Every finding on record at Caresouth HHA Holdings Gainesville, LLC

At the time of the survey, Enhabit Home Health in Gainesville, 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 April 14, 2022. A Focus Infection Control Survey was completed at the time of the survey. No deficiencies were cited.

At the time of the recertification survey, Enhabit Home Health in Gainesville, Georgia was in substantial compliance with 42 CFR Part 484, Requirements for Home Health Agencies as a result of the survey conducted on April 14, 2022. A Focus Infection Control Survey was completed at the time of the survey. Current census 396. The follow 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 included on plans of care for 7 of 17 (#2, #4, #5, #6, #10, #12 and #16) sampled patients (P). Findings were: 1. Review of the plan of care for P#2 with a recertification period of 2/19/22 to 4/19/22 revealed a pertinent diagnosis of Type 2 diabetes mellitus without complications. The plan of care instructs the clinicians to notify the physician of a fasting blood glucose level less than 70 or greater than 350 or a random blood glucose level of less than 70 or greater than 250. 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 4/14/21 at approximately 11:00 a.m., the Administrator and Regional Vice President confirmed the plan of care was incomplete and did not include clear instruction for the monitoring of the patient’s diabetic status. 2. Review of the plan of care for P#4 with a certification period of 3/27/22 to 5/25/22 revealed a pertinent diagnosis of Type 2 diabetes mellitus with hyperglycemia. The plan of care instructs the skilled nurse (SN) to teach diabetic care including diet, skin/foot care, administration of insulin and blood glucose testing. 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 4/14/21 at approximately 11:00 a.m., the Administrator and Regional Vice President confirmed the plan of care was incomplete and did not include clear instruction for the monitoring of the patient’s diabetic status. 3. Review of the plan of care for P#5 with a recertification period of 2/27/22 to 4/27/22 revealed a pertinent diagnosis of Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene. The plan of care instructs the clinicians to notify the physician of a fasting blood glucose level less than 70 or greater than 350 or a random blood glucose level of less than 70 or greater than 250. 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 4/14/21 at approximately 11:00 a.m., the Administrator and Regional Vice President confirmed the plan of care was incomplete and did not include clear instruction for the monitoring of the patient’s diabetic status. 4. Review of the plan of care for P#6 with a certification period of 3/5/22 to 5/3/22 revealed a pertinent diagnosis of Type 2 diabetes mellitus with hyperglycemia. The plan of care instructs the skilled nurse (SN) to teach diabetic care including diet, skin/foot care, administration of insulin and blood glucose testing. 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 4/14/21 at approximately 11:00 a.m., the Administrator and Regional Vice President confirmed the plan of care was incomplete and did not include clear instruction for the monitoring of the patient’s diabetic status. 5. Review of resumption of care orders for P#10 with a certification period of 3/3/22 to 5/1/22 revealed the patient has a pertinent diagnosis of diabetes mellitus without complications. The plan of care instructs the skilled nurse (SN) to teach diabetic care including diet, skin/foot care, administration of oral hypoglycemic medication and blood glucose testing. 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 4/14/21 at approximately 11:00 a.m., the Administrator and Regional Vice President confirmed the plan of care was incomplete and did not include clear instruction for the monitoring of the patient’s diabetic status. 6. Review of the plan of care for P#12 with a certification period of 2/20/22 to 4/20/22 revealed a primary diagnosis of Type 2 diabetes mellitus with hyperglycemia. The plan of care instructs the skilled nurse (SN) to teach diabetic care including diet, skin/foot care, administration of insulin and blood glucose testing. 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 4/14/21 at approximately 11:00 a.m., the Administrator and Regional Vice President confirmed the plan of care was incomplete and did not include clear instruction for the monitoring of the patient’s diabetic status. 7. Review of the plan of care for P#16 with a certification period of 5/19/21 to 7/17/21 (closed record) revealed a pertinent diagnosis of Type 2 diabetes mellitus with other diabetic kidney complication. The plan of care instructs the skilled nurse (SN) to teach diabetic care including diet, skin/foot care, administration of insulin and blood glucose testing. 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 4/14/21 at approximately 11:00 a.m., the Administrator and Regional Vice President confirmed the plan of care was incomplete and did not include clear instruction for the monitoring of 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 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 as ordered by physician for 4 of 17 (#2, #10, #11 and #15) sampled patients (P). Findings were: 1. Review of the plan of care for patient #2 with a recertification period of 2/19/22 to 4/19/22 with a diagnosis of encounter for other orthopedic aftercare required the physical therapist (PT) to notify the physician of a fasting blood glucose level of less than 70 or greater than 350 or a random blood glucose level of less than 70 or greater than 250. PT visited the patient on 3/21 and 3/28/22 however, the blood glucose level was not assessed. The agency failed to ensure the plan of care for blood glucose assessment was done as ordered. During an interview on 4/14/21 at approximately 11:00 a.m., the Administrator and Regional Vice President confirmed that the PT failed to assess the blood sugar as ordered. 2. Review of the plan of care for patient #10 with a certification period of 3/3/22 to 5/1/22 with a diagnosis of unspecified fracture of third lumbar vertebra contained resumption of care orders dated 3/22/22 which required the skilled nurse (SN) to assess the patient’s daily weights however, the SN visited the patient on 3/23/22 and the weight was not assessed as ordered. During an interview on 4/14/21 at approximately 11:00 a.m., the Administrator and Regional Vice President confirmed that the SN failed to assess the weight as ordered. 3. Review of the plan of care for patient #11 with a recertification period of 3/21/22 to 5/19/22 with a diagnosis of bilateral primary osteoarthritis of hip required the occupational therapist (OT) to notify the physician of a fasting or random blood glucose level of less than 60 or greater than 300. OT visited the patient on 3/22, 3/25, 3/29, and 3/31/22 however, the blood glucose level was not assessed. The agency failed to ensure the plan of care for blood glucose assessment was done as ordered. During an interview on 4/14/21 at approximately 11:00 a.m., the Administrator and Regional Vice President confirmed that the OT failed to assess the blood sugar as ordered. 4. Review of the plan of care for patient #15 with a certification period of 4/12/21 to 6/10/21 (closed record) with a diagnosis of hypertensive chronic kidney disease with stage 5 kidney disease required the occupational therapist (OT) and physical therapist (PT) to notify the physician of a fasting or random blood glucose level of less than 60 or greater than 300. OT visited the patient on 5/5 and 5/7/21 however, the blood glucose levels were not assessed. PT visited the patient on 5/3 and 5/5/21 however, the blood glucose level was not assessed. The agency failed to ensure the plan of care for blood glucose assessment was done as ordered by each discipline visiting the patient. During an interview on 4/14/21 at approximately 11:00 a.m., the Administrator and Regional Vice President confirmed that OT and PT failed to assess the blood sugar as ordered.

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 clinical record reviews and staff interviews, it was determined that the personnel furnishing services failed to maintain liaison to ensure their efforts were coordinated effectively and timely to support the objectives outlined in the plan of care for 1 of 17 (#12) patients (P). Findings were: 1. Review of the plan of care for P#12 with a recertification period of 2/20/22 to 4/20/22 and a diagnosis of Type 2 Diabetes Mellitus with hyperglycemia required the physical therapist (PT) to complete a physical therapy evaluation the week of 2/20/22. The clinical record lacked documentation of a completed evaluation the week of 2/20/22 as ordered. The clinical record contained a physician’s order dated 3/10/22 for the PT evaluation to be completed the week of 3/6/22 however, the patient was admitted to the hospital on 3/10/22. The PT still had not been completed prior to the patient being admitted to the hospital. The patient was discharged from the hospital on 3/18/22 with resumption of care orders requiring the PT to complete the PT evaluation the week of 3/20/22. The clinical record lacked documentation to indicate the PT evaluation was completed the week of 3/20/22. The clinical record also contained a physician’s order dated 3/24/22 instructing the PT to move the PT evaluation to the week of 3/28/22. The PT evaluation was not completed the week of 3/28/22. As of today, 4/14/22, the PT evaluation has not been completed as ordered. The clinical record did not contain any coordination notes to ensure the services were provided to meet the needs of the patient. PT failed to communicate and coordinate care with the care team and physician to effectively coordinate the patient’s care to ensure services were provided timely and as ordered. During an interview on 4/14/21 at approximately 11:00 a.m., the Administrator confirmed that the PT evaluation has not completed and will be scheduled this week.