Every finding on record at Bridgeway HHA Metro, LLC

At the time of the survey , Bridgeway home health in Snellville , 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 2, 2022. A Focus Infection control survey was completed at the time of the survey. Current census 20. Following deficiencies cited.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on staff interviews and the review of policies, procedures, and agency documents, it was determined that the agency failed to comply with all applicable Federal, State, and local emergency preparedness (EP) requirements by not testing the EP program to include the required number of exercises/events annually followed by an analysis and documentation of the agency's response with revision to the EP program as needed. The findings include: On 2/28/22, the surveyor requested the Emergency Plan (EP) for the agency. The documents provided for review included a disaster plan checklist for emergency plan conducted on 5/3/21 due to tornado warning on 5/3/21, which required an activation of the emergency plan .The emergency plan stated all staff were informed of the situations and all patients were called. The communication plan lacked the identification of all the specific persons that participated in the actual event, and specific details related to this event. The emergency plan conducted on 5/3/21, also lacked an analysis and documentation of the agency's response with revision to the EP program as needed. The agency failed to ensure the EP plan for this actual event dated 5/3/21 was efficient and complete. During an interview with the Administrator on 3/2/22 at 2:30 p.m., in the agency office the Administrator acknowledged that the agency failed to analyze the hospice's response to the actual event on 5/3/21,and revise the hospice's emergency plan, as needed. The Administrator also acknowledged that the communication plan for EP dated 5/3/21 was incomplete.

At the time of the survey, Bridgeway home health in Snellville, GA was in compliance with 42 CFR Part 484, Requirements for Home Health Agencies as a result of a recertification survey conducted on March 2, 2022. A Focus Infection control survey was completed at the time of the survey. Current census 20. Following deficiencies 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 clinical record reviews, home visit observations, and staff interviews, it was determined the agency failed to ensure that patients' medication profiles were updated to reflect current medications for one of four (P#) (#8) patients participating in home visit observations. Findings include: 1. Review of the plan of care/treatment for P# 8 with a certification period of 2/24/22 to 4/24/22, revealed that patient has a diagnosis of Type 2 diabetes mellitus. During a home visit observation on 2/14/22 at approximately 1:45 p.m., this surveyor compared the medications found in the home with the agency medication profile. According to patient, the patient is taking Jardience (anti-diabetic ) 25 milligrams once daily and Insulin Regular 100 units/ml 17 units and NPH 100 units/ml 30 units before breakfast, Regular Insulin 17 units at lunch and Regular Insulin 17 units and NPH 10 units at bedtime . However, according to the agency medication profile, the patient takes regular insulin 20 units before breakfast, 20 units before lunch and 15 units before dinner and Jardiance .5 mg once daily. The agency staff failed to update agency medication profile to reflect the patient's current medications. During an interview on 3/2/22 at 2:30 p.m., the Administrator confirmed that medication profile had not been updated to reflect the patient's current medications.

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 staff failed to include orders to cover all pertinent diagnoses and ensure the patients' needs were addressed to include disease specific interventions/treatments were included on the plans of care for seven of ten ( #1, ,#3, #4, #5, #6, #7,and #8) sampled patients (P). Findings include: 1. Review of the plan of care/treatment for P# 4 with a certification period of 1/18/22 to 3/18/22, revealed P#4 diagnosis included diagnosis Type 2 diabetes mellitus and long-term use of anticoagulant therapy with Apixaban 5 mg (blood thinner) twice daily. The plan of care lacked specific teaching and assessments of diabetes mellitus; frequency to check the blood sugar, teaching on diabetic complications, such as hyper and/or hypoglycemia and other diabetic complications. The plan also lacked evidence regarding reporting to the nurse and physician any bleeding complications. The agency failed to ensure the plan of care was complete and consistent to include the specific teaching and assessments of diabetes and anticoagulant therapy and its complications. 2. Review of the plan of care/treatment for P#1 (closed record) with a certification period of 1/17/21- 3/17/21, revealed P#1 has a diagnosis of hypertensive heart disease with long-term use of aspirin 81 mg (blood thinner) once daily. The plan of care lacked teaching and assessment of bleeding complications. The agency failed to ensure the plan of care was complete and consistent to include specific teaching and assessments of anticoagulation therapy and its complications. 3. Review of the plan of care/treatment for P#3 with a certification period of 1/6/22 to 3/6/22, revealed P#3 diagnosis included hypertension with long-term use of aspirin 81 mg (blood thinner) once daily. The plan of care lacked teaching and assessment of bleeding complications. The agency failed to ensure the plan of care was complete and consistent to include specific teaching and assessments of anticoagulation therapy and its complications. 4. Review of the plan of care/treatment for P#7 with a certification period of 2/1/22 to 4/1/22, revealed P#7 diagnosis included an artificial valve with pacemaker and long-term use of warfarin 5 milligrams (blood thinner) once daily and diabetes mellitus. The plan of care lacked specific teaching and assessments of diabetes mellitus; frequency to check the blood sugar, teaching on diabetic complications, such as hyperglycemia and/or hypoglycemia and other diabetic complications to be reported to the nurse and the physician. The plan of care lacked teaching and assessment of bleeding complications and the management of prothrombin time (PT) and International Normalized Ratio INR (PT/INR) levels to manage anticoagulant(warfarin) therapy. The agency failed to ensure the plan of care was complete and consistent to include the specific teaching and assessments of diabetes and anticoagulant therapy and its complications. The agency failed to ensure the plan of care was complete and consistent to include specific teaching and assessments of diabetes complications and anticoagulation therapy and its complications. 5. Review of the plan of care/treatment for P#6 with a certification period of 1/21/22 to 3/21/22 revealed P#6 diagnosis included lymphedema, congestive heart failure and diabetes mellitus with long term use of hypoglycemic drugs. The plan of care lacked teaching and assessment of lymphedema complications. The plan of care lacked specific teaching and assessments of diabetes mellitus; frequency to check the blood sugar, teaching on diabetic complications, such as hyper and/or hypoglycemia and other diabetic complications to be reported to the nurse and to the physician. The agency failed to ensure the plan of care was complete and consistent to include specific teaching and assessments of diabetic complications and lymphedema treatment and its complications. 6. Review of the plan of care/treatment for P#8 with a certification period of 2/24/22 to 4/24/22, revealed that patient has a diagnosis of Type 2 diabetes mellitus with long term use of hypoglycemic drug Jardiance 25 milligrams once daily, Arteriosclerotic heart disease (ASHD) with long-term use of aspirin 81 mg (blood thinner) once daily. The plan of care lacked specific teaching and assessments of diabetes mellitus; frequency to check the blood sugar, teaching on diabetic complications, such as hyper and/or hypoglycemia and other diabetic complications to be reported to the nurse and the physician. The plan of care also lacked teaching and assessment of bleeding complications. The agency failed to ensure the plan of care was complete and consistent to include specific teaching and assessments of diabetic management and anticoagulation therapy and its complications. 7. Review of the plan of care/treatment for P#5 with a certification period of 2/19/22 to 4/19/22, revealed P#5 has a diagnosis of cancer of the breast with long-term use of Eliquis 5 mg (blood thinner) once daily. The plan of care lacked teaching and assessment of bleeding complications. The agency failed to ensure the plan of care was complete and consistent to include specific teaching and assessments of anticoagulation therapy and its complications. During an interview on 3/2/22 at 2:30 p.m., the Administrator verbalized the plan of care/treatment did not cover all pertinent interventions for the comprehensive care for patient's regarding diabetic status and anticoagulant therapy.

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 provide services as ordered by the physician in the plans of care for four of ten (#4, #6, #7 and #8) sampled patients. Findings include : 1.Review of the plan of care/treatment for P# 4 with a certification period of 1/18/22 to 3/18/22, revealed that patient has a diagnosis of Type 2 diabetes mellitus. The plan of care required the skilled nurse (SN) to notify MD of blood sugar greater than 250 or less than 70. SN visited the patient on 1/20 , 2/1, 2/3, and 2/8/22. The SN visit notes lacked documentation of patient's blood sugar. The SN failed to follow the plan of care for blood glucose monitoring. 2. Review of the plan of care/treatment for P#7 with a certification period of 2/1/22 to 4/1/22 revealed that patient has a diagnosis of diabetes mellitus . The plan of care required the physical therapist (PT) Occupational therapist (OT) and to notify MD of blood sugar greater than 250 or less than 70. PT visited the patient on 2/8 and 2/11/22 and OT visited the patient on 2/10/22 . The PT and OT visit notes lacked documentation of patient's blood sugar. The PT and OT failed to follow the plan of care for blood glucose monitoring. 3. Review of the plan of care/treatment for P#6 with a certification period of 1/21/22 to 3/21/22 revealed that patient has a diagnosis of lymphedema, congestive heart failure and diabetes mellitus with left leg diabetic ulcer with long term use of hypoglycemic drugs. The plan of care required the skilled nurse (SN) to notify the physician of a weight increase greater than 2 pounds in 2 days or 5 pounds in 7 days, if unable to weigh the patient , then may measure the ankle every visit and report any increase in measurement to the physician. The SN visited the patient on 2/2, 2/4, and 2/8,/22 and failed to assess and document for adherence to daily weight monitoring and also failed to weigh the patient, or measure ankle circumference to monitor for edema as required by the plan of care. The SN failed to follow the plan of care for weight monitoring. Furthermore, the plan of care required the SN to perform blood sugar analysis at each visit and report blood sugar greater than 250 or less than 70. The visit notes dated 2/2, 2/4,2/8, 2/11, 2/15,and 2/22/22, lacked documentation of patient's blood sugar. Additionally, the plan of care required the skilled nurse (SN) to provide wound care to diabetic left leg ulcer as follows: cleanse site with wound cleanser and blot dry , apply foam dressing to site and secure , may apply Velcro wrapping to bilateral lower extremities, wound care to be done twice a week. However, the SN visit notes dated 2/2, 2/4,2/8, 2/11, 2/15,and 2/22/22, SN documented the wound was cleansed with soap and water, rinsed, blot dry , foam dressing applied and secured with compression stockings. The agency failed to ensure the physician's orders for wound care to the left leg ulcer was followed as per the plan of care. The SN failed to follow the plan of care for wound care, blood glucose and weight monitoring 4.Review of the plan of care/treatment for P#8 with a certification period of 2/24/22 to 4/24/22 revealed that patient has a diagnosis of Type 2 diabetes mellitus with long term use of hypoglycemic drug Jardiance 25 milligrams once daily. The plan of care required the PT to perform blood sugar analysis at each visit and report blood sugar greater than 250 or less than 70. The visit notes dated 2/28/22 lacked documentation of patient's blood sugar . The PT failed to follow the plan of care for blood glucose monitoring. During an interview on 3/2/22 at 2:30p.m., the Administrator did not provide evidence that PT, OT and the SN monitored the patient's weight and blood glucose as per the plan of care on the above referenced dates.