Inspection Reports for LEXX Homecare Agency, LLC
999 Whitlock Ave NW Suite 9, Marietta, GA 30064, United States, GA, 30064
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Inspection Report
Follow-Up
Deficiencies: 1
Aug 20, 2024
Visit Reason
The purpose of this visit was to conduct a follow up to the June 06, 2024 inspection. Rule violations were cited as a result of the inspection.
Findings
The provider failed to ensure that staff hired after October 1, 2019 had the required criminal background checks through fingerprinting for two of three employees sampled. This deficiency had been previously cited on June 06, 2024 and November 15, 2022.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staff hired effective October 1, 2019 had the required criminal background checks for employment for two of three employees sampled (Staff B and Staff C). | SS=F |
Report Facts
Previous citations: 2
Number of employees sampled: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Home Health Aide | Hired 06/12/2023, no criminal background check through fingerprinting |
| Staff C | Home Health Aide | Hired 04/22/2024, no criminal background check through fingerprinting |
| Staff A | During exit conference stated difficulty with getting caregivers to complete background checks |
Inspection Report
Routine
Deficiencies: 3
Jun 6, 2024
Visit Reason
The purpose of this visit was to conduct a periodic inspection on June 06, 2024.
Findings
Rule violations were cited as a result of this inspection, including failure to ensure required criminal background checks for three of six employees, failure to maintain documentation for unlicensed professionals as employees, and failure to ensure personal care employees were properly qualified or documented.
Severity Breakdown
E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure staff hired after October 1, 2019 had required criminal background checks for employment for three of six employees sampled (Staff C, Staff D, Staff E). | E |
| Failed to ensure unlicensed professionals maintained documentation as employees of the agency for one of six employees sampled (Staff C). | E |
| Failed to ensure employees providing personal care were qualified as certified nursing assistants or had proper competency documentation for one of six employees sampled (Staff D). | E |
Report Facts
Employees sampled: 6
Employees with deficiencies: 3
Employees with documentation issues: 1
Employees lacking qualification documentation: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Home Health Aide | Failed to have validated criminal background check and documentation as agency employee |
| Staff D | Home Health Aide | Failed to have validated criminal background check and lacked competency skills checklist documentation |
| Staff E | Home Health Aide | Failed to have validated criminal background check |
| Staff F | Interviewed regarding difficulties with caregivers obtaining background checks and acknowledged oversight in documentation |
Inspection Report
Follow-Up
Deficiencies: 0
Feb 8, 2023
Visit Reason
The purpose of this visit was to conduct a follow-up inspection to the November 15, 2022 inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Routine
Deficiencies: 6
Nov 15, 2022
Visit Reason
The purpose of this visit was to conduct a periodic inspection on November 15, 2022.
Findings
The inspection identified multiple rule violations related to personnel files, employee documentation, service agreements, and staff qualifications. Deficiencies included missing criminal background checks, incomplete employee documentation, lack of required service agreement details, missing annual competency evaluations, and inadequate staff training documentation.
Severity Breakdown
D: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure staff hired after October 1, 2019 had required criminal background checks for employment (Staff C). | D |
| Failed to ensure unlicensed professionals maintained documentation as employees of the agency (Staff C). | D |
| Failed to include the date the provider made initial contact with client for services on service agreements for four sampled clients. | D |
| Failed to include charges for services and billing/payment mechanisms on service agreements for two sampled clients. | D |
| Failed to include documentation of annual employee evaluations by direct observation or demonstration for two sampled staff (Staff D, Staff E). | D |
| Failed to ensure employees providing personal care were qualified as certified nursing assistants or had completed required competency testing and skills checklists for four sampled staff (Staff C, D, E, F). | D |
Report Facts
Number of sampled staff with missing criminal background checks: 1
Number of sampled clients missing initial contact date on service agreements: 4
Number of sampled clients missing charges and billing/payment mechanisms on service agreements: 2
Number of sampled staff missing annual competency evaluations: 2
Number of sampled staff lacking required personal care qualifications or competency documentation: 4
Minimum passing score for NLN test: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Provided interview statements regarding fingerprinting difficulties, service agreement details, and competency evaluations. | |
| Staff C | Home Health Aide | Hired 5/16/2020; lacked criminal background check and employee documentation; did not want to be a W2 employee; completed NLN test but lacked competency skills checklist. |
| Staff D | Home Health Aide | Hired 03/03/2020; lacked annual competency evaluation documentation; completed NLN test but lacked competency skills checklist. |
| Staff E | Home Health Aide | Hired 10/13/2021; lacked annual competency evaluation documentation; completed NLN test but did not pass; lacked competency skills checklist. |
| Staff F | Completed NLN test but lacked competency skills checklist. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Nov 9, 2021
Visit Reason
The purpose of this visit was to investigate complaint GA#00218053.
Findings
The provider failed to ensure staff provided personal care services according to the client's service plan for one of six sampled clients, and failed to establish and implement written policies and procedures for documenting services actually performed. Documentation was missing for October 2021, and no services were rendered during the week of September 20-24, 2021 and the entire month of October 2021.
Complaint Details
Complaint GA#00218053 was investigated and rule violations were cited. The complaint was substantiated as evidenced by findings related to failure to provide personal care services and failure to document services.
Severity Breakdown
E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Provider failed to ensure staff provided personal care services in accordance with client's service plans for one of six sampled clients (Client #5). | E |
| Provider failed to establish and implement written policies and procedures for documenting the services actually performed for its clients each day, and documentation was missing for Client #5 for October 2021. | E |
Report Facts
Number of sampled clients with deficiencies: 1
Service days missed: 7
Hours per day of service planned: 3
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 24, 2021
Visit Reason
The purpose of this visit was to investigate complaint GA#00216425.
Findings
The provider failed to establish and implement written policies and procedures for documenting the services actually performed for its clients each day, and documentation was incomplete for Client #1, including missing signatures from client, caregiver, and registered nurse.
Complaint Details
Visit was complaint-related for complaint GA#00216425. Rule violations were cited as a result of this inspection.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to establish and implement written policies and procedures for documenting services performed each day. | SS= D |
Inspection Report
Routine
Deficiencies: 2
Jan 20, 2021
Visit Reason
The purpose of this visit was to conduct a periodic inspection of Lexx Homecare Agency, LLC.
Findings
Rule violations were cited related to failure to document addendums to initial service agreements for changes in client services and failure to ensure personal care services were provided according to clients' service plans.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Provider failed to document addendum to the initial service agreement noting specific changes in services provided for two of three sampled clients. | SS= D |
| Provider failed to ensure staff provided personal care services in accordance with clients' service plans for one of three sampled clients. | SS= D |
Report Facts
Service frequency and duration discrepancies: 2
Clients sampled: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Offered no explanation for not documenting addendum to clients' initial service agreements. | |
| Staff A | Offered no explanation why services were not provided per the clients' service plans. |
Inspection Report
Original Licensing
Deficiencies: 0
Aug 15, 2019
Visit Reason
The purpose of this visit was to conduct an initial compliance inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Original Licensing
Deficiencies: 0
May 21, 2019
Visit Reason
A provisional licensure survey was conducted to review policies, procedures, personnel records, and client record forms as part of the initial licensing process for the home care agency.
Findings
No deficiencies were cited during the provisional licensure survey. A provisional license was issued to allow the provider time to demonstrate compliance with applicable rules and regulations.
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