Every finding on record at Caresouth HHA Holdings of Columbus, LLC

At the time of the survey, Encompass Health Home Health in Columbus, 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 February 17, 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, Encompass Health Home Health in Columbus, Georgia was in substantial compliance with 42 CFR Part 484, Requirements for Home Health Agencies as a result of the survey conducted on February 17, 2022. A Focus Infection Control Survey was completed at the time of the survey. Current census 586. 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 ensure the clinical records contained clear, complete, and accurate documentation in the clinical record for 5 of 17 (#1, #8, #9, #10, and #17) sampled patients (P). Findings were: 1. Review of the plan of care/treatment for P#1 with a certification period of 2/5/22 to 4/5/22 revealed a primary 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 frequency for monitoring blood glucose levels 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 2/17/22 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. 2. Review of the plan of care/treatment for P#8 with a certification period of 1/15/22 to 3/15/22 revealed a pertinent diagnosis of Type 2 diabetes mellitus without complications however, the plan of care lacks interventions such as blood glucose frequency for monitoring blood glucose levels which would prompt the staff to notify the physician for early intervention and treatment of diabetic exacerbation. The plan of care instructs the skilled nurse to perform finger stick blood sugar as needed for signs and symptoms of hyper/hypoglycemia. However, the plan of care does not specify when or how often to monitor the blood glucose level. 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 2/17/22 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. 3. Review of the plan of care/treatment for P #9 with a certification period of 1/5/22 to 3/5/22 revealed a pertinent diagnosis of Type 2 diabetes mellitus with diabetic polyneuropathy. The plan of care lacks interventions such as blood glucose frequency of monitoring blood glucose levels 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 2/17/22 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/treatment for P#10 with a recertification period of 1/8/22 to 3/8/22 revealed a primary diagnosis of Type 2 diabetes mellitus with hyperglycemia. The patient currently takes two oral hyperglycemic medications to control diabetes however, the plan of care lacks interventions such as blood glucose frequency for monitoring blood glucose levels 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 2/17/22 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. 5. Review of the plan of care/treatment for P#17 with a certification period of 12/1/21 to 1/29/22(closed 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 parameters or frequency for monitoring blood glucose levels 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 2/17/22 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

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 clinical record reviews and staff interviews, it was determined the agency staff failed to ensure that patients' plans of care/verbal orders were signed by the physician within 30 days as required for 4 of 17 (#7, #12, #13 and #14) sampled patients (P). Findings were: 1. Review of the plan of care for patient #7 with a recertification period of 1/5/22 to 3/5/22 which contains verbal orders, was not counter-signed by the physician until 2/7/22, more than 30 days after the verbal orders were obtained. The agency failed to ensure verbal orders are counter-signed by the physician within 30 days as required. During an interview on 2/17/22 at 11:00 a.m., the Administrator acknowledged the plan of care was not counter-signed by the physician within the required 30-day timeframe. 2. Review of the plan of care for patient #12 with a certification period of 12/28/21 to 2/25/22 which contains verbal orders, has not been counter-signed by the physician as of 2/17/22, more than 30 days after the verbal orders were obtained. The agency failed to ensure verbal orders are counter-signed by the physician within 30 days as required. During an interview on 2/17/22 at 11:00 a.m., the Administrator acknowledged the plan of care has not been counter-signed by the physician within the required 30 day timeframe. 3. Review of the clinical record for patient #13 with a certification period of 12/9/21 to 2/6/22 (closed record) revealed a verbal order dated 12/29/21, has not been counter-signed by the physician as of 2/17/22, more than 30 days after the verbal orders were obtained. The agency failed to ensure verbal orders are counter-signed by the physician within 30 days as required. During an interview on 2/17/22 at 11:00 a.m., the Administrator acknowledged the verbal order dated 12/29/21 has not been counter-signed by the physician within the required 30 day timeframe. 4. Review of the clinical record for patient #14 with a certification period of 9/12/21 to 11/10/21 (closed record) revealed verbal orders dated 9/27 and 10/15/21 have not been counter-signed by the physician as of 2/17/22, more than 30 days after the verbal orders were obtained. The agency failed to ensure verbal orders are counter-signed by the physician within 30 days as required. During an interview on 2/17/22 at 11:00 a.m., the Administrator acknowledged the verbal orders dated 9/27 and 10/15/21 had not been counter-signed by the physician within the required 30 day timeframe.