Every finding on record at Colquitt Regional Medical Center

A Recertification survey was conducted at Colquitt Regional Home Care on September 8, 2025, and concluded on September 10, 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 Colquitt Regional Home Care on September 8, 2025, and concluded on September 10, 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 102. 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 policy titled “OASIS Data Collection and Submission,” review of the Centers for Medicare & Medicaid Services (CMS) Home Health Agency (HHA) Error Summary by agency report, and staff interview, 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 days. Findings include: Review of the policy titled “OASIS Data Collection and Submission,” revised 08/2025, revealed the following: I. Purpose: To establish standardized procedures for the collection, completion, and submission of the Outcome and Assessment Information Set (OASIS) in accordance with Medicare Conditions of Participation (CoPs), the Home Health Quality Reporting Program (HHQRP), and Georgia state regulations. This policy ensures compliance, accuracy, and timeliness in reporting patient assessment data. IV. Policy Statement: 2. OASIS assessments shall be submitted to CMS within 30 days of completion, per 42 CFR 484.45(a). 3. All staff shall comply with the required timelines, submission processes, and quality assurance standards outlined herein. B. Submission Requirements: Clinical staff shall enter all OASIS data into the EMR within established deadlines. Review of CMS report titled “HHA Error Summary by Agency,” with report period of 08/01/2024-08/01/2025 and run date of 08/13/2025, revealed the agency failed to transmit OASIS data to CMS system within 30 days. On 09/09/2025 at approximately 11:15 a.m., during an in-office interview, the Director revealed that she was not aware that the 30-day OASIS submission timeframe requirements were not met during the time frame of 08/01/2024 through 08/01/2025.

Colquitt Regional Home Care, Moultrie, Georgia, was in compliance with 42 CFR Part 418.113, Emergency Preparedness and Covid-19 infection control for Hospice as a result of an onsite survey conducted on 10/21/22.

A recertification survey was conducted at Colquitt Regional Home Care, Moultrie, Georgia, on 10/21/22, by Surveyor. It was revealed that the agency was in compliance with Chapter 42 CFR Part 418, Rules and Requirements for Home Health and Hospice Agencies. The census was 111. The following deficiencies were cited.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record reviews and staff interviews, it was determined the agency failed to ensure that the patients' clinical record contained complete, concise and clear documentation of all services, including weights, evaluations, treatments, progress notes, and individualized plan of care to address the patients' needs for one (1) of eighteen (18) (P#1) sampled patients. The Findings include: Review of the plan of care for Patient (P#1) with a certification period of 6/16/22 to 8/14/22 required the skilled nurse (SN) to assess and instruct patient/caregiver on precautions to monitor and document daily weight for a patient diagnosed of congestive heart failure. However, according to the plan of care, the patient was neither weighed nor measured for bilateral lower extremities for edema. The agency failed to follow the physician’s order, and also failed to notify physician. During an interview on 10/20/22 at 3:58 p.m., Registered Nurse (RN) AA, and (RN) BB confirmed that the agency failed to obtain P#1’s weights, and also failed to notify physician.

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 clinical record reviews and staff interviews, it was determined that the agency failed to follow physician’s order to weigh Patients (P#1), daily, and document, one (1) of eighteen (18) sampled patients. The Finding Include: Patient #1 was admitted to agency on 6/16/22, with a diagnosis of congestive heart failure. A review of the plan of care dated 7/2/22, revealed that physician ordered skilled nurse to assess, monitor and record daily weight, and to notify physician if P#1 gained two pounds in one day or five pounds in one week. Registered Nurse (RN) AA did not weigh P#1 on 6/22/22, upon visit; and (RN) BB also did not weigh P#1 on 6/20/22, 6/27/22, and 6/29/22, upon visit. There was no record showing that (RN) (RN) AA, and (RN) BB notified the physician for not obtaining the patient’s weight for four weeks. On 10/20/22, at 3:48 p.m., an interview was conducted with (RN) AA, who stated that she did not weigh P#1. Also (RN) AA also confirmed that she did not notify the physician. On 10/20/22, at 3:52 p.m., an interview was conducted with (RN) BB, who stated that she forgot to weigh P#1. Also (RN) BB confirmed that she did not notify the physician.