Every finding on record at Trinity Home Health Services

A complaint GA#61504 survey was conducted at St. Mary Home Health, Watkinsville, Georgia, on 7/14/22. The complaint was Substantiated with citations. The agency is in compliance with-Chapter 42 CFR Part 418, Rules and Requirements for Home Health and Hospice Agencies. The census was 261. The following deficiencies were 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 review and staff interviews, it was determined the agency staff failed to conduct an initial assessment within 48 hours of referral or on physician’s order for start of care date, for one (1) of three (3) sampled patients (P#1). The Findings include: Review of the plan of care for Patient (P#1) with a diagnosis of sarcopenia, gout, vitamin B deficiency, rheumatoid arthritis, osteoarthritis, hypertension, and gastroesophageal reflux disease, revealed that the agency staff received home health referral for services on 11/15/21. However, services did not begin for the patient until 11/19/21. The clinical record lacked justification for the delay of the start of care and documentation: the physician was neither notified nor was authorization obtained concerning the start of care later than 48 hours from the referral. During an interview on 7/12/22 at 2:50 p.m., Registered Nurse (RN) BB, did not provide any additional information regarding the lack of documentation or if the physician was notified of the delay on start of care. In an interview on 7/12/22 at 12:45 p.m., the Administrator also confirmed that the surveyor has been provided with all available documentation for the patients’ record.

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 review of clinical records, it was determined the interdisciplinary group failed to ensure that the initial comprehensive assessment was completed within 5 days of admission for one (1) of three (3) sampled patients (P#1). The Findings Include: Review of the clinical record for (P#1), who was admitted on 12/1/21, with a diagnosis of sarcopenia, gout, vitamin B deficiency, rheumatoid arthritis, osteoarthritis, hypertension, and gastroesophageal reflux disease, revealed that the initial physical therapy and occupational therapy assessment were completed on 12/1/21, twelve days after the patient's admission. The clinical record lacked documentation regarding the staff's delay in completing the assessments. In an interview on 7/13/22 at 10:45 a.m., the Administrator also confirmed that the surveyor has been provided with all available documentation for the patient’s record.