Northeast Georgia Home Health

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on observation, record review, staff interview, and review of agency policy, it was determined that the agency physician failed to sign plan of care (POC) for five patients (P) (P#1, P#4, P#6, P#8, and P#9) of 21 sampled patients. Findings include: Review of the agency policy titled “Physician Orders”, revised 10/01/23, Policy Number: 2.1.008 reveals the following: Procedure: 4. The Plan of Care (POC), telephone and or verbal orders must be signed and dated by the physician or authorized practitioner within a timely manner per state regulation: STATE Timeliness of Physician Signature Georgia 30 days The governing body failed to have POC signed by physician and failed to have POC signed by physician in a timely manner. 1. Review of clinical record of P#1 revealed P#1 was admitted to the home health agency on 10/27/2023. The physician signed the POC on 11/29/2023. 2. Review of record for P#4 revealed P#4 was admitted to the home health agency on 11/1/2023. The physician failed to sign the POC. 3. Review of record for P#5 revealed P#5 was admitted to the home health agency on 12/15/2023. The physician signed the POC on 1/16/2024. 4. Review of clinical record for P#6 revealed P#6 was admitted to the home health agency on 12/14/2023. The physician signed the POC on 1/19/2024. 5. Review of clinical record for P#9 revealed a patient was admitted to the home health agency on 12/3/2023. The physician failed to sign the POC. On 1/23/24 at 3:30 p.m., an interview was conducted with clinical manager (CM) who revealed the agency has problems with one physician that does not sign the patients verbal order plan of care in a timely manner.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record reviews, and staff interview, it was determined the agency failed to ensure the patient plan of care (POC), contained complete, concise and clear documentation of all services, including dialysis interventions to monitor dialysis site for infection or bleeding after dialysis procedures, teaching, evaluations, treatments, progress notes, and individualized plan of care to address the patients’ needs for one patient (P) (P#7) of 21 sampled patients. The Findings include: Review of the POC for P#7 (certification period of 12/1/2023 to 1/29/2024) revealed P#7 was admitted to home health agency on 12/1/2023, with a diagnosis of end stage renal failure dependence on renal dialysis (a condition where the kidney reaches advanced state of loss of function). The agency failed to address interventions for P#7 on the POC to monitor dialysis site for bleeding, or infection during skilled nurses’ visits after the dialysis procedures (a procedure to remove wasted products and excess fluid from the blood when the kidney stops working). During an interview on 1/23/2024 at 2:46 p.m., with Registered Nurse (RN) BB, revealed RN BB confirmed that the agency failed to addressed interventions and failed to notify physician for not following the POC for P#7. No Policy was provided during the survey and upon exit.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on record review, staff interview, and review of agency policy, it was determined that the home health agency physician failed to sign patient plan of care (POC) within 30 days for five patients (P) (P#1, P#4, P#6, P#8, P#9), of 21 sampled patients. Specifically, the POC was signed late for three patients (P#1, P#4, P#9) and failed to sign the POC for two patients (P#4, P#9). The Findings include: Review of the agency policy titled “Physician Orders”, revised 10/01/23, Policy Number: 2.1.008 reveals the following: Procedure: 4. The Plan of Care (POC), telephone and or verbal orders must be signed and dated by the physician or authorized practitioner within a timely manner per state regulation: STATE Timeliness of Physician Signature Georgia 30 days 1. Review of clinical record of P#1 revealed P#1 was admitted to the home health agency on 10/27/2023.The physician signed the POC on 11/29/2023. 2. Review of clinical record of P#4 revealed P#4 was admitted to the home health agency on 11/1/2023. The physician failed to sign the POC. 3. Review of clinical record of P#6 revealed P#6 was admitted to the home health agency on 12/14/2023. The physician signed the POC on 1/19/2024. 4. Review of clinical record of P#8 revealed P#8 was admitted to the home health agency on 12/6/2023. The physician signed the POC on 1/8/2024. 5. Review of clinical record of P#9 revealed a patient was admitted to the home health agency on 12/3/2023. The physician failed to sign the POC. On 1/23/2024 at 3:25 p.m., an interview was conducted with the Clinical Manager (CM) who acknowledged that physicians failed to sign P#1, and P#9 POCS, also signed P#5, P#6, and P#8 POCS late. CM stated it is a struggle for one of their physicians.”

“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 reviews, and staff interview, it was determined the agency failed to obtain patient weight, calf measurement, and document findings as ordered for five patients (P) (P#1, P#3, P#4, P#5, P#6) of 21 sampled patients. The Findings include: 1. Review of the plan of care (POC) for P#1 (certification period of 10/27/23 to 12/25/23) revealed P#1 admitted to the home health agency on 10/27/2023, with a diagnosis of heart failure (when the heart muscle doesn’t pump blood as well as it should), required the skilled nurse (SN) to assess and instruct patient/caregiver on precautions to monitor and document daily weight, calf measurements each visit, and report gain of two to three pounds daily, or five pounds in one week. Visit notes for P#1 failed to reveal weight and calf measurements on 11/7/2023, 11/22/2023, and 12/1/2023 2. Review of the POC for P#3 (certification period of 12/8/23 to 2/5/24), revealed P#3 was admitted to the home health agency on 12/8/2023 with a diagnosis of heart failure and required the SN to assess and instruct patient/caregiver on precautions to monitor and document daily weight, calf measurements each visit, and report gain of two to three pounds daily, or five pounds in one week. Visit notes for P#3 failed to reveal weight and calf measurements on 12/9/2023, and 1/11/2024. 3. Review of the POC for P#4 (certification period of 12/31/23 to 2/28/24) revealed P#4 was , admitted to the home health agency on 11/1/2023, with a diagnosis of congestive heart failure and required the SN to assess and instruct patient/caregiver on precautions to monitor and document daily weight, calf measurements each visit, and report gain of two to three pounds daily, or five pounds in one week. Visit notes for P#4 failed to reveal weight and calf measurements on 11/7/2023, and 11/15/2023. 4. Review of the POC for P#5 (certification period of 12/15/23 to 2/12/24) was admitted to the home health agency on 12/15/2023 with a diagnosis of heart failure and required the SN to assess and instruct patient/caregiver on precautions to monitor and document daily weight, calf measurement each visit, and report gain of two to three pounds daily, or five pounds in one week. Visit notes for P#5 failed to reveal weight and calf measurements on 1/5/2024, and 1/10/2024. 5. Review of the POC for P#6 (certification period of 12/14/23 to 2/11/24) was admitted to the home health agency on 12/14/2023 with a diagnosis of congestive heart failure and required the SN to assess and instruct patient/caregiver on precautions to monitor and document daily weight, calf measurements each visit, and report gain of two to three pounds daily, or five pounds in one week. Visit notes for P#6 failed to reveal weight, and calf measurements on 12/22/2023, and 12/26/2023. On 1/23/2024 at 4:02 p.m., an interview was conducted with Licensed Practical Nurse (LPN) BB. LPN BB revealed the patient scale broke, or they did not have a scale and she was not aware it needed to be documented in the nursing notes or notify a physician. No policy was available during the survey or upon exit.”

“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 record reviews, and staff interview, it was determined the agency failed to notify physician for weights not completed for five patients (P) (P#1, P#3, P#4, P#5, P#6) of 21 sampled patients. The Findings include: 1. Review of the plan of care (POC) for P#1 (certification period of 10/27/23 to 12/25/23) required the skilled nurse (SN) to assess and instruct patient/caregiver on precautions to monitor and document daily weight for a patient diagnosed of heart failure (when the heart muscle doesn’t pump blood as well as it should). The agency failed to notify the physician that the SN was unable to weigh the patient. 2. Review of the POC for P#3 (certification period of 12/8/23 to 2/5/24) required the SN to assess and instruct patient/caregiver on precautions to monitor and document daily weight for a patient diagnosed of congestive heart failure. The agency failed to notify the physician that the SN was unable to weigh the patient. 3. Review of the POC for P#4 (certification period of 12/31/23 to 2/28/24) required the SN to assess and instruct patient/caregiver on precautions to monitor and document daily weight for a patient diagnosed of congestive heart failure. The agency failed to notify the physician that the SN was unable to weigh the patient. 4. Review of the POC for P#5 (certification period of 12/15/23 to 2/12/24) required the SN to assess and instruct patient/caregiver on precautions to monitor and document daily weight for a patient diagnosed of congestive heart failure. The agency failed to notify the physician that the SN was unable to weigh the patient. 5. Review of the POC for P#6 (certification period of 12/14/23 to 2/11/24) required the SN to assess and instruct patient/caregiver on precautions to monitor and document daily weight for a patient diagnosed of congestive heart failure. The agency failed to notify the physician that the SN was unable to weigh the patient. On 1/22/24 at 4:47 p.m., an interview was conducted with Licensed Practical Nurse (LPN) DD who revealed that the scale was broke for P#4, P#5, and P#6, and she forgot to notify the physician. No policy was available during the survey and upon exit.”