Every finding on record at Lhcg Clxiv, LLC

At the time of the survey, University Home Health Services in Augusta, Georgia was in compliance with 42 CFR Part 484.22 Emergency Preparedness for Home Health Agencies as a result of a standard recertification survey conducted on November 3, 2021. A Focus Infection Control Survey was completed at the time of the survey. Current census 165. No deficiencies were cited.

At the time of the Recertification survey, University Home Health Services in Augusta, Georgia was in substantial compliance with 42 CFR Part 484, Requirements for Home Health Agencies as a result of the survey conducted on November 3, 2021. A Focus Infection Control Survey was completed at the time of the survey. Current census 165. 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 patients' individualized plan of care/treatment included all of the required elements to address the patients' needs for one of thirteen (P) (P#8) sampled patients. Findings include: Review of the plan of care/treatment for patient #8 with a certification period of 9/21/21 to 11/19/21 revealed a pertinent diagnosis of type II diabetes mellitus with diabetic chronic kidney disease. However, 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. Furthermore, the plan of care also revealed patient with a pertinent diagnosis of chronic kidney disease with dependent on dialysis. However, the plan of care did not identify the presence of the shunt. According to the physical therapy (PT) note dated 9/21/21, patient has intact dialysis access shunt in the left upper extremity, and attends a dialysis treatment center on Mondays, Wednesdays, and Fridays. However, the agency staff failed to include the presence of a dialysis access shunt in the care plan/treatment with precautionary measures such as avoiding blood pressures or venipunctures in the affected arm to protect the patient and the shunt from harm. Additionally , the plan of care revealed a diagnosis of heart failure . However, the plan of care lacked vital signs parameters and parameters for weight monitoring and increased edema which would show abnormal findings and indicate the need to notify the physician for early intervention to minimize complications. The agency failed to ensure that the plan of care/treatment covered all pertinent interventions for the comprehensive care of the patient's diabetic status, chronic kidney disease status and heart failure status. During an interview on 11/3/21 at 2:00 p.m., the Director and the Clinical Manager acknowledged the plan of care/treatment lacked interventions for the presence and care of the patient's dialysis shunt. The administrator and the Clinical Manager did not provide any additional information regarding the plan of care containing blood glucose monitoring frequencies and the teaching and assessments of diabetic complications and heart failure complications.

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Based on clinical record reviews and staff interviews, it was determined the agency failed to ensure the patient's individualized plan of care was updated to address an exacerbation of illness for 1 of 13 sampled patients (P) (P#6). 1. Review of the plan of care for P#6 with a certification period of 10/1/21 to 11/29/21 revealed a pertinent diagnosis of hypertensive chronic kidney disease. The clinical record indicates the patient went to the emergency room on 10/5/21 due to a headache and elevated blood pressure. The patient was observed and sent home with instruction to double hypertensive medication to control blood pressure. The skilled nurse visited the patient on 10/15/21 and assessed the patient however, the clinical record lacked documentation to show the plan of care was updated to show the current exacerbation of hypertension with interventions to assess and monitor for complications. The clinical record lacked blood pressure parameters in which to notify the physician of potential patient complications and early intervention. The agency failed to update the plan of care to monitor and teach signs/symptoms of exacerbation, complications, and management. During an interview on 11/3/21 at 2:00 p.m., the Administrator and the Clinical Manager acknowledged the plan of care was not updated to reflect a change in the patient's current health status to monitor for complications.

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 that their efforts were coordinated effectively to support the objectives outlined in the plan of care for 2 of 13 sampled patients (P) (P#3 and P#10) sampled patients receiving home health services. Findings were: 2. Review of the plan of care for patient #10 with a recertification period of 5/30/21 to 7/28/21 (discharge record) revealed that patient has diagnosis of stage 1 pressure ulcer of sacral region and type II diabetes mellitus with long term use of insulin. Review of the skilled nurse (SN) visit note dated 6/27/21 revealed that patient’s family is not willing and able to care for the patient and patient requested a social worker (SW) assistance for further resources. Review of the clinical record revealed that there were no further communications or documentation in the clinical record to indicate the SW attempted to see the patient. The clinical record lacked consultation with Medical Social Services for assistance with meeting patient’s needs. Furthermore, the SN visit coordination note dated 7/26/21 revealed that patient was being discharged due to noncompliance with medications , wound care, and lack of care giver support. However, the clinical record lacked documentation of communication and coordination amongst the care team, with the patient/family, and/or with the physician to secure additional resources. The clinical record lacked documentation of case conferences with the agency staff providing care to this patient's current needs. The agency failed to communicate timely and coordinate care effectively to meet the identified needs of the patient. During an interview on 11/3/21 at 2:00 p.m., the Administrator and the Clinical Manager provided no evidence of coordination with the physician or team members regarding coordination of services to ensure the patient’s needs were met prior to discharge. 1. Review of the plan of care for P#3 with a certification period of 9/24/21 to/11/22/21 revealed the patient has a pertinent diagnosis of type 2 diabetes with diabetic neuropathy. The skilled nurse (SN) is required to instruct on diabetes to include disease process, signs and symptoms of exacerbation, complications and management. The SN is also required to instruct the patient on blood glucose testing, frequency, and therapeutic range of 70-300 mg/dl. During a home visit observation on 11/2/21 at approximately 9:30 a.m. with the SN, this surveyor asked the patient how often he/she monitors blood glucose levels. The patient stated that he/she does not have a blood glucose monitor and therefore does not monitor blood sugars. The patient also reports not comfortable with using needles to take blood sugar. When asked by this writer how often blood sugars are monitored, the patient stated only when he/she goes to the doctor. The patient does have wounds to bilateral lower extremities and appears to have a knowledge deficit when the SN was discussing how diabetes can impact wound healing. The patient does report taking an oral hypoglycemic medication but during the home visit the bottle was empty. The patient stated he/she had ran out of the hypoglycemic medication. During a review of the clinical record, the record lacked documentation of coordination of care with the physician to show the physician was made aware that the patient did not have access to a blood glucose monitor and was not monitoring blood sugars as ordered. Additionally, the record lacked communication and coordination amongst care team members to assist in providing the care and resources to meet the identified needs of the patient. The agency failed to communicate timely and and coordinate care effectively to meet the identified needs of the patient. During an interview on 11/2/21 at 10:00 a.m., the SN did acknowledge that the patient had not been taking blood sugars due to not having access to a blood sugar monitor but would call the physician to request a monitor which would not require using a needle. During an interview on 11/3/21 at 2:00 p.m. the Administrator stated the agency would provide a blood glucose monitor to the patient while the patient's device is being ordered.