. During an interview with OS-1 on 6/7/2022 at 12:03 p.m. it was indicated that all staff should have all their orientation completed with documentation in the personnel file as well as any annual or in-service trainings. OS-1 indicated that MD-1 doesn't really do ITRAIN and doesn't give copies of any continuing education completed to the office for the personnel file.

Based on record review and interview, the agency failed to ensure hospice staff furnished orientation on hospice philosophy, policies and procedures regarding methods of comfort, pain control, symptom management, principles about death and dying at all skilled nursing or assisted living facilities that provide care to hospice patients for 2 of 2 active facilities, with the potential to affect all contracted facilities. (Entities 1 and 2) Findings include: 1. A 4/27/2022 contract titled NURSING FACILITY SERVICES AGREEMENT was copied by AD-1 on 5/11/2022 at 4:45 p.m. The contract indicated, but was not limited to, " ...3.3 Hospice Care Training. Hospice shall provide orientation and ongoing hospice care training to Facility's personnel as necessary to facilitate the provision of safe and effective care to Hospice Patients. Such orientation must include Hospice policies and procedures regarding methods of comfort, pain control and symptom management, as well as principles about death and dying, individual responses to death, patient rights, appropriate forms, and record keeping requirements." 2. During an interview on 6/2/2022 at 12:20 p.m. a facility nurse caring for patient 6 indicated that no training had been received by any hospice staff. 3. During an interview on 6/1/2022 at 9:45 a.m. Executive Director (AS-1) indicated he/she was unsure on how training was completed within the contracts for skilled nursing or assisted living facilities, but training was completed. AS-1 indicated the Patient Care Manager (AS-2) completed training regarding care and needs of the patient with facility staff when a patient was placed. AS-1 indicated being unsure if training provided by AS-2 was formal or documented and was unable to provide evidence of any training being completed at any facilities contracted with, including but not limited to, Entities 1 and 2.

Based on record review and interview, the agency failed to have officials responsible for the day-to-day operations of the agency as officers on their application with the state for 1 of 1 hospice agency. (Entity 1). Findings include: 1. The Indiana Code (IC) 16-25-3-3 stated in Sec. 3. (a) An applicant shall submit an application for a hospice license or for approval of a hospice program on a form prescribed by the state department. (b) The applicant shall attach to the application evidence of the applicant's ability to comply with the minimum standards established for licensure under this article. (c) The application must contain the following information: (1) The applicant's name. (2) The type of hospice program the applicant will own or operate. (3) The location of the hospice program owned or operated by the applicant. (4) The name of the individual or individuals responsible for the day-to-day operation of the hospice program owned or operated by the applicant. 2. A revised 06/01/19 policy number 6.001 was provided by the Executive Director (AS-1) on 6/6/2022 at 8:46 a.m. The policy indicated, but was not limited to, "PURPOSE: To establish the authority and responsibilities for the governing body for planning of agency operations. POLICY: ...The governing body, as outlined by Senior Management, shall include the following: Executive Director, Agency Medical Director ..." 3. During entrance conference on 5/31/2022 at 9:40 a.m. the Executive Director could not name the individuals of the governing body but indicated the names of those that met for QAPI (Quality Assurance and Performance Improvement) quarterly. 4. Upon review of officer's names given to the state, AS-1 could not determine who those people were except they were corporate level people with LHC and had to speak with AS-1's supervisor to get clarification. 5. During an interview on 6/1/2022 at 10:57 a.m. AS-1 indicated the list of names given to the state was the LHC Group, Inc Officers but not the governing body of the OMNI hospice agency.