longterm care Assigmt2

PRINTED: 5/9/2020 FORM APPROVED

OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM CMS-2567(02-99) Previous Versions Obsolete 6899 STNL11 Facility ID: GA057292H If continuation sheet Page 1 of 8

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

057-292-H

(X2) MULTIPLE CONSTRUCTION A. BUILDING

B. WING

(X3) DATE SURVEY COMPLETED

03/04/2020

NAME OF PROVIDER OR SUPPLIER

PRUITTHEALTH AT HOME - ROME

STREET ADDRESS, CITY, STATE, ZIP CODE

39 THREE RIVERS DRIVE NE ROME, GA 30161

(X4) ID PREFIX

TAG SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LS C IDENTIFYING INFORMATION)

ID PREFIX

TAG

PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-

REFERENCED TO THE APPROPRIATE DEFICIENCY)

(X5) COMPLETION

DATE

E 000 Initial Comments

At the time of the survey, Pruitthealth Home Health - Rome, Georgia was in compliance with 42 CFR Part 418.113 Emergency Preparedness for Hospices as a result of a recertification survey conducted on March 2 - 4, 2020.

No deficiencies were cited.

E 000

G 000 INITIAL COMMENTS

At the time of the survey, Pruitthealth Home Health - Rome, Georgia was in substantial compliance with 42 CFR Part 484, Requirements for Home Health Agencies as a result of a partial-extended recertification survey conducted from March 2 - 4, 2020.

The following deficiencies were cited:

G 000

G 0536 484.55(c)(5) A review of all current medications

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 REQUIREMENT is not met as evidenced by:

This RULE is not met as evidenced by:

Based on clinical record reviews, home visit observations, and staff interviews, it was determined the agency failed to ensure that patient's medication profile was updated to reflect current medications at the time of the comprehensive assessment for 1 of 13 (#11) sample patients.

G 0536

PRINTED: 5/9/2020 FORM APPROVED

OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM CMS-2567(02-99) Previous Versions Obsolete 6899 STNL11 Facility ID: GA057292H If continuation sheet Page 2 of 8

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

057-292-H

(X2) MULTIPLE CONSTRUCTION A. BUILDING

B. WING

(X3) DATE SURVEY COMPLETED

03/04/2020

NAME OF PROVIDER OR SUPPLIER

PRUITTHEALTH AT HOME - ROME

STREET ADDRESS, CITY, STATE, ZIP CODE

39 THREE RIVERS DRIVE NE ROME, GA 30161

(X4) ID PREFIX

TAG SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LS C IDENTIFYING INFORMATION)

ID PREFIX

TAG

PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-

REFERENCED TO THE APPROPRIATE DEFICIENCY)

(X5) COMPLETION

DATE

1. Review of the plan of care/treatment for patient #11 (closed record)with a certification period of 5/21/19 to 7/29/19 revealed a resumption of care order dated 6/4/19. According to the resumption of care order, patient is to administer Insulin Glargine 100 unit/ml 21-24 units twice daily, and Novolog Flexpen U-100 3 ml 7-15 units three times daily. However, the medication order and the medication profile does not specify the exact dosage of insulin to be taken by the patient daily. The agency staff failed to update the patient's medication profile during each skilled visit. The agency failed to ensure the medication profile accurately reflected the patient's current medication regimen.

During an interview on 3/4/20 at 1:00 p.m., the administrator and the clinical manager provided no evidence that the medication profile had been reviewed and updated to reflect the patient's current medication regimen.

G 0574 484.60(a)(2)(i-xvi) Plan of care must include the following

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;

G 0574

PRINTED: 5/9/2020 FORM APPROVED

OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM CMS-2567(02-99) Previous Versions Obsolete 6899 STNL11 Facility ID: GA057292H If continuation sheet Page 3 of 8

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

057-292-H

(X2) MULTIPLE CONSTRUCTION A. BUILDING

B. WING

(X3) DATE SURVEY COMPLETED

03/04/2020

NAME OF PROVIDER OR SUPPLIER

PRUITTHEALTH AT HOME - ROME

STREET ADDRESS, CITY, STATE, ZIP CODE

39 THREE RIVERS DRIVE NE ROME, GA 30161

(X4) ID PREFIX

TAG SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LS C IDENTIFYING INFORMATION)

ID PREFIX

TAG

PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-

REFERENCED TO THE APPROPRIATE DEFICIENCY)

(X5) COMPLETION

DATE

(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 may choose to include.

This REQUIREMENT is not met as evidenced by:

This RULE 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 plans of care/treatment included all of the required elements to address the identified needs for 1 of 13 sampled patients (#2 ).

Findings were:

1. Review of the plan of care for patient #2 with a certification period of 1/17/20 to 3/16/20 revealed that the patient has a diagnosis of hypertensive heart disease with heart failure and diastolic congestive heart failure (CHF) and requires the skilled nurse (SN) to observe and assess cardiovascular system to identify changes and intervene to minimize complications. However, the plan of care lacks patient specific interventions such as edema assessments or weight monitoring which would

PRINTED: 5/9/2020 FORM APPROVED

OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM CMS-2567(02-99) Previous Versions Obsolete 6899 STNL11 Facility ID: GA057292H If continuation sheet Page 4 of 8

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

057-292-H

(X2) MULTIPLE CONSTRUCTION A. BUILDING

B. WING

(X3) DATE SURVEY COMPLETED

03/04/2020

NAME OF PROVIDER OR SUPPLIER

PRUITTHEALTH AT HOME - ROME

STREET ADDRESS, CITY, STATE, ZIP CODE

39 THREE RIVERS DRIVE NE ROME, GA 30161

(X4) ID PREFIX

TAG SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LS C IDENTIFYING INFORMATION)

ID PREFIX

TAG

PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-

REFERENCED TO THE APPROPRIATE DEFICIENCY)

(X5) COMPLETION

DATE

prompt the staff to notify the physician for early intervention and treatment of CHF exacerbation. The agency failed to ensure the plan of care was complete and comprehensive for the care and monitoring of the patient's heart failure status. The agency failed to ensure that the plan of care/treatment covered all pertinent interventions for the comprehensive care of the patient's heart failure status.

During an interview on 3/4/20 at 1:30 p.m., the administrator and the clinical manager provided no evidence that the plan of care included patient specific interventions to monitor the patient's heart failure status.

G 0614 484.60(e)(1) Visit schedule

Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA.

This REQUIREMENT is not met as evidenced by:

This RULE is not met as evidenced by:

Based on the clinical record review, staff interviews and home visit observations, it was determined that the agency failed to ensure that a written visit schedule, including frequency of visits were provided to the patient which is consistent with the patient's most current plan of care for 4 out of 4 home visit (#1,#2, #3 and #4) sample patients. .

Findings were:

During a home visit observations for patient #1, #2, #3, and #4, revealed that these patient's home folder did not include visit schedule with frequencies as per the plan of care.

During an interview on 3/4/2020 at 1.00 p.m., the administrator and the clinical manger confirmed that the home folders did not include

G 0614

PRINTED: 5/9/2020 FORM APPROVED

OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM CMS-2567(02-99) Previous Versions Obsolete 6899 STNL11 Facility ID: GA057292H If continuation sheet Page 5 of 8

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

057-292-H

(X2) MULTIPLE CONSTRUCTION A. BUILDING

B. WING

(X3) DATE SURVEY COMPLETED

03/04/2020

NAME OF PROVIDER OR SUPPLIER

PRUITTHEALTH AT HOME - ROME

STREET ADDRESS, CITY, STATE, ZIP CODE

39 THREE RIVERS DRIVE NE ROME, GA 30161

(X4) ID PREFIX

TAG SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LS C IDENTIFYING INFORMATION)

ID PREFIX

TAG

PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-

REFERENCED TO THE APPROPRIATE DEFICIENCY)

(X5) COMPLETION

DATE

the visit schedule for each patents.

G 0710 484.75(b)(3) Provide services in the plan of care

Providing services that are ordered by the physician as indicated in the plan of care;

This REQUIREMENT is not met as evidenced by:

This RULE 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/treatment for 1 of 13 (#4 ) sampled patients.

Findings were:

1. Review of the plan of care for Patient #4 with recertification period of 2/1/20 to 3/31/20 revealed a verbal order dated 2/10/20, which required the social worker (SW) to evaluate and assist patient with obtaining Medicaid. However, according to the clinical record, there was no evidence to show that the SW evaluated the patient for financial assistance as per physicians order. The clinical record lacked documentation to indicate the SW evaluation was done as ordered. The record also lacked documentation to notify the physician that the SW evaluation was not done as ordered. The agency failed to follow the plan of care for evaluating the patient's need for SW services.

During an interview on 3/4/2020 at 1:00 p.m., the administrator and the clinical manager did not provide documentation to indicate the SW evaluation was done as ordered.

G 0710

G 1014 484.110(a)(2) Interventions and patient response

All interventions, including medication administration, treatments, and services, and responses to those interventions;

G 1014

PRINTED: 5/9/2020 FORM APPROVED

OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM CMS-2567(02-99) Previous Versions Obsolete 6899 STNL11 Facility ID: GA057292H If continuation sheet Page 6 of 8

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

057-292-H

(X2) MULTIPLE CONSTRUCTION A. BUILDING

B. WING

(X3) DATE SURVEY COMPLETED

03/04/2020

NAME OF PROVIDER OR SUPPLIER

PRUITTHEALTH AT HOME - ROME

STREET ADDRESS, CITY, STATE, ZIP CODE

39 THREE RIVERS DRIVE NE ROME, GA 30161

(X4) ID PREFIX

TAG SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LS C IDENTIFYING INFORMATION)

ID PREFIX

TAG

PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-

REFERENCED TO THE APPROPRIATE DEFICIENCY)

(X5) COMPLETION

DATE

This REQUIREMENT is not met as evidenced by:

This RULE is not met as evidenced by:

Based on clinical record reviews and staff interviews, it was determined the agency failed to ensure documentation in the clinical records included all interventions and responses to the interventions in accordance with professional standards for 2 of 13 (#6, and #8) sampled patients.

Findings were:

1. Review of the plan of care/treatment for patient # 6 with a recertification period of 2/1/20 to 3/31/20 required the skilled nurse (SN) perform wound care to bilateral lower legs as follows: cleanse wound with wound cleanser and gauze, apply Unna dressing in a fan folded fashion. Apply roll gauze, secure with coban using clean technique. Wound care to be done two times a week. SN visited the patient on 2/10, 2/14, 2/17 and 2/21/20 and documented wound care provided to the patient. The SN failed to identify the specific steps and supplies used to complete the wound care as per the plan of care. SN failed to document clear, complete and precise steps and supplies used to provide wound care to the patient.

During an interview on 3/4/20 at 1:00 p.m., the administrator and the clinical manager did acknowledge the wound care documentation was not clear and complete.

2. Review of the plan of care/treatment for patient #8 with a recertification period of 1/4/20 to 3/3/20 required the skilled nurse (SN) to perform central line peripherally inserted central catheter(PICC) dressing changes weekly to

PRINTED: 5/9/2020 FORM APPROVED

OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM CMS-2567(02-99) Previous Versions Obsolete 6899 STNL11 Facility ID: GA057292H If continuation sheet Page 7 of 8

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

057-292-H

(X2) MULTIPLE CONSTRUCTION A. BUILDING

B. WING

(X3) DATE SURVEY COMPLETED

03/04/2020

NAME OF PROVIDER OR SUPPLIER

PRUITTHEALTH AT HOME - ROME

STREET ADDRESS, CITY, STATE, ZIP CODE

39 THREE RIVERS DRIVE NE ROME, GA 30161

(X4) ID PREFIX

TAG SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LS C IDENTIFYING INFORMATION)

ID PREFIX

TAG

PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-

REFERENCED TO THE APPROPRIATE DEFICIENCY)

(X5) COMPLETION

DATE

right upper arm as follows: remove old dressing per asceptic technique, then using sterile technique ; cleanse with chlorprep swab times one using back and forth motion. Allow to air dry, apply generic biopatch cover with bioclusive clear dressing. Flush PICC line with 10 ml of normal saline followed by 5 ml of heparin. Change injection caps weekly and as needed. According to the clinical record, the SN visited the patient on 2/11/20 and 2/17/20 and documented the central line dressing change was performed however, the SN failed to document the steps and supplies used to change the dressing during each visit. Clinical notes must include clear, accurate information, and contain complete documentation of any and all services provided. The agency failed to ensure the procedure was documented to include the steps and supplies used to complete the dressing change on the above mentioned visit dates. Additionally, the plan of care required the SN to obtain the following labs: Complete Blood Count (CBC) with Differential, Complete Metabolic Panel (CMP), ESR and CRP every week. May use PICC line for drawing labs using aseptic technique; cleanse PICC injection cap with alcohol wipe, flush with 10 ml of sterile normal saline and aspirate 10 ml of blood and discard. Obtain blood for ordered labs, then flush with 20 ml sterile normal saline followed by 5 ml heparin (10 u/ml). Change injection cap weekly and after every blood draw.

The SN visited the patient on 2/11/20 and 2/17/20 and documented labs were drawn per orders. The SN failed to document the specific labs obtained as required, the SN failed to document the specific steps and supplies used to draw the blood as required.

During an interview on 3/4/20 at 1:00 p.m., the administrator and the clinical manager acknowledged that the SN failed to document the steps and supplies used to complete PICC line dressing change, failed to document specific labs drawn and failed to document the specific amount of saline and heparin used during the port flushes as required.

PRINTED: 5/9/2020 FORM APPROVED

OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM CMS-2567(02-99) Previous Versions Obsolete 6899 STNL11 Facility ID: GA057292H If continuation sheet Page 8 of 8

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

057-292-H

(X2) MULTIPLE CONSTRUCTION A. BUILDING

B. WING

(X3) DATE SURVEY COMPLETED

03/04/2020

NAME OF PROVIDER OR SUPPLIER

PRUITTHEALTH AT HOME - ROME

STREET ADDRESS, CITY, STATE, ZIP CODE

39 THREE RIVERS DRIVE NE ROME, GA 30161

(X4) ID PREFIX

TAG SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LS C IDENTIFYING INFORMATION)

ID PREFIX

TAG

PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-

REFERENCED TO THE APPROPRIATE DEFICIENCY)

(X5) COMPLETION

DATE