Every finding on record at Augusta Home Care Services, LLC

A Recertification survey was conducted at Trinity Home Health on February 24, 2025, and concluded on February 26, 2025. 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 Trinity Home Health on February 24, 2025, and concluded on February 26, 2025. At the time of the survey, the agency was not in compliance with Chapter 42 CFR Part 418, Rules and Requirements for Home Health and Hospice Agencies. The census was 392. The following deficiencies were 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 Centers for Medicare & Medicaid Services (CMS) Home Health Agency (HHA) Error Summary by agency report, staff interview, and policy titled “Oasis Data Capture, Transmission, Verification, Display and Reports,” it was determined that the agency failed to electronically transmit monthly Outcome and Assessment Information Set (OASIS) data collected to the CMS system every 30. 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. The Findings include: Review of the policy titled “OASIS Data Capture, Transmission, Verification, Display and Reports,” last revised 03/01/2021, revealed the following: 1e. “Once an OASIS data set passes the OASIS edit check program, the OASIS data set will be reserved to prevent subsequent editing. The reserving mechanism ensures the stability of the patient assessment data at the time point of the assessment. The reserving mechanism prevents the override of current assessment information with future or past information without specific documentation as to why the assessment is being opened. All assessments will be reserved and transmitted within 30 days of the M0090 date”. Review of CMS HHA Error Summary by agency report ran on 02/11/2025 for period 01/01/2024 to 12/31/2024 revealed the agency failed to transmit OASIS data to the CMS system within 30 days. On 2/24/2025 at 3:56 p.m., an interview was conducted with the Administrator who stated that the agency was bought by a new company and during the transition the OASIS was transmitted late. The Administrator confirmed awareness of the 30-day OASIS submission time limit requirements not met during the time frame of 01/01/2024 to 12/31/2024.

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 interviews, and agency policy “Plan of Care (POC),” it was determined the agency failed to include goals, and interventions with a diagnosis of end stage renal disease (a medical condition in which a person’s kidneys are no longer able to function adequately on their own and requires dialysis or kidney transplant to maintain life) for one patient (P) (P#16) of 17 sampled patients. The Findings include: Review of the policy titled “Plan of Care (POC) (Policy Number: 2.1.007),” revised 009/01/24, reveals the following: Policy: “Each patient has an individualized Plan of Care (POC) developed in consultation with the patient, physician or authorized practitioner, and staff that integrates comprehensive assessment findings to address patient’s problems, needs, and goals, as well as to address specific services being provided”. PROCEDURE: 2. The POC includes: h. Pertinent diagnosis (es). i. Patient specific interventions and education; measurable outcomes and goals identified by the agency and patient. Review of the plan of care (POC) for P#16 (certification period (start of care) of 2/8/2024 to 4/7/2024) revealed P#16 was admitted to the Home Health agency on 2/28/2024, with a diagnosis of end stage renal disease. The agency failed to address goals, and interventions, on the POC to assess and monitor the fistula (connection that a surgeon makes between an artery and a vein to make it possible for you to receive hemodialysis) on left upper arm site for dialysis for bleeding and signs of infection. During an interview on phone with Registered Nurse (RN) DD on 2/25/2025 at 2:15 p.m., RN DD confirmed that the agency failed to address intervention on diagnosis of end stage renal disease on P#16, POC, because she was not aware that she had to obtain order to assess and monitor for bleeding and infection at fistula site. During an interview on phone with RN EE on 2/25/2025 at 2:58 p.m., RN EE confirmed that the agency failed to address intervention on diagnosis of end stage renal disease on P#16, POC, because she was not aware that she had to include it (intervention). On 2/4/2025 at 3:38 p.m., an interview conducted with the Administrator, who acknowledged that she failed to correct or include intervention for the diagnosis of end stage renal disease for P#16.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record reviews, and staff interviews, it was determined that the skilled nurse (SN) failed to perform treatments as ordered by a physician for two patients (P) (P#1, P#2) of 17 sampled patients. The Findings include: 1. Review of plan of care (POC) for P#1 (certification period of 1/25/2025 to 3/25/2025) revealed P#1 was admitted to the Home Health agency on 1/25/2025. Review of records for P#1 reveals a stage one wound on sacral area (bottom of the spine). The POC revealed that the skilled nurse would perform wound care as follows: Skilled nurse to perform and instruct patient and caregiver procedure of wound care to sacral area daily and as needed; irrigate and cleanse with soap and water; apply barrier cream (a cream use to protect irritants and prevent skin breakdown). Review of the POC and nursing visit notes failed to reveal the skilled nurse performed wound care to sacral area. Licensed Practical Nurse (LPN) AA failed to perform stage 1 sacral wound area as ordered by physician. During an interview on phone with LPN AA on 2/25/2025 at 12:20 p.m., LPN AA confirmed that she failed to perform stage 1 sacral wound because she was not aware of the wound care order written in P#1 POC; she just performed the right upper arm wound care. On 2/25/2024 at 1:09 p.m., an interview was conducted with the Administrator who acknowledged that LPN AA failed to follow physician’s order. 2. Review of the plan of care (POC) for P#2 (certification period of 1/21/2025 to 3/21/2025) revealed P#2 was admitted to the Home Health agency on 1/21/2025, with a diagnosis of type 2 diabetes mellitus (inability to produce enough insulin results in high blood sugar). Review of records for P#2 revealed P#2 was taking two insulins (HUMULIN 70/30 inject 10 units subcutaneous twice daily, and Novolin 15units subcutaneous daily), (insulin is used to lower high blood glucose). The plan of care (POC) failed to reveal order to monitor blood sugar for P#2. During an interview on phone with Registered Nurse (RN) BB on 2/25/2025 at 1:30 p.m., RN BB confirmed that she just missed it, (that is, she failed to obtain order to check P#2 blood sugar). On 2/25/2025 at 2:46 p.m., an interview conducted with the Administrator who acknowledged that RN BB failed to obtain order to check P#2’s blood sugar.

At the time of the survey, Trinity Home Health in Augusta, GA was in compliance with 42 CFR Part 484.22 Emergency Preparedness for Home Health Agencies as a result of a recertification survey conducted on March 3, 2022. A Focus Infection Control survey was completed at the time of the survey. No deficiencies were cited.

At the time of the survey, Trinity Home Health in Augusta, GA was in substantial compliance with 42 CFR Part 484 Requirements for Home Health Agencies as a result of a recertification survey conducted on March 3, 2022. A Focus Infection Control survey was completed at the time of the survey. Current census 188. The following deficiencies were cited.

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 and staff interviews, it was determined the agency failed to include orders to cover all pertinent diagnoses to ensure the patients' identified needs were addressed and failed to ensure disease specific treatments/interventions were included on plans of care for 5 of 17 (#6, #9, #10, #14, and #17) sampled patients. Findings were: 1. Review of the plan of care for P#6 with a recertification period of 2/5/22 to 4/5/22 revealed a pertinent diagnosis of Type 2 diabetes mellitus with diabetic neuropathy. The plan of care lacks interventions such as blood glucose monitoring frequency which would ensure the patient is monitoring levels consistently for complications which would prompt the staff to notify the physician for early intervention and treatment of diabetic exacerbation. The agency failed to ensure the plan of care/treatment was complete and comprehensive for the care and monitoring of the patient's diabetic status. During an interview on 3/3/22 at 10:00 a.m. the Administrator provided no evidence the plan of care included patient specific interventions to monitor the patient's diabetic status. 2. Review of the plan of care for P#9 with a certification period of 1/13/22 to 3/13/22 revealed a primary diagnosis of Type 2 diabetes mellitus without complications. The plan of care lacks interventions such as blood glucose monitoring frequency which would ensure the patient is monitoring levels consistently for complications which would prompt the staff to notify the physician for early intervention and treatment of diabetic exacerbation. The agency failed to ensure the plan of care/treatment was complete and comprehensive for the care and monitoring of the patient's diabetic status. During an interview on 3/3/22 at 10:00 a.m. the Administrator provided no evidence the plan of care included patient specific interventions to monitor the patient's diabetic status. 3. Review of the plan of care for P#10 with a recertification period of 1/15/22 to 3/15/22 revealed the patient has a pertinent diagnosis of type 2 diabetes mellitus with other specified complication. The patient currently takes insulin therapy to control diabetes however, the plan of care lacks interventions such as blood glucose monitoring frequency which would ensure the patient is monitoring levels consistently for complications which would prompt the staff to notify the physician for early intervention and treatment of diabetic exacerbation. The agency failed to ensure the plan of care/treatment was complete and comprehensive for the care and monitoring of the patient's diabetic status. During an interview on 3/3/22 at 10:00 a.m. the Administrator provided no evidence the plan of care/treatment included patient specific interventions to monitor the patient's diabetic status. 4. Review of the plan of care for P#14 with a certification period of 1/12/21 to 3/12/21 revealed a primary diagnosis of Type 2 diabetes mellitus with hyperglycemia. The plan of care lacks interventions such as blood glucose parameters which would prompt the staff to notify the physician for early intervention and treatment of diabetic exacerbation. The agency failed to ensure the plan of care was complete and comprehensive for the care and monitoring of the patient's diabetic status. During an interview on 3/3/22 at 10:00 a.m. the Administrator provided no evidence the plan of care included patient specific interventions to monitor the patient's diabetic status. 5. Review of the plan of care for P#17 with a certification period of 6/11/21 to 8/9/21 (discharge record) revealed a pertinent diagnosis of Type 2 diabetes mellitus with hyperglycemia. The patient currently takes insulin therapy to control diabetes however, the plan of care lacks interventions such as blood glucose monitoring frequency which would ensure the patient is monitoring levels consistently for complications which would prompt the staff to notify the physician for early intervention and treatment of diabetic exacerbation. The agency failed to ensure the plan of care was complete and comprehensive for the care and monitoring of the patient's diabetic status. During an interview on 3/3/22 at 10:00 a.m. the Administrator provided no evidence the plan of care included patient specific interventions to monitor the patient's diabetic status.

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 clinical record reviews and staff interviews, it was determined the agency failed to ensure that appropriate care and services were provided in conformance with the patients' plans of care/treatment as ordered by physicians for 4 of 17 (#1, #6, #10, and #17) sampled patients. Findings were: 1. Review of the plan of care for P#1 with a recertification period of 2/20/22 to 4/20/22 required the SN to monitor the patient for weight gain of 2 pounds overnight or 5 pounds over one week. If patient unable to stand perform body measurement of bilateral calves and notify physician of increase of 2cm. The SN visited the patient on 2/9 and 2/16/22 however, failed to assess the patient’s weight or measure the calves as ordered. Additionally, the SN is required to notify the physician of blood glucose levels outside therapeutic range of 60 to 250. During the visits of 2/9 and 2/16/22 the blood glucose level was not assessed. The SN failed to follow the ordered plan of care for monitoring weight and blood glucose levels. During an interview on 3/3/22 at 10:00 a.m., the Administrator did acknowledge that the SN failed to assess the patient’s weight and blood glucose on 2/9 and 2/16/22 as ordered. 2. Review of the plan of care for P#6 with a recertification period of 2/5/22 to 4/5/22 revealed the patient has a pertinent diagnosis of type 2 diabetes mellitus with diabetic neuropathy and the SN is required to notify the physician of blood glucose levels less than 60 or greater than 250. The SN visited the patient on 2/11 and 2/16/22 however, the SN failed to assess the patient’s blood glucose level to ensure the patient’s blood glucose levels were within the parameters specified. During an interview on 3/3/22 at 10:00 a.m., the Administrator did acknowledge that the SN failed to assess the patient’s blood glucose on 2/11 and 2/16/22 as ordered. 3. Review of the plan of care for P#10 with a recertification period of 1/15/22 to 3/15/22 revealed the patient has a pertinent diagnosis of Type 2 Diabetes Mellitus with other specified complication. The patient is on insulin therapy to control diabetes and the SN is required to notify the physician of blood glucose levels less than 60 or greater than 250. The SN visited the patient on 2/18/22 however, the SN failed to assess the patient’s blood glucose to ensure the patient’s blood glucose levels were within the parameters specified. During an interview on 3/3/22 at 10:00 a.m., the Administrator did acknowledge that the SN failed to assess the patient’s blood glucose on 2/18/22 as ordered. 4. Review of the plan of care for P#17 with a certification period of 6/11/21 to 8/9/21 (discharge record) revealed a pertinent diagnosis of Type 2 diabetes mellitus with hyperglycemia. The patient currently takes insulin therapy to control diabetes and the SN is required to notify the physician of blood glucose levels less than 60 or greater than 250. The SN visited the patient on 6/30/21 however, the SN failed to assess the patient’s blood glucose to ensure the patient’s blood glucose levels were within the parameters specified. During an interview on 3/3/22 at 10:00 a.m., the Administrator did acknowledge that the SN failed to assess the patient’s blood glucose on 6/30/21 as ordered.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, it was determined the agency failed to ensure the clinical records contained clear, complete, and accurate documentation in the clinical record for 5 of 17 (#11, #12, #14, #16, and #17) sampled patients (P). Findings were: 1. Review of the plan of care for patient (P) #11 with a certification period of 1/14/22 to 3/14/22 revealed an incomplete oxygen therapy order which reads as follows: oxygen 2 liters at night however, the order does not specify the route of administration such as nasal cannula or face mask. The skilled nurse (SN) failed to obtain a complete oxygen therapy order. During an interview on 3/3/22 at 10:00 a.m., the Administrator did acknowledge that the SN failed to obtain a complete oxygen therapy order. 2. Review of the plan of care for P#12 with a certification period of 1/6/22 to 3/6/22 revealed an incomplete oxygen therapy order which reads as follows: oxygen 2 liters as needed for shortness of breath however, the order does not specify the route of administration such as nasal cannula or face mask. The skilled nurse (SN) failed to obtain a complete oxygen therapy order. During an interview on 3/3/22 at 10:00 a.m., the Administrator did acknowledge that the SN failed to obtain a complete oxygen therapy order. 3. Review of the plan of care for P#14 with a certification period of 1/12/21 to 3/12/21 (discharge record) revealed an order for the SN to administer a B12 injection 1000mcg intramuscular every week for six weeks then monthly. The SN visited the patient on 2/8 and 2/17/21 and documented the B12 injection was given however, the SN failed to document the amount of medication given during the injection at each visit. During an interview on 3/3/22 at 10:00 a.m., the Administrator did acknowledge that the SN failed to document the amount of medication given with each B12 injection. 4. Review of the plan of care for P#16 with a certification period of 12/26/21 to 2/23/21 required the SN to perform suprapubic catheter changes every month using a16fr/5cc balloon. Inflate with 5cc sterile water. The SN visited the patient on 2/22/21 and documented the suprapubic catheter was changed however, the SN failed to document or specify the catheter size used, balloon inflation size or the patient’s tolerance to the procedure as required. During an interview on 3/3/22 at 10:00 a.m., the Administrator did acknowledge that the SN failed to fully document the procedure used to change the catheter. 5. Review of the plan of care for P#17 with a recertification period of 6/11/21 to 8/9/21 required the SN to provide wound care to buttocks as follows: cleanse with wound cleanser, pat dry with gauze, apply covilan skin protectant and sureprep rapid dry to periwound area. Add santyl to wound bed with Qtip, cover with adhesive foam dressing. The SN visited the patient on 6/30 and 7/9/21 and documented wound care was done per physician orders. However, the SN failed to document the specific steps and supplies used during wound care as required. During an interview on 3/3/22 at 10:00 a.m., the Administrator did acknowledge that the SN failed to document the specific steps and supplies used during wound care.