| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 017027 | (X3) Date Survey Completed 05/22/2025 |
| Name of Provider or Supplier Hga Homecare, Llc | Street Address, City, State 2050 Beltline Rd Sw, Decatur, AL | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| G0716 | Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on medical record (MR) review, agency policy and procedure, and interview, it was determined the home health agency failed to ensure the skilled nurse (SN) assessed and documented wounds per policy. This deficient practice affected one of five records reviewed with wounds, including home visit (HV) # 5, and had the potential to affect all patients with wounds served by this agency. Findings include: Agency Policy: Wound Assessment, Documentation, and Photography Policy Number: 2.2.001 Revised Date: 09/01/24 Purpose: To ensure the accurate and consistent assessment and documentation of wounds. Policy: Upon initial visit and subsequently as indicated below, all wounds will be assessed with appropriate documentation within the MR... ...Unless otherwise ordered by the physician, the qualified clinician...will assess wounds at least: ...Every other week for patients receiving wound care by the agency at a frequency less than daily. ...Reassessments will be documented on the Wound Assessment Tool. The assessment includes measurement of the length, width and depth... Procedure: ...3. Document the following in the MR: ...c. Wound size: Length, Width and Depth are measured in centimeters... 1. HV # 5 was admitted for home health services on 3/28/25 with a primary diagnosis of Chronic Diastolic (Congestive) Heart Failure. Review of the 3/28/25 SN OASIS (Outcome and Assessment Information Set) admission visit note revealed HV # 5 had multiple venous stasis ulcers to his/her bilateral lower extremities. Review of the Home Health Certification and Plan of Care for certification period 3/28/25 to 5/26/25 revealed orders for the SN to visit one time a week for nine weeks to provide wound care, and also two PRN (as needed) visits were ordered for issues/complications that included an increase in wound size and/or staging of the wound. Review of SN visit notes dated 3/28/25, 4/1/25, 4/8/25 and 4/22/25 revealed HV # 5's wounds were not measured. The SN documented he/she was "unable to measure due to no beginning or end of wound." Review of SN visit notes dated 4/29/25, 5/8/25, 5/14/25, and 5/20/25 revealed HV # 5's wounds were not measured. The SN documented no measurements were taken and the reason documented was "unable." There was no documentation within the MR the SN had measured the wounds on any visit. The SN failed to measure and document the wounds every other week per agency policy. An interview was conducted on 5/22/25 at 1:29 PM with Employee Identifier # 2, Area Administrator, who confirmed the wounds were not measured and documented per policy. |