Every finding on record at The Medical Center of Central Georgia Inc.

A Recertification survey was conducted at Atrium Health Navicent At Home on February 17, 2025, and concluded on February 19, 2025. At the time of the survey, the agency was in compliance with Chapter 42 Part 418.113, Emergency Preparedness.

A Recertification survey was conducted at Atrium Health Navicent At Home on February 17, 2025, and concluded on February 19, 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 475. The following deficiencies were 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, policy “OASIS Assessments,” 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 Assessments” last revised 07/05/2024, revealed the following: Encoding and Transmission: As the OASIS and PPS systems evolves, the requirements for encoding and transmission are subject to change, so CGHH will be guided by the appropriate HCFA regulations in this area. Review of CMS report titled “HHA Error Summary by Agency,” with report period of 01/01/2024-12/31/2024 and run date of 2/3/2025, revealed the agency failed to transmit OASIS data to CMS system within 30 days. During an in-office interview on 2/18/2025 at 3:20 pm, the Director explained that she was unaware that the 30-day OASIS submission timeframe requirements were not met during the time frame of 01/01/2024 through 12/31/2024.

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 review of the policy titled “Plan of Care and Provider Orders”, record reviews, staff and patient interview, it was determined the agency failed to ensure that the individualized plan of care includes all medications and treatments related to the patient’s diagnoses for two patients (P) (P #9, P #16) of 17 sampled patients. Findings include: Review of the policy titled, “Plan of Care and Provider Orders”, Policy Number PC 014, effective date 10/15/2024, reveals the following: Policy Services will be provided in accordance with the Plan of Care, signed by an approved provider, and based on the patient’s diagnosis and assessment of immediate and long-range needs and patient/community resources. Home Health 1. The Plan of Care includes: • Pertinent Diagnoses. • All medications and treatments 1. Record review reveals P#9 was admitted on 1/27/2025 with the diagnosis of femur (thigh bone) fracture and co-morbidities that include atrial fibrillation (a medical condition where the upper chambers of the heart beat irregularly and rapidly, causing an abnormal heart rhythm). Review of “Home Health Certification and Plan of Care”, dated 1/27/2025, reveals P#9 was prescribed Warfarin (a blood thinning medication used to treat and prevent blood clots). Further review of the clinical record failed to reveal interventions related to bleeding precautions or ongoing monitoring of Warfarin. An interview on 2/18/2025 at approximately 10:30 a.m. was conducted during a home visit with P#9, who confirmed taking Warfarin. The patient revealed that he is followed monthly by his physician for lab work to manage the Warfarin. 2. Record review reveals P#16 was admitted on 9/25/2025 with a diagnosis of Type 2 Diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) with foot ulcer. Review of “Home Health Certification and Plan of Care”, dated 1/22/2025, reveals P#16 has an insulin pump (a small, portable device that delivers insulin continuously or in bolus doses to people with diabetes). Further review of the clinical record failed to reveal insulin dosage or interventions related to the care and maintenance of the insulin pump. An interview on 2/19/2025 at approximately 10:00 a.m. was conducted at the agency with the Director, who confirmed the plan of care was incomplete for both patients.

Atrium Navient Home Health is in compliance with 42 CFR Part 418.113, Emergency Preparedness and Covid-19 for HHA, as a result of an onsite survey conducted on 3/3/22 by Surveyor.

A Recertification survey was conducted at Atrium Navient Home Health, Macon, Georgia, on 3/3/22, by Surveyor. It was revealed that the agency is in compliance with Chapter 42 CFR Part 418, Rules and Requirements for Home Health and Hospice Agencies. The census was 393.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observations, clinical record reviews, and staff interviews, it was determined that the agency failed to ensure that patient's medication profile was updated to reflect current medications at the time of the comprehensive assessment for one (1) of eighteen (18) Patients (P) sampled (P#1). The Findings include: During the observation on 2/28/22, at 1:30 p.m., with (RN) AA, it revealed that P#1’s home medication did not match the agency’s medication profile and plan of care. Patient #1 was taking metformin 500mg one tablet twice daily oral for high blood glucose, but the agency medication profile revealed Actoplus met tablet 15 milligram-500milligram (MG) take one tablet twice daily for blood glucose. Patient #1 was admitted to home health agency on 12/1/21, with a diagnosis of type 2 diabetes, hypertension and right distal dorsum amputation. On 2/28/22 at 1:53 p.m., an interview was conducted with (RN) AA, who confirmed that she was not aware of the above medication discrepancy.

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 observations, clinical record reviews, and staff interviews, it was determined that the agency failed to ensure that patient's plan of care was updated to reflect current medications at the time of the comprehensive assessment for one (1) of eighteen (18) Patients (P) sampled (P#1). The Findings include: During the observation on 2/28/22, at 1:30 p.m., with (RN) AA, it revealed that P#1’s home medication did not match the agency’s plan of care. Patient #1 was taking metformin 500mg one tablet twice daily oral for high blood glucose, but the agency medication profile revealed Actoplus met tablet 15 milligram-500milligram (MG) take one tablet twice daily for blood glucose. Patient #1 was admitted to home health agency on 12/1/21, with a diagnosis of type 2 diabetes, hypertension and right distal dorsum amputation. On 2/28/22 at 1:53 p.m., an interview was conducted with (RN) AA, who confirmed that she was not aware of the above medication discrepancy.

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, observations, and staff interviews, it was determined that the agency failed to follow physician’s order for P#1’s right distal dorsum open wound care dressing for one (1) of eighteen (18) patients (P) sampled. The Findings include: Patient #1 was admitted to agency on 12/1/21, with a diagnosis of type 2 diabetes, hypertension and right distal dorsum amputation. Physician order dated 1/26/22, revealed that skilled nurse should clean right distal dorsum wound with wound cleanser, place white foam then black foam in wound bed, may use white foam in tunnels, apply skin prep. Cover entirely with occlusive transparent dressing, apply trac pad and attach to cannister tubing. May apply oil emulsion to wound bed to prevent dressing from adhering or if tendons or ligaments exposed. Perform wound dressing three times a week continuous pressure setting at negative 125mm/hg. Care to begin on 1/31/22, may discontinue wound care when wound is healed. On 2/28/22, at 1:40 p.m., surveyor observed (RN) AA, clean P#1 right distal dorsum surgical open wound with wound cleanser, applied black foam, oil emulsion, secured with tape, then connected it to cannister tubing and set it to 125mm/hg. (RN) AA, failed to follow physician’s order by choosing not to use white foam as ordered by physician. During the interview with (RN) AA, on 2/8/22 at 1:55 p.m., she confirmed that she did not follow physician’s order for P#1’s distal dorsum open wound dressing.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on clinical record reviews and staff interviews, it was determined that the hospice agency failed to use standard precaution to prevent infection for wound care dressing by using dirty gloves to touch clean gauze three times and used it to wipe P#1, open wound. Also, agency failed to change gloves and water during bed bath and used the dirty gloves and dirty water to wash P#2 peri area. Affected two (2) of eighteen (18) sampled patients (P) (#1 and #2). The Findings include: 1. On 2/28/22 at 12:30 p.m., surveyor observed Registered Nurse (RN) AA, perform wound care to P#1 right distal dorsum surgical wound. (RN) AA used dirty gloves to touch clean gauze and used it to wipe right distal dorsum surgical open wound three times, then used the same dirty gloves to complete the wound vacuum dressing. On 2/28/22 at 1:58 p.m., an interview was conducted with (RN) AA, stated that she did know better but was nervous, and would take the blame for using dirty gloves to touch the clean gauze three times, and used the same dirty gloves to clean the wound and complete the dressing. 2. On 2/28/22 at 2:30 p.m., surveyor observed Certified Nurse Aide (CNA) BB, perform bed bath to P#2. (CNA) BB, used the same dirty gloves to wash P#2 upper body, lower extremities and peri area; but (CNA) BB, did not change the water, she used the same bowl water to wash upper body, lower extremities, and peri area. On 2/28/22 at 3:00p.m., an interview was conducted with (CNA) BB, stated that she was nervous, and that caused her to use the same dirty water and dirty gloves to wash peri area.