Every finding on record at Ware Visiting Nurses Service, Inc

A Recertification survey was conducted at SunCrest Home Health Services on March 24, 2025, and concluded on March 26, 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 SunCrest Home Health Services on March 24, 2025, and concluded on March 26, 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 52. 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, policy titled “OASIS Data Capture, Transmission, Verification, Display and Reports,” 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 Capture, Transmission, Verification, Display and Reports,” last revised 03/01/2021, revealed the following: Procedure: 1. e. Once an OASIS data set passes the OASIS edit check program, the OASIS data set will be reserved to prevent subsequent editing. The reserving mechanism ensures the stability of the patient assessment data at the time point of the assessment. The reserving mechanism prevents the override of current assessment information with future or past information without specific documentation as to why the assessment is being opened. All assessments will be reserved and transmitted within 30 days of M0090 date. 2. Transmittal of OASIS data: a. At least monthly, the agency will electronically transmit accurate, completed, encoded and locked OASIS data to the state agency. All OASIS assessments completed must be transmitted within thirty (30) days of M0090 date. Review of CMS report titled “HHA Error Summary by Agency,” with report period of 02/01/2024-02/01/2025 and run date of 2/17/2025, revealed the agency failed to transmit OASIS data to CMS system within 30 days. During an in-office interview on 3/24/2025 at approximately 2:00 p.m., the Executive Director (ED) revealed that she was aware that the 30-day OASIS submission timeframe requirements were not met during the time frame of 02/01/2024 through 02/01/2025.

At the time of the survey, Charlton Visiting Nurse Services in Nahunta, 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 April 6, 2022. No deficiencies were cited.

At the time of the survey, Charlton Visiting Nurse Services in Nahunta, Georgia was in substantial compliance with 42 CFR Part 484, Requirements for Home Health Agencies as a result of a standard recertification survey conducted April 6, 2022. No deficiencies were cited.

Medical social services supervised by MSW CFR(s): 484.75(c)(3) Medical social services are provided under the supervision of a social worker that meets the requirements of §484.115(m). This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, it was determined that the agency failed to ensure the availability of medical social services to ensure patient's significant social and financial factors related to identified health problems, were addressed for 1 of 10 (#2) sampled patients (P). Findings were: 1. During a home visit observation on 4/5/22 at approximately 9:00 a.m., with the home health aide (HHA) for patient #2 with a certification period of 3/31/22 to 5/29/22 and a primary diagnosis of Encounter for other orthopedic aftercare, this surveyor observed that the patient had difficulty ambulating and completing ADLs (activities of daily living). During the chair bath, the HHA inquired if the patient had a brush to groom hair and t patient responded that he/she did not own a brush. The HHA asked if the patient would like to have lotion after bath and the patient reports not having any lotion to use. The patient also verbalized not having the ability to stand and make meals or complete self care without assistance. Currently, caregiver provides some care but patient states this may be too much for the caregiver to provide. Review of the plan of care revealed orders for the skilled nurse, physical therapy and the home health aide however, Social work services were not ordered. During an interview with the Administrator on 4/6/22 at 11:00 a.m., the Administrator reports that the agency currently does not have a medical social worker. The Administrator did acknowledge the patient has social deficits and the Administrator has reached out to the community for resources. However, medical social services should be provided by a qualified social worker who can assist the team members in understanding the social and emotional factors related to the health problems as well as work with the family, utilize appropriate community resources, participate in discharge planning and act as a consultant to other agency personnel to ensure the patient receive appropriate care and services.