Every finding on record at Healthfield Home Health, LLC

An Abbreviated/Partial Extended survey investigating complaint #2594637 was conducted at Centerwell Home Health on August 25, 2025, and concluded on August 26, 2025. At the time of the survey, the agency was not in compliance with Chapter 42 Part 418, Rules and Requirements for Home Health and Hospice Agencies. The census was 566. Based on record reviews and interview(s), the agency was not found to be in compliance with complaint #2594637. The following deficiencies were cited:

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on clinical record reviews, staff and caregiver interview, and review of policy titled “Coordination of Care-Case Conferences,” it was determined that the agency staff failed to ensure their efforts were coordinated effectively and timely with patient’s family in order to support the objectives outlined in the plan of care for one patient (P) (P#3) of four sampled patients. Findings included: Review of policy titled “Coordination of Care-Case Conferences,” revised 2018, indicated the following: All healthcare providers associated with direct care must maintain close communication to ensure each patient receives coordinated care that meets their needs and supports the objectives outlined in the Plan of Care. Review of the plan of care for P#3 revealed the patient was admitted to services on 7/26/25 with a sacral wound. Review of coordination note dated 8/13/25 revealed the patient requiring a higher level of care needed than the SN (skilled nurse) was able to provide. The agency referred the patient to a wound center to have wound evaluation on 8/14/25. However, the clinical record failed to reveal care coordination with the family to ensure the family had transportation arrangements available to ensure the patient was able to make it to the scheduled appointment. The clinical record failed to reveal social work interventions to assist the family coordinate the patients care and services. During an telephone interview with the caregiver on 8/25/25 at 11:00 a.m., it was confirmed that the patient missed the scheduled wound care appointment on 8/14/25 as the family was unable to transport the patient to the appointment. The caregiver also confirmed that the agency did not assist in helping coordinate transportation arrangements for the patient to the appointment. During an office interview with the Market Executive of Operations on 8/26/25 at 11:30 a.m., it was confirmed that the agency staff failed to provide coordination of care with the patient/caregiver to educate on resources available to assist with transportation arrangements for the appointment. The agency failed to communicate with the physician and team to effectively coordinate the patient's care for identifying the patient's needs and services.

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, staff interview, and review of policy titled “Care Planning,” it was determined the agency failed to provide services as ordered by the physician in the plan of care for one patient (P) (P#3) of four sampled patients. Findings included: Review of policy titled “Care Planning,” revised 2018. indicated the following: Each patient must receive an individualized written Plan of Care (POC) including ongoing updates and/or additions related to the patient findings: Professional disciplines must assume responsibility for: • Providing services ordered by the physician/ allowed practitioner as indicated in the POC/interim orders Review of a physician’s order dated 8/15/25 for patient #3 required the skilled nurse (SN) to visit the patient 3 times a week for wound care. The clinical record revealed the SN only visited the patient two times the week of 8/17/25. The record failed to reveal documentation to indicate the physician was notified of the missed visit resulting in one unauthorized missed visit. During an interview with the Associate Director on 8/25/25 at 11:40 a.m., it was confirmed the agency failed to follow the ordered plan of care to visit the patient as ordered until the discharge order had been written. The Associate Director additionally confirmed that the agency missed one visit the week of 8/17/25 resulting in an unauthorized missed visit.

A Recertification survey was conducted at Centerwell Home Health on December 16, 2024, and concluded on December 18, 2024. 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 Centerwell Home Health on December 16, 2024, and concluded on December 18, 2024. In addition, complaint #110612 was investigated in conjunction with this Recertification survey. Based on record reviews, and interview, the facility was in compliance with complaint #110612. However, the agency was not in compliance with Chapter 42 CFR Part 418, Rules and Requirements for Home Health and Hospice Agencies. The census was 1834. 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 the Centers for Medicare & Medicaid Services (CMS) Home Health Agency (HHA) Error Summary by agency report, agency policy, 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,” last revised 08/2024, revealed the following: OASIS Data Collection • The Home Health agency will collect OASIS data response items and other pertinent information for each agency patient receiving skilled care to be billed to Medicare/Medicaid (primary or secondary) and those patients under a managed-care or Medicaid waiver program according to Company procedures. • OASIS data items will be collected and transmitted within 30 calendar days of the completion of the OASIS assessment. Review of CMS report titled “HHA Error Summary by Agency,” with a run date of 12/2/24, revealed the agency failed to transmit OASIS data to the CMS system within 30 days. On 12/16/2024 at 1:00 pm, during an in-office interview, the Administrator confirmed awareness of the 30-day OASIS submission timeframe requirements not met during the time frame of 12/01/2023 through 12/02/2024. The Administrator explained the agency OASIS reviewing and submission process was completed by the 30-day time frame but was rejected by the insurance and therefore had to be resubmitted to the Centers for Medicaid and Medicare Services (CMS).

At the time of the survey, Centerwell Home Health in Marietta, Georgia was in compliance with 42 CFR Part 484, Requirements for Home Health, as a result of an onsite complaint investigation conducted on August 16, 2022 for complaint numbers 71370 and 71109. The complaint #71370 was partially substantiated and deficiencies were cited related to the complaint and complaint 71109 was substantiated and a deficiency was cited related to the allegation. The agency census was 1481 at the time of the onsite visit.The following deficiencies were cited:

Property and person treated with respect CFR(s): 484.50(c)(1) Have his or her property and person treated with respect; This ELEMENT is not met as evidenced by: Based on clinical record reviews, complaint log and patient/staff interviews, it was determined the agency failed to ensure that staff treated all patients and their property with respect for 1 of 5 (#1) sampled patients (P). Findings were: 1. Review of the complaint log did contain an entry dated 7/6/22 for patient (P) #1 with an an certification period of 6/22/22- 8/22/22 and a diagnosis of severe (morbid) obesity which is summarized as follows: On 6/17/21 the complainant ( Humana Case Manager) called the office and spoke with the Registered Nurse Case Manager who reported the patient called Humana insurance and reported their concerns with the social worker interaction. According to the complainant, the Social Worker refused to enter the patient's home saying the house was filthy and he was not going in. Per the patient, both the patient and Social Worker were yelling back and forth at each other. After the yelling the patient called the police due to feeling threatened however, the Social Worker had left prior to the arrival of the police. The police advised the patient to call his insurance company and the home health agency to report the incident. Both entities were notified. During an interview with the Stockbridge Branch Manager on 8/16/22 at approximately 11:00 a.m., the Director acknowledged learning of the complainant allegations on 7/21/22. The Branch Director followed up with the Social Worker on 7/25/22 and the Social Worker denied everything except refusing to enter the home. The Social Worker did admit to refusing to go into the home due to the environmental conditions of the home and did take pictures of the home in front of the caregiver which was offensive according to the caregiver. The Agency staff failed to show respect to the patient/family and the patient's property by refusing to come into the home to complete the evaluation but rather stood outside the door and asked the caregiver questions.

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 as ordered by physician for 1 of 5 (#4) sampled patients (P). Findings were: 1.Review of the clinical record for P #4 with a recertification period of 5/10/22 to 7/8/22 and a diagnosis of type 2 diabetes with foot ulcer revealed a physician's order dated 5/10/22 which required the skilled nurse (SN) to perform wound cleansing and preparation to the left lateral plantar foot as follows: cleanse wound with antibacterial soap and water, rinse well/pat dry. Cleanse wound with normal saline only/pat dry. Apply moisture barrier ointment to peri-wound edges. Moisturize legs with Vaseline or other moisture barrier cream. Apply Unna boot, cast padding, coban, apply moistened Prisma to base of wound bed and cover with silver alginate. Cover with 4X4 gauze, super absorbent dressing and ABD pad. Secure with rolled gauze. The skilled nurse (SN) visited the patient on 5/20, 5/23, 5/26, 6/3, 6/4, 6/13, and 6/17/22 however, the SN performed wound care as follows: cleansed wound with wound cleanser, applied barrier ointment to the periwound, applied silver alginate to the wound bed. covered with gauze, absorbent dressing, ABD pad and roll gauze, then applied unna boot. The SN failed to follow the physician's wound care order. During an interview on 8/16/22 at 12:30 p.m., with the Marietta Administrator it was confirmed the SN failed to follow the ordered wound care. During an interview on 8/16/22 at approximately 1:30 p.m., it was confirmed with the Branch Manager at the Gwinnett office that the SN failed to follow wound care orders.

At the time of the survey, Centerwell Home Health, in Marietta, Georgia was in compliance with 42 CFR Part 484, Requirement for Home Health, because of an onsite complaint investigation conducted on July 26, 2022, for complaint numbers #61328. The complaint was unsubstantiated, however deficiencies were cited unrelated to the complaint. The agency census was 1399 at the time of the onsite visit. The following deficiencies were cited.

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 one of four (#4) sampled patients. Findings include: Review of the plan of care for patient #4 with a certification period of 6/10/22 to 8/8/22 revealed pertinent diagnosis of stage 4 pressure ulcer to the sacrum. The plan of care requires the skilled nurse (SN) to provide wound care to sacrum area as follows: SN to perform and teach pressure ulcer care to sacrum, cleanse wound with wound cleanser, apply aquacel, cover with gauze, secure with border dressing using clean technique. Change dressing every day and as needed for soiling /dislodgement, once taught caregiver to perform on days skilled nurse is not in home. SN to observe, assess and identify changes and intervene to minimize complications, significant changes and report findings and changes to the physician. Review of the SN visit note (admission assessment note) dated 6/10/22 revealed that SN made the visit but failed to assess wound and provide wound care to the patient. SN documents wound care provided by caregiver. Review of the SN visit notes dated 6/17, 6/22, 6/29, 7/6, 7/14, and 7/21/22, the SN documents wound care not provided, caregiver provided the wound care. However, the clinical record lacked documentation of communication or coordination efforts made with care team members and physician to discuss the concerns of not assessing the wound for complications and not providing wound care to the patient as ordered in the plan of care. Review of the SN visit note dated 7/6/22, the SN documents the physician notified that caregiver refused to have SN provide wound care to the patient. However, there is no evidence of follow up with the physician and possible revision of plan care related to wound care treatment for the patient. Furthermore, there were no documentation or coordination note to reflect the clinical manager was notified of wound care not being provided to the patient. During an interview with the Director of Operation (DOO) on 7/26/22 at 11:00 a.m., the DOO stated the wound is managed by the wound clinic and the caregiver refuses to have the SN assess and provide wound care to the patient, but there is no change or revision of plan of care for wound treatment for the patient. During an interview with division AVP at 12:15 p.m., the AVP stated that patient goes to wound clinic once a week and caregiver refuses to have SN assess and provide wound care to patient. The division AVP verbalized that there is no evidence in the clinical record that physician was notified of caregiver refusal of wound care to the patient and orders were obtained to reflect change in plan of treatment for patient’s wound. During an interview with the caregiver of the patient at 2:00 p.m., the caregiver verbalized that wound clinic manages the wound and caregiver provides wound care to the patient. The caregiver also stated that home health agency does not manage patient’s wound. The agency failed to communicate with the physician and team to effectively to coordinate the patient's care for identifying the patient's needs and services. During an interview on 7/20//22 at 1:00 p.m., the DOO provided no evidence of coordination with the physician and/or agency team members regarding patient’s wound issues and patient specific needs.

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 that clinical records contained clear, complete, and accurate documentation and orders in the record for two of four (#1 and #4) sampled patients. Findings include: 1. Review of the plan of care for patient #1 with a recertification period of 4/27/22 to 6/25/22 revealed pertinent diagnosis of pressure ulcer to coccyx and cellulitis of left lower leg. The plan of care required a skilled nurse (SN) to provide wound care to coccyx as follows: cleanse with wound cleanser, apply barrier cream to peri wound area, and gluteal fold, pack wound with iodoform while open and apply silver gel, cover with foam dressing. Secure with tape using clean aseptic technique. Change dressing every week and as needed for soiled or dislodgement. Wound care to the left lower leg as follows: cleanse with wound cleanser apply barrier cream to peri wound, apply silver gel to wound bed cover with bordered foam dressing, secure with rolled gauze. Change dressing every 3 days and as needed for soiled or dislodgement. However, SN visit notes dated 5/4, 5/13, 5/20, 5/27 and 6/10/22, the SN documents wound care provided. The SN visit notes lacked documentation of the specific steps taken and specific supplies used during the wound care procedure by the SN. The agency failed to ensure the clinical record was complete to include documentation of the care provided to the patient during the wound care procedure. 2. Review of the plan of care for patient #4 with a certification period of 6/10/22 to 8/8/22 revealed an incomplete Foley catheter order which reads as follows: Skilled nurse to perform insertion of 16 French catheter, 10 cc balloon. Change every month and as needed for dislodgement/stoppage. The order lacked specific type and the amount of fluid to instill into the balloon. The skilled nurse (SN) failed to obtain a complete Foley catheter order. During an interview on 7/26/22 at 1:30 p.m., the Director of Operations acknowledged the documentation of the wound care on the above referenced dates was incomplete and the plan of care revealed an incomplete Foley catheter order.

At the time of the survey, Kindred at Home in Marietta, GA with in compliance with 42 CFR Part 484.22 Emergency Preparedness for Home Health Agencies as a result of a recertification survey conducted on January 21, 2022. A Focus Infection control survey was completed at the time of the survey. Current census 1126. No deficiencies cited.

At the time of the survey, Kindred at Home in Marietta, GA with in compliance with 42 CFR Part 484, Requirements for Home Health Agencies as a result of a recertification survey conducted on January 21, 2022. A Focus Infection control survey was completed at the time of the survey. Current census 1126. Following deficiencies cited:

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, it was determined that the agency staff failed to conduct an initial assessment within 48 hours of referral or on the physician ordered start of care date for 6 of 17 ( #4, #6, #12, #14, #16, and #17) sampled patients (P). Findings were: 1. Review of the plan of care/treatment for patient #4 admitted on 1/3/22 with a diagnosis of pressure ulcer of left buttock stage 2 with a certification period of 1/3/22 to 3/3/22 revealed the agency staff received a home health referral for services on 12/24/21. However, the patient was not admitted to services until 1/3/22. The clinical record lacked justification for the delay of start of care and documentation that the physician was notified and authorized the start of care later than 48 hours from the referral, resulting in an unauthorized start of care delay. During an interview on 1/21/22 at 12:00 p.m., the Director of Clinical Operations, AA did not provide any additional information regarding the lack of documentation or if the physician was notified of the start of care delay. 2. Review of the plan of care/treatment for patient #6 with a diagnosis of Hypertensive Heart Disease with heart failure with a certification period of 12/3/21 to 1/31/22 revealed the agency staff received a home health referral for services on 4/3/21. However, the patient was not admitted to services until 4/7/21. The clinical record lacked justification for the delay of start of care and documentation that the physician was notified and authorized the start of care later than 48 hours from the referral, resulting in an unauthorized start of care delay. During an interview on 1/21/22 at 12:00 p.m., the Director of Clinical Operations, AA did not provide any additional information regarding the lack of documentation or if the physician was notified of the start of care delay. 3. Review of the plan of care/treatment for patient #12 with a diagnosis of Type 2 Diabetes with a certification period of 12/4/21 to 2/1/22 revealed the agency staff received a home health referral for services on 10/1/21. However, the patient was not admitted to services until 10/5/21. The clinical record lacked justification for the delay of start of care and documentation that the physician was notified and authorized the start of care later than 48 hours from the referral, resulting in an unauthorized start of care delay. During an interview on 1/21/22 at 12:00 p.m., the Branch Director (BD), EE did not provide any additional information regarding the lack of documentation or if the physician was notified of the start of care delay. 4. Review of the plan of care/treatment for patient #14 with a diagnosis of Pressure Ulcer of Sacral region stagee 4 with a certification period of 6/7/21 to 8/5/21 (discharge record) revealed the agency staff received a home health referral for services on 6/9/21. However, the patient was not admitted to services until 6/12/20. The clinical record lacked justification for the delay of start of care and documentation that the physician was notified and authorized the start of care later than 48 hours from the referral, resulting in an unauthorized start of care delay. During an interview on 1/21/22 at 12:00 p.m., the Branch Director (BD), DD did not provide any additional information regarding the lack of documentation or if the physician was notified of the start of care delay. 5. Review of the plan of care/treatment for patient #16 (discharge record) with a diagnosis of Urinary Tract Infection with a certification period of 6/11/21 to 8/9/21 revealed the agency staff received a home health referral for services on 6/4/21. However, the patient was not admitted to services until 6/11/21. The clinical record lacked justification for the delay of start of care and documentation that the physician was notified and authorized the start of care later than 48 hours from the referral, resulting in an unauthorized start of care delay. During an interview on 1/21/22 at 12:00 p.m., the Branch Director (BD) EE did not provide any additional information regarding the lack of documentation or if the physician was notified of the start of care delay. 6. Review of the plan of care/treatment for patient #17 with a diagnosis of Pressure Ulcer of Right Buttocks with a certification period of 6/10/21 to 8/8/21 (discharge record) revealed the agency staff received a home health referral for services on 6/7/21. However, the patient was not admitted to services until 6/10/21. The clinical record lacked justification for the delay of start of care and documentation that the physician was notified and authorized the start of care later than 48 hours from the referral, resulting in an unauthorized start of care delay. During an interview on 1/21/22 at 12:00 p.m., the Branch Director (BD) DD did not provide any additional information regarding the lack of documentation or if the physician was notified of the start of care delay.

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/treatment for 3 of 17 (#1, #2, and #9) sampled patients. Findings were: 1. Review of the plan of care/treatment for patient #1 with a certification period of 1/10/22 to 3/10/2 revealed a primary diagnosis of encounter for surgical aftercare following surgery on the digestive system and admission to services on 1/10/22. During a home visit observation with the SN on 1/18/22 this surveyor observed the patient had a jackson pratt (JP) drain with attached bulb located on the left lower abdominal area. However, the plan of care lacked documentation of the presence of this device or instruction for the care and maintenance of the drain. The agency staff failed to ensure the plan of care/treatment was comprehensive for the care and safety of the patient. During an interview on 1/21/22 at 12:00 p.m., the Director of Clinical Operations, AA acknowledged the plan of care/treatment lacked documentation of the presence of the JP drain and lacked instruction for the care and maintenance of the drain. 2. Review of the plan of care/treatment for patient #2 with a certification period of 1/6/22 to 3/6/22 and a primary diagnosis of diabetes mellitus type II and admission date of 1/6/22 required the physical therapist (PT) to instruct/reinforce patient/caregiver diabetic foot care to include monitoring for presence of skin lesion on the lower extremities. The plan of care did contain blood glucose parameters in which to notify the physician of complications however, the frequency of blood glucose monitoring was not specified. The agency failed to ensure the plan of care/treatment was comprehensive for the care and safety of the patient's diabetic care. During an interview on 1/21/22 at 12:00 p.m., the Director of Clinical Operations, AA acknowledged the plan of care/treatment lacked blood glucose monitoring frequency to ensure the patient was monitoring blood glucose levels for complications. 3. Review of the plan of care/treatment for patient #9 with a certification period of 12/6/21 to 2/3/22 and a pertinent diagnosis of diabetes mellitus type II and admission date of 12/6/21 required the skilled nurse (SN) to teach related to diabetes management including disease process, nutrition, medications, activities and personal environmental factors. However, the frequency of blood glucose monitoring was not specified. The agency failed to ensure the plan of care/treatment was comprehensive for the care and safety of the patient's diabetic status. During an interview on 1/11/18 at 4:00 p.m., the Branch Director (BD) DD acknowledged the plan of care/treatment lacked blood glucose monitoring frequency to ensure the patient was monitoring blood glucose levels for complications.

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 staff failed to ensure treatments were administered only as ordered by the physician for 1 of 17 (#10) sampled patients (P). Findings were: 1. Review of skilled nurse (SN) visit note dated 1/4/22 for patient #10 with a certification period of 12/22/21 to 2/19/22 and admission date of 12/22/21 revealed the SN performed a Foley catheter bladder irrigation using sterile technique on the patient on this date however, the clinical record lacked an order for this intervention. The agency failed to ensure this procedure was administered only as ordered by a physician. During an interview on 1/21/22 at 12:00 p.m., the Branch Director (BD) EE acknowledged the catheter irrigation was performed without a physician's order.

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 care and services were provided in conformance with the patients' plans of care/treatment as ordered by physicians for 6 of 17 (#1,#4, #6 #7, #8, and #9) sampled patients (P). Findings were: 1. Review of the plan of care/treatment for patient #1 with a certification period of 1/10/22 to 3/10/22 and a diagnosis of encounter for surgical aftercare following survey of digestive system and admission date of 1/10/22 required the skilled nurse (SN) to observe/assess and report weight gain of 2-3 pounds in one day or 5 pounds in a week. The SN visited the patient on 1/14/22 and 1/18/22 however, the weight was not assessed. The agency failed to ensure the plan of care/treatment for monitoring weights was assessed as ordered. During an interview on 1/21/22 at 12:00 p.m., the Director of Clinical Operations, AA acknowledged the SN failed to monitor weights as ordered. 2. Review of the plan of care/treatment for patient #4 with a certification period of 1/3/22 to 3/3/22 with a diagnosis of pressure ulcer of left buttocks, stage 2 and admission date of 1/3/22 required the SN to observe/assess and report weight gain of 2-3 pounds in one day or 5 pounds in a week. The SN visited the patient on 1/3/22 and 1/12/22 however, the weight was not assessed. Additionally, the SN was required to measure the patient's abdominal girth at each visit. The SN visited the patient on 1/12/22 however, failed to assess the patient's abdominal girth. The agency failed to ensure the plan of care/treatment for monitoring weights and abdominal girth measurements were assessed as ordered. During an interview on 1/21/22 at 12:00 p.m., the Director of Clinical Operations, AA acknowledged the SN failed to monitor weights and perform abdominal girth measurements as ordered. 3. Review of the plan of care/treatment for patient #6 with a recertification period of 12/3/21 to 1/31/22 with a diagnosis of hypertensive heart disease with heart failure, an admission date of 12/3/21, required the SN to observe/assess and report weight gain of 2-3 pounds in one day or 5 pounds in a week. The SN visited the patient on 12/29/21 however, the weight was not assessed. The agency failed to ensure the plan of care/treatment for monitoring weights was assessed as ordered. During an interview on 1/21/22 at 12:00 p.m., the Clinical Director of Operations, AA acknowledged the SN failed to monitor weights as ordered. 4. Review of the plan of care/treatment for patient #7 with a certification period of 12/16/21 to 2/13/22 with a diagnosis of encounter for surgical aftercare following survey, an admission date of 12/16/21 on the digestive system required the SN to observe/assess and report weight gain of 2-3 pounds in one day or 5 pounds in a week. The SN visited the patient on 12/30/21 and 1/7/22 however, the weight was not assessed. The agency failed to ensure the plan of care/treatment for monitoring weights was assessed as ordered. During an interview on 1/21/22 at 12:00 p.m., the Director of Clinical Operations, AA acknowledged the SN failed to monitor weights as ordered. 5. Review of the plan of care/treatment for patient #8 with a recertification period of 11/10/21 to 1/8/22 with a diagnosis of essential primary hypertension, an admission date of 7/13/21 required the SN to observe/assess and report weight gain of 2-3 pounds in one day or 5 pounds in a week. The SN visited the patient on 1/4/22 however, the weight was not assessed. The agency failed to ensure the plan of care/treatment for monitoring weights was assessed as ordered. During an interview on 1/21/22 at 12:00 p.m., the Branch Director (BD) CC acknowledged the SN failed to monitor weights as ordered. 6. Review of the plan of care/treatment for patient #9 with a certification period of 12/6/21 to 2/3/22 with a diagnosis of chronic pain, an admission date of 12/6/21, required the SN to observe/assess and report weight gain of 2-3 pounds in one day or 5 pounds in a week. The SN visited the patient on 12/28/21 however, the weight was not assessed. The agency failed to ensure the plan of care/treatment for monitoring weights was assessed as ordered. During an interview on 1/21/22 at 12:00 p.m., the Branch Director (BD) DD acknowledged the SN failed to monitor weights as ordered.

An unannounced complaint investigation GA00213964 was conducted at Kindred At Home in Lawrenceville, GA on 6/30/21. As a result of the investigation, the complaint was unsubstantiated; however, deficiencies were cited not related to the complaint. A review of Covid-19 infection control revealed that the agency was in substantial compliance with 42 CFR Part 484, Requirements for Home Health Agencies.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, it was determined the agency failed to ensure an updated comprehensive assessment was done at the time of the patient's discharge for patients two of four sampled patients (P) (P#2, and P#3 ) requiring a discharge OASIS (Outcome and Assessment Information Set) assessment. 1. Review of the clinical record for Patient (P#3) with a certification period of 3/27/21 to 5/25/21 required the skilled nurse (SN) to visit the patient 1 time a week for 1week, 2 times a week for 4 weeks, 1 time a week for 5 weeks and 4 visits as needed for colostomy issues. According to the discharge summary note dated 4/19/21, the patient had refused visit and decided to go with another home health agency. The clinical record revealed a physician’s order to discharge patient from services. However, the clinical record lacked the OASIS discharge assessment , which was not completed as required. The agency failed to complete a discharge OASIS at the time of the patient's discharge. During an office interview at the office on 6/29/21 at 12:20 p.m., the Executive Director and the clinical manager did not provide any documented evidence to show the discharge OASIS was completed at the time of discharge as required. 2. Review of the clinical record for Patient (P#2) with a certification period of 4/13/21 to 6/11/21 required the physical therapist (PT) to visit the patient 1 time a week for 2 weeks, 2 times a week for 3 weeks, and 1 time a week for 4 weeks. According to the clinical coordination note dated 4/23/21 , patient has moved to an out of service area. However, the clinical record lacked the OASIS discharge assessment , which was not completed as required. The agency failed to complete a discharge OASIS at the time of the patient's discharge. During an office interview on 6/29/21 at 12:20 p.m., the Executive Director and the clinical manager did not provide any documented evidence to show the discharge OASIS was completed at the time of discharge as required.