Every finding on record at Altamaha Homecare, Inc.

A recertification survey was conducted at Altamaha Homecare on April 22, 2024, and concluded on April 24, 2024. At the time of the survey, the agency was in compliance with 42 CFR Part 418.113, Emergency Preparedness and Covid-19 infection control.

A recertification survey was conducted at Altamaha Homecare on April 22, 2024, and concluded on April 24, 2024. At the time of the survey, the agency was not in compliance with compliance with Chapter 42 CFR Part 418, Rules and Requirements for Home Health and Hospice Agencies. The census was 88. The following deficiency was cited:

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 the Centers for Medicare & Medicaid Services (CMS) Home Health Agency (HHA) Error Summary by agency report, agency policy, and staff interview, it was determined that the agency failed to electronically transmit monthly Outcome and Assessment Information Set (OASIS) data collected to the State Agency every 30 days. Findings include: Review of the policy titled “Reporting of OASIS Information,” revised 2021, revealed the following: Policy The Agency will report required data collected for the Outcome and Assessment Information Set (OASIS) items. Procedure 1. The agency will report electronically all OASIS data collected according to current federal and/or state requirements. 3. Agency will electronically transmit completed, encoded and locked OASIS data for each completed OASIS assessment at least monthly to the System. Review of CMS report titled “HHA Error Summary by Agency”, dated 4/22/24, revealed the agency failed to transmit OASIS data to the State Agency within 30 days. An interview was conducted with the agency Director of Nursing (DON) on 4/22/2024 at 1:00 p.m. The DON confirmed OASIS reports had not been submitted to CMS within 30 days of completing the assessments.

Altamaha Homecare Baxley, Georgia was compliance with 42 CFR Part 418.113, Emergency Preparedness for HHA, as a result of an onsite survey conducted on 4/23/2021 by Qualified Nurse Surveyor.

An unannounced Recertification survey was conducted at Altamaha Homecare Baxley, Georgia, on 4/23/2021 .A review of Covid-19 infection control revealed that the agency was compliance with Chapter 42 CFR Part 418, Rules and Requirements for Home Health and Hospice Agencies. The census is 120. The deficiencies were cited.

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 home visit observations, clinical record reviews and staff interviews, it was determined that the home health agency failed to ensure that patients' medication profile was updated to reflect current medications at the time of the comprehensive assessment for 2 out of 10 Patients (P) #2, and #3) observed during home visits. Findings include: 1. During a home visit observation on 4/21/21 at approximately 11:50 a.m. with Licensed Practical Nurse (LPN AA), P#2 certification period noted from 3/5/21 to 5/3/21. During comparison of P#2's current medication list in the private home to the home health agency's medication profile, there were discrepancies. According to P#2's medication at the private home Oxycodone-Acetaminophen milligrams (Percocet 7.5mg-325mg) take one tablet oral every six hours for pain since 1/26/21, Aspirin 81mg take one tablet oral daily for anti-inflammatory to prevent heart attack dated 9/5/20, and Diclofenac Sodium Delay Release (DR) 75mg take one tablet oral twice daily with meals for aches and pain dated 1/14/19. The medications listed above was missing in home health agency's medication profile and plan of care. On 4/21/21 at 12:10 p.m., during interview with P#2 regarding medicaiton, P#2 said she has been taking the above medications since December 2020 but could not remember the exact date. P#2 also confirmed that all the medications listed in the home health agency medication profile has been discontinued since December 2020, (Coreg 25mg take one tablet oral twice daily; Eliquis 5mg take one tablet oral twice daily; Gentamicin topical for wound care; timolol ophthalmic one drop in both eyes twice daily; Hibiclens topical for wound care; Amikacin 1% Vancomycin 2% topically for wound care; and Stimulen gel 5 milliliters (ML) topically for wound care). On 4/21/21 at 12:10 p.m., during an interview with LPN AA she said P#2's frequency was Skilled Nurse (SN) three times a week for nine weeks for wound care. LPN AA visited P#2 on 4/19/21 for wound care. LPN AA stated that she was not aware that P#2 was not on the above medications. LPN AA confirmed she did not conduct a medication review nor update the medication profile during the visits. 2. On 4/21/21 at 12:56 p.m., a home health aide (HHA) was observed during a visit to P#3. Upon review of P#3's medications with P#3's care giver, it was revealed that P#3 home medications (Mucinex 600mg take one tablet oral daily as needed for congestion have been discontinued since 8/20/19, Myrbetriq 25mg oral daily for urinary antispasmodics, Aspirin 81mg take one table oral daily salicylates, Miralax 17 grams daily oral for constipation, and Tamsulosin 0.4 mg daily oral antiadrenergic agents) have been discontinued since 1/5/21. These medications were in the home health agency medication profile and plan of care during the initial comprehensive assessment and certification period of 3/23/21 to 5/21/21. The plan of care was not updated on the current medication profile provided to surveyor on 4/21/21. On 4/21/21 at 1:15 p.m. during a interview with P#3's caregiver who said P#3 was not taking the above medications since 2/5/21. The caregiver state she could not remember the exact date that P#3 stopped taking the medications. On 4/21/21 at 3:30 p.m., during a interview with RN BB, she said that she was not aware of P#3's medication discrepancies. RN BB could not provide evidence that the medication profile had been updated to reflect the patient's current medication regimen. On 4/23/21 at 9:15 a.m., during a interview with RN CC, she said that she was not aware of P#2 medication profile discrepancy. RN CC stated she started homecare six months ago and she was learning and would make sure this will not occur again. On 4/23/21 at 9:00 a.m., an interview was conducted with Director of Nursing (DON), stated that home health nurses communicated with her often. The DON verbalized that she did not know how the patients' home medications did not match home health agency's medication profile.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interviews, it was revealed that the home health agency failed to ensure that Patient (P) #9 was admitted to the service within 48 hours of the patient's return home from the hospital. Finding include: On 4/22/21 at 11:00 a.m., P#9 clinical record revealed that home health agency failed to admit P#9 after discharge from the hospital on 9/5/20 she was not admitted. On 9/9/20 (five days) after being discharged from the hospital P#9 was admitted to the home health agency, there was no evidence that physician was notified of the delay of admission. On 4/22/21 at 11:51 a.m., during interview with the Case Manager (CM) from the discharged hospital, the CM stated she could not remember P#9's date of discharge. She said that she would call the surveyor back, but she did not. During interview on 4/22/21 at 12:00 p.m., with the Director of Nursing (DON) stated that she did not have a reason why the admission was delayed nor any reason why physician was not notified. The DON confirmed that the admission nurse did not notify physician of admission delayed. The admission nurse was not available for interview.

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 clinical record reviews, home visit observations, and staff interviews, it was determined that the home health agency failed to ensure that patients' plan of care was updated to reflect current medications at the time of the comprehensive assessment for 2 of 10 Patients (P) #2, and #3 when observed during home visits. Findings include: During a home visit observation on 4/21/21 at approximately 11:50 a.m. with Licensed Practical Nurse (LPN AA), patient (P) #2 certification period of 3/5/21 to 5/3/21, the surveyor compared the patient's current medication list in her private home (where the patient resides) to the home health agency's medication profile, there were discrepancies. According to the patient's medication at P#2 private home, the patient was on Oxycodone-Acetaminophen milligrams (Percocet 7.5mg-325mg) take one tablet oral every six hours for pain since 1/26/21, Aspirin 81mg take one tablet oral daily for anti-inflammatory to prevent heart attack dated 9/5/20, and Diclofenac Sodium Delay Release (DR) 75mg take one tablet oral twice daily with meals for aches and pain dated 1/14/19. The medications listed above was missing in home health agency's medication profile and plan of care. On 4/21/21 at 12:10 p.m., during interview with P#2, stated that she has been taking the above medications since December 2020 but could not remember the exact date. P#2 also confirmed that all the medications listed in the home health agency medication profile has been discontinued since December 2020, (Coreg 25mg take one tablet oral twice daily; Eliquis 5mg take one tablet oral twice daily; gentamicin topical for wound care; timolol ophthalmic one drop in both eyes twice daily; Hibiclens topical for wound care; Amikacin 1% Vancomycin 2% topically for wound care; and Stimulen gel 5 milliliters (ML) topically for wound care). On 4/21/21 at 12:10 p.m., during interview with LPN AA she stated that P#2 frequency was Skilled Nurse (SN) three time a week for nine weeks for wound care. LPN AA visited P#2 on 4/19/21 for wound care. LPN AA stated that she was not aware that P#2 was not on the above medications. LPN AA confirmed that she did not do medication review nor update the medication profile during the visits. On 4/21/21 at 12:56 p.m., the sureyor observed home health aide (HHA) on home visit to P#3. Upon review of P#3's medications with P#3 care giver, it was revealed that P#3 home medications (Mucinex 600mg take one tablet oral daily as needed for congestion discontinued since 8/20/19, Myrbetriq 25mg oral daily for urinary antispasmodics, Aspirin 81mg take one table oral daily salicylates, Miralax 17 grams daily oral for constipation, and Tamsulosin 0.4 mg daily oral antiadrenergic agents) have been discontinued since 1/5/21. It was active in home health agency medication profile and plan of care during initial comprehensive assessment and certification period of 3/23/21 to 5/21/21. It was not updated with current medication profile provided to surveyor on 4/21/21. On 4/21/21 at 1:15 p.m., during interview with P#3's caregiver she stated the patient was not taking the above medications since 2/5/21. The caregiver stated that she could not remember the exact date that P#3 stopped taking the medications. On 4/21/21 at 3:30 p.m., an interview was conducted with RN BB, stated that she was not aware of P#3's medication discrepancies. RN BB provided no evidence that the medication profile had been updated to reflect the patient's current medication regimen. On 4/23/21 at 9:15 a.m., an interview was conducted with RN CC, stated she was not aware of P#2 medication profile discrepancy. RN CC stated that she started homecare six months ago and she was learning and would make sure this will not occur again. On 4/23/21 at 9:00 a.m., an interview was conducted with Director of Nursing (DON), stated that home health nurses communicated with her often. The DON verbalized that she did not know how the patients' home medications did not match home health agency's medication profile.