Georgia Home Health

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on review of policy “OASIS DATA CAPTURE, TRANSMISSION, VERIFICATION, DISPLAY AND REPORTS,” review of the Centers for Medicaid and Medicare Services (CMS) report, and staff interview, it was determined that the agency failed to submit to CMS system a completed Outcome and Assessment Information Set (OASIS) within thirty days of completing the assessments. Failure to submit OASIS within 30 days has the potential to cause delay in care and affect quality of care for all patients with late OASIS submission. Findings include: Review of the policy titled “OASIS Data Capture, Transmission, Verification, Display and Reports,” last revised 03/01/21, revealed the following: 2. a. At least monthly, Agency will electronically transmit accurate, completed, encoded and locked OASIS data to the state agency. All OASIS assessments completed must be transmitted within thirty (30) days of M0090 date. Review of CMS report ran on 1/13/25 for period 01/01/2024 to 12/31/2024 titled “HHA Error Summary by Agency,” revealed the agency failed to transmit OASIS data to the State Agency within 30 days. On 1/29/2024 at 10:00 a.m., during an in-office interview, the Executive Director (ED) confirmed awareness of the 30-day OASIS submission time frame requirements not met during the time frame of 01/01/2024 to 12/31/2024.”

“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 observation, clinical record review, staff interviews, and review of policy “Wound Assessment, Documentation, and Photography,” it was determined the agency failed to ensure the care and services were provided in conformance with the patients’ plan of care and treatment as ordered by physician for two patients (P) (P#11 and P#14) of seven sampled patients. Review of the clinical record for P#11 revealed the patient was admitted to hospice on 1/14/25 with an admitting diagnosis of non-pressure chronic ulcer other part of left lower leg. Review of the plan of care required the skilled nurse (SN) to visit the patient 1 time a week and obtain weights every visit and notify physician of weight gain or loss of seven pounds within seven days. Instruct patient/caregiver on importance of obtaining weight and keeping a weight log. The SN visited on 1/28/25 however, the SN failed to obtain a weight as required. Additionally, the plan of care required the SN to perform wound care to the left tibia (shinbone) weekly until healed as follows: cleanse with wound cleanser, pat dry, apply opticell (a wound dressing used to heal wounds) or equivalent to wound bed, moisturize legs with ointment. Apply ABD (thick absorbent padding) pad as overlay. Secure with kerlix (gauze bandage) and coban (self adherent wrap to secure bandages). During a home visit observation on 1/28/25 at approximately 10:30 a.m., with RN BB, this surveyor observed RN BB perform wound care to the right lower extremity. Once completed, RN BB began to perform wound care to the left leg. RN BB did confirm P#11 had bilateral wounds to lower extremities requiring wound care. However, the plan of care did not contain wound orders for the right lower extremity. The agency failed to obtain orders for wound care to the right lower extremity. During an interview on 1/29/25 at approximately 11:00 am., the Executive Director confirmed that the plan of care lacked physician orders for wound care to the right lower extremity. It was also confirmed that the SN failed to perform weekly weights on 1/28/25 as required. The Findings include: Review of policy titled: “Wound Assessment, Documentation, and Photography. Policy Number 2.2.001, page 2 of 3. Revised 09/01/24”. Procedure: number 2. Perform wound care according to LHC adopted clinical skills guidelines and physician orders. Review of the plan of care (POC), for P#14 with a certification period of 1/23/2025 to 3/23/2025 revealed the patient had pertinent diagnoses of pressure ulcer of sacral region stage 2. The physician’s order revealed a skilled nurse (SN), to perform wound care to right buttock stage two, twice a week, and as needed if soil. Cleanse the buttock wound with soap and water, apply hydrogel and cover with ABD pad and secure with tape, using clean technique. On 1/28/2025 at 11:00 a.m., observed Licensed Practical Nurse (LPN) AA perform wound care to P#14, sacral area. LPN AA cleaned the wound with soap and water, pat dry, then covered the sacral wound with abdominal pad (ABD) and secured the pad with tape. On 1/28/2025 at 11:56 a.m., an interview was conducted with LPN AA at the Livingroom in patient’s apartment. LPN AA said that P#14 was admitted on 1/23/2025 (five days ago), and they ordered for hydrogel, but it was not delivered, and she thought she had it in her car but unfortunately it had finished. LPN AA said that she would notify the physician that the hydrogel was not available when she visited the patient. After the interview, LPN AA went back to P#14 and told him that the hydrogel was not available. On 1/28/2025 at 12:15 p.m., an interview was conducted with the Administrator on phone. She acknowledged the LPN AA failed to apply hydrogel to P#14 sacral wound as ordered because the medicine was not available during SN visit.”