Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Routine
Deficiencies: 3
Dec 1, 2022
Visit Reason
The purpose of this visit was to conduct a periodic inspection on December 1, 2022.
Findings
Rule violations were cited as a result of this inspection. Deficiencies included failure to ensure service agreements included authorization for access to clients' funds and vehicles, lack of documentation of supervisory review of services provided by staff, and failure to ensure timely supervisory home visits for clients.
Severity Breakdown
SS= D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Service agreements did not include authorization from clients or responsible parties for access to clients' funds and personal vehicles for three of four sampled clients. | SS= D |
| Lack of documentation of supervisory review of services provided by staff for four sampled clients. | SS= D |
| Failure to ensure supervisory home visits were made at least every 92 days for one sampled client. | SS= D |
Report Facts
Number of sampled clients with missing authorization in service agreements: 3
Number of sampled clients with missing supervisory review documentation: 4
Number of sampled clients with missed supervisory home visits: 1
Supervisory home visit frequency requirement: 92
Client #1 personal care service start date: 09/08/2021 (date, not numeric)
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Provided interview statements regarding missing authorizations and supervisory visits | |
| Staff G | Provided interview statement regarding supervisory review documentation capability |
Inspection Report
Follow-Up
Deficiencies: 0
Apr 8, 2021
Visit Reason
The purpose of this visit was to conduct a follow up inspection to the January 28, 2021 inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Routine
Deficiencies: 6
Jan 28, 2021
Visit Reason
The purpose of this visit was to conduct a periodic inspection. Rule violations were cited as a result of this inspection.
Findings
The inspection identified multiple deficiencies related to personnel records, including missing five-year employment histories, incomplete documentation of employee qualifications such as CPR certification, lack of annual tuberculosis screening documentation, missing annual employee evaluations, insufficient annual training hours, and failure to provide personal care services in accordance with client service plans.
Severity Breakdown
SS= D: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure a five year employment history was obtained for three sampled employees (Staff B, Staff C, Staff D). | SS= D |
| Failed to maintain complete personnel records providing documentation of employee qualifications including current CPR certification for two sampled staff (Staff C, Staff D). | SS= D |
| Employee records lacked documentation of a satisfactory annual tuberculosis screening test for one sampled employee (Staff B). | SS= D |
| Failed to include documentation that employees were evaluated by direct observation or demonstration of tasks performed annually for two sampled staff (Staff B, Staff D). | SS= D |
| Failed to ensure staff had a minimum of eight clock hours of training or instruction annually after the first year of employment for two sampled employees (Staff B, Staff D). | SS= D |
| Failed to ensure staff provided personal care services in accordance with client service plans for two sampled clients (Client #2, Client #3). | SS= D |
Report Facts
Number of sampled employees with missing five year employment history: 3
Number of sampled employees lacking complete CPR certification documentation: 2
Number of sampled employees lacking TB screening documentation: 1
Number of sampled employees lacking annual evaluation documentation: 2
Number of sampled employees lacking minimum annual training hours documentation: 2
Number of sampled clients with personal care service plan discrepancies: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant | Named in deficiencies related to missing five year employment history, missing TB screening, missing annual evaluation, and missing annual training hours. |
| Staff C | Certified Nursing Assistant | Named in deficiencies related to missing five year employment history and incomplete CPR certification documentation. |
| Staff D | Certified Nursing Assistant | Named in deficiencies related to missing five year employment history, incomplete CPR certification documentation, missing annual evaluation, and missing annual training hours. |
| Staff A | Interviewed and acknowledged deficiencies during exit conference. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Aug 7, 2019
Visit Reason
The purpose of this visit was to investigate complainant # GA 00198034.
Findings
Rule violations were cited related to missing five year employment histories and credible evidence statements for two employees, and failure to ensure nursing services included the establishment and implementation of a service plan for one client.
Complaint Details
Investigation of complaint # GA 00198034 resulted in citations for rule violations.
Severity Breakdown
SS= D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure a five year employment history was obtained for two of four sampled employees (#1, #4). | SS= D |
| Failed to have an oral or written statement that employees had never been shown by credible evidence to have abused or neglected any person for two of four sampled employees (#1, #4). | SS= D |
| Failed to ensure nursing services included the establishment and implementation of a service plan for one of four clients sampled (#4). | SS= D |
Report Facts
Employees sampled: 4
Clients sampled: 4
Employees missing 5 year employment history: 2
Employees missing abuse statement: 2
Clients missing nursing service plan: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Certified Nursing Assistant | Missing five year employment history and abuse statement |
| Employee #4 | Certified Nursing Assistant | Missing five year employment history and abuse statement |
| Employee #5 | Interviewed and provided information about missing documentation |
Inspection Report
Routine
Deficiencies: 4
Feb 11, 2019
Visit Reason
The purpose of this visit was to conduct a periodic compliance inspection of BrightStar Care of Marietta.
Findings
The inspection identified multiple rule violations including failure to determine medical frailty or compromise status for clients, incomplete service agreements missing required elements, lack of documentation of annual tuberculosis screening for employees, and incomplete service plans missing duration and discharge plans.
Severity Breakdown
SS= D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to implement policies and procedures to determine whether clients may be medically frail and/or medically compromised for two of five sampled clients (#4, #5). | SS= D |
| Service agreements for two of five sampled clients (#4, #5) lacked required elements such as referral date, request for services, duration, charges, billing mechanisms, and authorization to use auto. | SS= D |
| Employee records lacked documentation of a satisfactory annual tuberculosis (TB) screening test for three of five employees sampled (#1, #4, #5). | SS= D |
| Service plans for four of five sampled clients (#1, #2, #3, #4) were incomplete, missing duration of services and discharge plans. | SS= D |
Report Facts
Sampled clients: 5
Clients with deficiencies: 2
Employees sampled: 5
Employees with missing TB screening: 3
Clients with incomplete service plans: 4
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