Every finding on record at Peachtree Home Health, LLC

A recertification survey was conducted at Bridgeway Home Health, on May 6, 2024, and concluded on May 8, 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 Bridgeway Home Health on May 6, 2024, and concluded on May 8, 2024. At the time of the survey, the agency was not in compliance with compliance with Chapter 42 CFR Part 418, Rules and Requirements for Home Health and Hospice Agencies. The census was 216.

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 report, review of policy and procedures, and staff interview, it was determined that the agency failed to electronically transmit Outcome and Assessment Information Set (OASIS) data collected to the State Agency every 30 days. Review of the policy titled “Reporting of OASIS Information,” revised 2021, revealed the following: Policy The Agency will report required data collected for the Outcome and Assessment Information Set (OASIS) items. Procedure 1. The agency will report electronically all OASIS data collected according to current federal and/or state requirements. 3. Agency will electronically transmit completed, encoded and locked OASIS data for each completed OASIS assessment at least monthly to the System. Review of CMS report ran on 5/1/24 for period 2/1/23 to 1/31/24 titled “HHA Error Summary by Agency”, revealed the agency failed to transmit OASIS data to the State Agency within 30 days. An interview was conducted with the Administrator on 5/06/2024 at 1:00 p.m. The Administrator confirmed OASIS reports had not been submitted to CMS within 30 days of completing the assessments.

At the time of the survey, Bridgeway Home Health, in Conyers, Georgia was in compliance with 42 CFR Part 484, Requirement for Home Health, as a result of an onsite complaint investigation conducted on July 13 , 2022 for complaint number 71029 . The complaint was substantiated and deficiencies were cited related to the complaint. The agency census was 152 at the time of the onsite visit. The following deficiencies were cited:

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on review of document titled, “Complaint Form” dated 6/23/22, and review of the complaint log from 7/1/21 to present, the agency failed to follow-up on a complaint for one of three (#1) patients with complaint. Findings include: 1. Review of the plan of care for P#1 with recertification period of 5/28/22 to 7/26/22 with diagnosis of encounter for fitting and adjustment of urinary device with indwelling Foley catheter. The plan of care requires skilled nurse (SN) to flush catheter with 10 cc of sterile water weekly and as needed (PRN). Review of the on-call log dated 6/24/22 revealed that caregiver called the answering services three times; on 6/23/22 at 6:24 p.m., stating that P#1 has not had any urine output and patient had the Foley reinserted on 6/22/22. The on-call log also revealed that caregiver called again on 6/23/22 at 7:45 p.m. with same concerns. The on-call service received another on 6/24/22 at 8:24 a.m., caregiver stating that this is the 3rd call and patient's catheter is bleeding and patient is confused. The on-call report revealed that message was delivered to the administrator on 6/23/22 at 6:24 p.m., with no answer, "gave message" at 7:19 p.m., message delivered at 7:46 p.m., and message delivered on 6/24/22 at 8:04 a.m. Review of document titled, "complaint form" dated 6/23/22 states that the caregiver verbalized to the administrator that the patient had no urine output since yesterday and when SN changed the catheter, small amount of urine noted. the caregiver reports that patient has blood in the catheter and has pain and patient was taken to the hospital. Further review of the “Complaint note” dated 6/23/22, revealed the resolution column; patient was taken to the hospital. During an interview on 7/12/22, at 10:00 a.m., the Administrator who documented the complaint note stated the Administrator never received the calls that were on the on-call log and did not provide any resolution related the complaint and the on-call issues.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. 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 complete therapy assessments within 5 days for a comprehensive assessment of the patient's needs for 4 of 4 sampled patients (#1, #2, #3 and #4). Findings were: 1. Review of the plan of treatment for patient #3 with a certification period of 6/21/22 to 8/19/22 revealed an order for the physical therapist (PT) to assess and evaluate the patient during the timeframe of 6/21/22 to 8/19/22. This timeframe is not appropriate as the evaluation must be done within 5 days of the patient's admission to services. Review of the clinical record revealed the PT evaluation was not completed until 6/28/22 (7 days after the patient was admitted to services.) PT failed to perform the evaluation within the required timeframe of days. 2. 1. Review of the plan of treatment for patient #4 with a certification period of 6/07/22 to 8/05/22 revealed an order for the occupational therapist (OT) to assess and evaluate the patient during the timeframe of 6/07/22 to 8/05/22. This timeframe is not appropriate as the evaluation must be done within 5 days of the patient's admission to services. Review of the clinical record revealed the OT evaluation was not completed until 6/22/22 (15 days after the patient was admitted to services.) OT failed to perform the evaluation within the required timeframe of days. During an interview on 6/12/22 at 10:00 a.m., administrator did confirm PT and OT failed to perform the evaluation within the required timeframe of five (5) days.

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's skilled professional staff failed to provide services as ordered by the physician in the plans of care for three of four (#1, #2, and #4) sampled patients. Findings include : 1. Review of the plan of care for P#4 with certification period of 6/7/22 to 8/5/22 with diagnosis of abdominal wounds requires a skilled nurse (SN) to provide wound care as follows: cleanse wound with vashe wound cleanser, let sit for 3 to 5 minutes, pat dry , apply zinc paste to peri wound skin, lightly pack with Prisma collagen into small opening at the base of abdomen , then apply hydrofera blue foam dressing cut to fit to wound bed, cover with 4x4 gauze and abdominal combine pad. secure with adhesive island dressing or tape. SN to perform wound care twice weekly. However, review of SN visit notes revealed the SN visited the patient once weekly on the week of (6/5/22) 6/7, week of (6/12/22) 6/16, and week of (6/19/22) 6/21/22. The clinical documentation lacked evidence that physician was notified of the missed visits. SN did not follow the frequency of two times weekly for wound care for the patient. 2. Review of the plan of care for P#1 with recertification period of 5/28/22 to 7/26/22 with diagnosis of encounter for fitting and adjustment of urinary device with indwelling Foley catheter. The plan of care requires skilled nurse (SN) to flush catheter with 10 cc of sterile water weekly and as needed (PRN). However, the SN visit notes dated 6/8, 6/10, 6/15 and 6/22/22 lack documentation that SN irrigated the Foley as ordered in the plan of care. Furthermore, the plan of care revealed a diagnosis of pressure ulcer of left heel, cellulitis of right and left lower limb. The plan of care requires the SN to change dressings as follows: Remove entire dressing , cleanse using soap and water and Dermal cleanser (leaving Green sorbact layer intact), apply betadine to base of ulcer heel area and antifungal powder to both legs , pat dry apply zinc paste to wound edges the DACC(green sorbact) dressing over all wounds all 4x4 gauze over DACC layer , wrap circumferentially from the base of the toes to the tibial tuberosity 4" ace wrap. Secure inflated boot back to legs. SN to change dressing three times a week. However, review of the SN visit notes revealed that SN made visit on the following dates 6/1, 6/8, 6/10, 6/15, 6/17 and 6/22/22. SN did not provide wound care three times a week as ordered in the plan of care. The clinical documentation lacked evidence that physician was notified of the missed visits. 3. Review of the plan of care for P#2 with recertification period of 5/24/22 to 7/22/22 with diagnosis of paraplegia revealed a verbal order for wound care dated 6/10/22 as follows: Instruct/perform wound care; cleanse with normal saline m or wound cleanser, apply zinc barrier cream to wound bed, cover and secure with bordered foam, change dressing every 2-3 days. However, review of the SN visit notes revealed that SN made visits on, 6/8, 6/21, 6/28 and 7/11/22, the SN did not provide wound care every 2-3 days as ordered on the plan of care. The clinical documentation lacked evidence that physician was notified of the missed visits. The agency's skilled professional staff failed to provide services as ordered by the physician in the plans of care. During an interview on 7/12//22 at 11:00 a.m., the Administrator acknowledged the SN did not follow the frequency for wound care and Foley irrigation as ordered in the plans of care for P#1, P#2, and P#4 and lacked evidence that physician was notified of the missed visits.

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 communication to ensure their efforts were coordinated effectively and timely to support the objectives outlined in the plan of care for 2 of 4 (#3 and #4) sampled patients. Findings were: 1. Review of the plan of care for patient #3 with a certification period of 6//21/22 to 8/19/22 required the medical social worker (MSW) to visit the patient 1 time a month for 1 month. An additional written order was obtained on 7/01/22 to change orders to start on 7/03/22 to visit the patient 1 time a month for 1 month. MSW was required to visit the patient 1 time a month for 1 month effective 6/21/22. According to the clinical record, the MSW was scheduled to visit the patient on 7/8/22, MSW did not visit patient. There was no documentation in the record to indicate the physician had been made aware of the MSW visits not being completed as ordered. The clinical record also lacked any communication or coordination efforts made with the physician or amongst the care team members to assist in locating a MSW to provide the ordered care or discharging the patient from services due to not being able to meet the identified needs of the patient. The agency failed to communicate with the physician and team to effectively coordinate the patient's care for continued services or discharge planning. 2. Review of the plan of care for patient #4 with a certification period of 6/07/22 to 8/05/22 required the physical therapist (PT) to visit the patient 1 time a week for 1 week then 1 time a week for 1 week. According to the clinical record, the PT did not perform an evaluation and did not make any visits with the plan of care indicating the patient would benefit from skilled PT interventions to increase functional independence. There were several missed visit notes in the record dated 6/7, 6/22, and 6/28/22 which indicated a therapist was not available to provide the ordered visits. There was no documentation in the record to indicate the physician had been made aware of the PT visits not being completed as ordered. The clinical record also lacked any communication or coordination efforts made with the physician or amongst the care team members to assist in locating a PT to provide the ordered care or discharging the patient from services due to not being able to meet the identified needs of the patient. The agency failed to communicate with the physician and team to effectively coordinate the patient's care for continued services or discharge planning. During an interview on 7/12/22 at 11:00 a.m., administrator provided no evidence of coordination with the physician or team members regarding coordination of the patient's care for continued need for services or discharge planning.

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 3 of 4 ( #1 #2 and #4) sampled patients. Findings include: 1.Review of the plan of care for P#1 with recertification period of 5/28/22 to 7/26/22 with diagnosis of encounter for fitting and adjustment of urinary device with indwelling Foley catheter. The plan of care requires skilled nurse (SN) to flush catheter with 10 cc of sterile water weekly and as needed (PRN). However, the Foley catheter order lacks the size of the catheter, the type and amount of solution to inflate the balloon and the frequency to change the catheter. Furthermore, the plan of care revealed a diagnosis of pressure ulcer of left heel, cellulitis of right and left lower limb. The plan of care requires the SN to change dressings as follows: Remove entire dressing , cleanse using soap and water and Dermal cleanser (leaving Green sorbact layer intact), apply betadine to base of ulcer heel area and antifungal powder to both legs , pat dry apply zinc paste to wound edges the DACC(green sorbact) dressing over all wounds all 4x4 gauze over DACC layer , wrap circumferentially from the base of the toes to the tibial tuberosity 4" ace wrap. Secure inflated boot back to legs. change three times a week. Review of SN visit notes dated 6/1, 6/17 and 6/22/22, the SN documents wound care provided as per MD orders. The SN failed to document the steps and supplies used to complete the ordered wound care for the patient. 2. Review of the plan of care for P#4 with certification period of 6/7/22 to 8/5/22 with diagnosis of abdominal wounds requires a skilled nurse (SN) to provide wound care as follows: cleanse wound with vashe wound cleanser, let sit for 305 minutes pat dry , apply zinc paste to peri wound skin, lightly pack with Prisma collagen into small opening at the base of abdomen , then apply hydrofera blue foam dressing cut to fit to wound bed, cover with 4x4 gauze and abdominal combine pad. secure with adhesive island dressing or tape. SN to perform wound care twice weekly. however, review of SN visit notes dated 6/7, 6/16, and 6/21/22, the SN documents wound care performed. The SN failed to document the steps and supplies used to complete the ordered wound care for the patient. 3. Review of the plan of care for P#2 with recertification period of 5/24/22 to 7/22/22 with diagnosis of paraplegia revealed a verbal order for wound care dated 6/10/22 as follows: Instruct/perform wound care; cleanse with normal saline m or wound cleanser, apply zinc barrier cream to wound bed, cover and secure with bordered foam, change dressing every 2-3 days. However, the wound care order lacks the location and type of wound. The skilled nurse (SN) failed to obtain accurate and complete wound care orders. furthermore, the SN visit notes dated, 6/8, 6/21, 6/28 and 7/11/22, the SN documents wound care provided as ordered. the SN failed to document the steps and accurate supplies used to complete wound care for the patient. During an interview on 7/12/22 at 11: 00 a.m., the Administrator acknowledged that SN visit notes for P#1, P#2 and P#4 lacked clear, accurate and complete documentation of wound care provided to the patient on above mentioned dates.

A standard survey was conducted at Bridgeway Home Health in Conyers from April 26, 2021, through April 28, 2021. The standard survey revealed that the facility was in substantial compliance with 42 CFR Part 484.22, Emergency Preparedness for Home Health. A Focus Infection Control Survey was completed at the time of the survey. The census was 243.

A standard survey was conducted at Bridgeway Home Health in Conyers from April 26, 2021, through April 28, 2021. The standard survey revealed that the facility was in substantial compliance with 42 CFR Part 484 Requirements for Home Health. However, the following standard level deficiencies resulted from the facility's noncompliance related to the survey.

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 (POC) included all the required elements to address the patients' needs for seven of 13 Patient's (P) #2, #3, #4, #5, #6, #7, and #9 who were receiving home health services. 1. A review of P#2's POC dated 4/1/21 to 5/30/21 revealed under Activities Permitted: Up as tolerated, exercises prescribed, cane, walker, transfer bed-chair. Under Homebound status: Patient requires use of RW (rolling walker) to leave home. Under Orders and Treatments: Therapist to instruct patient in use of prescribed device when ambulating. However, this statement does not specify a cane, walker, or rolling walker. 2. A review of P#3's POC dated 4/3/21 to 5/31/21 revealed under Secondary/Other Diagnoses: Encounter for attention to gastrostomy. The only other mention for a gastrostomy for this patient is under the medications section of the POC, where there is an order for aspirin to be administered daily via a peg tube. Also, under Orders and Treatment: Skilled nurse (SN) to assess/evaluate wound (s) at each dressing change. However, there is no diagnosis of a wound, no site, no type of wound, and no wound care order. There is another intervention for the SN to instruct on gastroesophageal reflux disease (GERD) however, P#3 does not have a diagnosis of GERD on the POC. Another intervention states Occupational Therapist to instruct on pain control to include use of modalities as prescribed by physician. However, the intervention does not specify the prescribed modalities. Additionally for P#3 under Goals: Patient will verbalize understanding of proper use of pain medication. However, the POC does not contain an order for any pain medication. 3. A review of P#4s POC dated 4/2/21 to 5/31/21 revealed under Orders and Treatment: SN to change suprapubic with an 18 fr (French) 10cc (cubic centimeter) catheter every month. The intervention does not state how much or what type of fluid to instill in the 10cc balloon. 4. A review of P#5's POC dated 4/3/21 to 6/11/21 revealed under DME and Supplies a nebulizer is listed. However, the patient is not receiving any nebulizer medications per the POC medication list. Under Orders/Treatments is an intervention for peripherally inserted central catheter (PICC) flushes. The intervention reads "(if double lumen) flush 2nd lumen with 5-10 ml (milliliter) NS (normal saline) and 3-5ml heparin". The POC does not specify if the patient has a double lumen PICC. The POC also does not include any interventions for PICC site assessments. 5. A review of P#6s POC dated 3/23/21 to 5/21/21 reveals a diagnosis of Type 2 diabetes mellitus. Under Orders and Treatments: notify the physician of a fasting blood sugar of greater than 250 or less than 70. Under the section DME (durable medical equipment) and Supplies, diabetic monitoring supplies are not listed. There is also no intervention to monitor blood sugar readings, and no mention if the patient monitors blood sugar reading. On the SNV dated 4/23/21, the nurse documented under the pain assessment comments "Patient stated he takes Tylenol for pain. Tylenol was not listed under the medications on P#6's POC. 6. A review of P#7s POC dated 3/25/21 to 5/23/21 revealed under Homebound Status: Patient needs the aid of supportive devices such as crutches, canes, wheelchairs, and walkers. However, the POC does not specify which of these assistive devices P#7 requires. Also under DME and Supplies, there are no assistive devices listed. Under Secondary/Other Diagnosis: Long-term use of oral hypoglycemic's although P#7 is not on an oral hypoglycemic medication, instead insulin is listed in the medications on the POC. 7. A review of P#9's POC dated 3/26/21 to 5/24/21 revealed under Nutritional/Requirements: Regular and other: wound healing. The requirements do not specify the diet further. Also, under Orders and Treatment: SN to change foley catheter with 16fr 10 cc catheter. However, this order does not specify how much or what type of fluid should be used to inflate the balloon. Another intervention states for the SN to report to physician if pain medications not effective or patient unable to tolerate pain medications. However, patient does not have a pain medication listed under the medication section of the POC. During an interview with the acting Administrator and Registered Nurse (RN), BB on 4/27/21 at 10:15 am. and again on 4/26/21 at 3:00 p.m., this surveyor asked for any additional information related to the above findings and offered that the information could be provided at any time before the exit of the survey planned for 4/28/21. No additional information was received. At the time of the exit interview on 4/28/21 at 11:00 a.m. the Administrator stated there was no additional information.

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, review of policy number 2.2.001 titled "Wound Assessment, Documentation, and Photography, and staff interviews, it was determined that the agency staff failed to provide treatment as required by the plan of care (POC) for 5 of thirteen Patients (P) #3, #5, #6, #7, and #9 who were receiving home health services. 1. A review of P#5's POC dated 4/3/21 to 6/1/21 revealed under Secondary/Other Diagnosis: Type 2 diabetes mellitus. Under Orders and Treatments is an intervention to notify the physician for fasting or random blood sugar of greater than 300 or less than 60. Also, another intervention to instruct the patient on home blood sugar logs. On skilled nurse visits (SNV) dated 4/4/21, 4/6/21, 4/12/21, 4/19/21, and 4/26/21 no blood sugars were documented. Another invention for P#5 states SN for PICC line care, change dressing 1 x week and as needed, cleanse with 3 alcohol swabs, and 3 betadine swabs or chloraprep as provided in dressing kit. Cover with transparent dressing. On an SNV dated 4/26/21 the nurse's documentation for the dressing change states, "Cleaned PICC line insertion site using alcohol wipes, chlorprep, and secured with dressing." 2. A review of P#9's POC dated 3/26/21 to 5/24/21 revealed under Orders and Treatments: SN to assess/evaluate wound at each dressing change; SN to instruct patient/caregiver on wound care as follows cleanse with wound cleanser, pat dry, cover wound site with gauze moistened with ¼ str. Dakin solution until MRI results available. (No packing specified by MD) Cover with gauze. Secure with tape. Patient #9 had a SNV on 4/23/21, which included the following documentation "Old wound dressing intact. No drainage noted to the outer dressing. Aseptic tech provided as following: wound cleansed wound cleanser, and pat dry. Skin prep to peri-wound, alginate placed in wound cavity loosely dry gauze applied, and covered with ABD (abdominal) pad and secured with tape. Another comment under "Skin" states Wound to sacral area decreasing in size. No redness or irritations noted to the peri-wound. The documentation did not include wound measurements, wound bed description, wound edges, or if drainage was present. A review of the agency's policy number 2.2.001titled "Wound Assessment, Documentation, and Photography with a revision date of 2/1/21 states on page 1 of 3 that during routine visits, the wound will be documented in the Wound Assessment Tool within the computer system. Also on page one of three, the policy states unless otherwise ordered by the physician, the Registered Nurse or Physical Therapist will assess wounds at least: Weekly for patient with a stage four pressure injury. The assessment includes measurements of the length, width, and depth, undermining and tunneling, wound bed description, wound edges, exposed tissue types, drainage, and the condition of the peri-wound. At each dressing change, the clinician should record the wound bed description, wound edges, exposed tissue types, and drainage, and the condition of the peri-wound. 3. A review of P#3's POC dated 4/2/21 to 5/31/21 revealed under Orders and Treatments an order for an HHA 1 w (week) 9. A further review of the clinical record did not show where an aide ever visited nor was there any mention of a reason. 4. A review of P#7's POC dated 3/25/21 to 5/23/21 revealed under Orders and Treatments: Notify the physician of a fasting or random blood sugar of greater than 350 and less than 70. Another intervention for the SN to instruct patient/caregiver home blood sugar logs, and for patient/caregiver to check blood sugars 1-3 times daily. On SNV 3/30/21, 4/1, 4/7, 4/14. 4/23 no blood sugars were documented. On the SNV 4/23, the nurse documented the patient had dropped and broken her glucometer the previous night. However, no blood sugars were documented before the glucometer was broken. 5. A review of P#6's POC dated 3/23/21 to 5/21/21 revealed a patient with a Primary diagnosis of Type 2 diabetes mellitus. The patient was referred to home health services for therapy only. An order was obtained for SN to evaluate patient on 3/28/21. There is no documentation that a SNV was performed until 4/11/21. There is documentation on 4/11/21 that the SN contacted the physician and obtained orders for SN, but no order was found on the clinical record. However, SNV's were performed 4/11/21, 4/16/21, 4/22/21, and 4/23/21. During an interview with the acting Administrator and Registered Nurse (RN) BB, on 4/27/21 at 10:15 am. and again on 4/26/21 at 3:00 p.m., this surveyor asked for any additional information related to the above findings and offered that the information could be provided at any time before the exit of the survey planned for 4/28/21. No additional information was received. At the time of the exit interview on 4/28/21 at 11:00 a.m. the Administrator stated there was no additional information.