Every finding on record at Pruitthealth Home Health-South Atlanta, Inc.

A Recertification survey was conducted at PruittHealth @ Home-Griffin on June 23, 2025, and concluded on June 25, 2025. At the time of the survey, the agency was in compliance with 42 CFR Part 418.113, Emergency Preparedness and Covid-19 infection control.

A Recertification survey was conducted at PruittHealth @ Home-Griffin on June 23, 2025, concluded on June 25, 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 340. The following deficiencies were 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 policy titled “OASIS Data,” the Centers for Medicare & Medicaid Services (CMS) Home Health Agency (HHA) Error Summary by agency report, 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,” revised 02/08/2023, revealed the following: Procedure: The HHA will encode and electronically transmit each completed OASIS assessment to the CMS OASIS contractor 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. Review of CMS report titled “HHA Error Summary by Agency,” with report period of 05/01/2024-05/01/2025 and run date of 05/27/2025, revealed the agency failed to transmit OASIS data to CMS system within 30 days. On 06/23/2025 at approximately 11:00 a.m., during an in-office interview, the Administrator revealed that she was unaware that the 30-day OASIS submission timeframe requirements were not met during the time frame of 05/01/2024 through 05/01/2025. The Administrator explained that the Business Office Manager is responsible for submitting and tracking OASIS, and the late OASIS submissions may have been a result of the computer program system transition the agency was undergoing at that time.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) 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; (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 or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record reviews, staff interviews, and agency policy “Plan of Care (POC),” it was determined the agency failed to include goals, and interventions with a diagnosis of end stage renal disease (a medical condition in which a person’s kidneys are no longer able to function adequately on their own and requires dialysis or kidney transplant to maintain life) for three patients (P) (P#1, P#6, P#8) of 11 sampled patients. Findings include: Review of the policy titled “Plan of Care (POC) (Version: 3),” revised 11/06/2018, reveals the following: Policy Statement: It is the policy of PruittHealth Home Health, in accordance with Program Regulations that the agency develops and implement an individualized plan of care for each patient admitted for care/services. The individual plan of care will specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care will also specify the patient and caregiver education and training that the HHA will provide, specific to the patient’s care needs, and will be furnished in accordance with accepted standards of practice Procedure: 1. Upon admission to the agency, each patient has an initial comprehensive assessment. • If a physician refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan. 2. As determined by the comprehensive assessment, identified patient needs, and physician orders, a patient specific goal-directed plan of care is initiated with measurable outcomes and goals. • The plan of care establishes a means of recording the patient’s plan of care, which reflects the current problems, planned interventions and expected outcomes of those interventions relating to the care and services which have been ordered. 1. Review of the plan of care (POC) for P#1 (certification period (start of care) of 5/26/2025 to 7/24/2025) revealed P#1 was admitted to the Home Health agency on 5/26/2025, with a diagnosis of end stage renal disease. The agency failed to address goals, and interventions on the POC to assess and monitor permanent catheter (connection that a surgeon makes between an artery and a vein to make it possible for you to receive hemodialysis) on right chest catheter site for dialysis for bleeding and signs of infection. 2. Review of the plan of care (POC) for P#6 (certification period (start of care) of 6/11/2025 to 8/9/2025) revealed P#6 was admitted to the Home Health agency on 2/11/2025, with a diagnosis of end stage renal disease. The agency failed to address goals, and interventions on the POC to assess and monitor the fistula (connection that a surgeon makes between an artery and a vein to make it possible for you to receive hemodialysis) on left lower arm site for dialysis for bleeding and signs of infection. 3. Review of the plan of care (POC) for P#8 (certification period (start of care) of 5/1/2025 to 6/29/2025) revealed P#8 was admitted to the Home Health agency on 5/1/2025, with a diagnosis of end stage renal disease. The agency failed to address goals, and interventions, on the POC to assess and monitor the fistula (connection that a surgeon makes between an artery and a vein to make it possible for you to receive hemodialysis) on left upper arm site for dialysis for bleeding and signs of infection. During an interview on phone with Registered Nurse (RN) AA on 6/24/2025 at 1:45 p.m., RN AA confirmed that the agency failed to address interventions on diagnosis of end stage renal disease on P#1, P#6, P#8, POC, because she was not aware that she had to obtain order to assess and monitor for bleeding and infection at fistula site. During an interview on phone with RN BB on 6/24/2025 at 2:18 p.m., RN BB confirmed that the agency failed to address interventions on diagnosis of end stage renal disease on P#1, P#6, P#8, POC, because she was not aware that she had to include it (intervention). On 6/24/2025 at 2:45 p.m., an interview conducted with the RN CC, who acknowledged that she failed to include interventions for the diagnosis of end stage renal disease for P#1, P#6, P#8.

Pruitt Health Griffin, Georgia, was in compliance with 42 CFR Part 418.113, Emergency Preparedness and Covid-19 infection control for Hospice as a result of an onsite survey conducted on 9/1/22.

A Recertification survey was conducted at Pruitt Health Griffin, Georgia, on 9/1/22, by Surveyors. It was revealed that the agency was in compliance with Chapter 42 CFR Part 418, Rules and Requirements for Home Health and Hospice Agencies. The census was 219. The following deficiencies were cited.

A review of all current medications CFR(s): 484.55(c)(5) 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 ELEMENT is not met as evidenced by: Based on observation, clinical record review, and staff interviews, it was determined that the agency failed to ensure that patients’ medication profiles were updated to reflect current medications at the time of the comprehensive assessment for three (3) of eighteen (18) sampled patients (P#1, #9, and #10). The Findings include: During a home visit observation conducted on 8/31/22 at approximately 9:25 a.m. with Licensed Practical Nurse (LPN) AA for (P#1), it was revealed that (P#1) was admitted on 3/28/22, with a diagnosis of type 2 diabetes, end stage renal disease, and amputation of great right toe. The surveyor compared P#1's current medication list at home to the hospice agency's medication profile. Discrepancies were found. Patient #1 was taking Calcium acetate 667milligrams (mg) three tablets oral daily for supplement, and Vitamin D3 microgram (mcg), one tablet oral daily for supplement. The above medications were missing from P#1's hospice medication profile and plan of care. On 8/23/22 at 10:40 a.m., an interview was conducted with Licensed Practical Nurse (LPN) AA, who confirmed that she was not aware that P#1 was taking Vitamin D3 and Calcium. A home visit observation was conducted on 8/30/22 at approximately 12:30 p.m. with Physical Therapist (PT) BB for (P#9). The surveyor compared P#9's current medications at patient’s home to the home health agency's medication profile. Discrepancies were found. Patient (P# 9) was admitted to the home health agency on 8/29/22, diagnosed with chronic kidney disease stage 3, unspecified. According to agency medication profile for P#9, physician’s order dated 7/1/22, revealed Metoprolol Succinate ER 200 milligram (MG) tablet, extended release 24 hours 1 tablet daily for Cardiovascular therapy. The pharmacy label dated 7/29/22 revealed Metoprolol Succinate ER 25 MG tablet, extended release 24 hours 1 tablet daily. Potassium Chloride ER 20 milliequivalent (MEQ) tablet, extended release one tablet oral daily for electrolyte balance. The pharmacy label revealed Potassium Chloride ER 20 MEQ tablet, extended release 2 tablets daily. On 8/30/22 at 1:00 p.m., an interview was conducted with PT (BB), with PT (BB) who confirmed he was not aware of medication discrepancies. A home visit observation was conducted on 8/30/22 at approximately 1:45 p.m., with Physical Therapist (PT) CC, for (P#10). The surveyor compared P#10's current medications at patient’s home to the home health agency's medication profile. Discrepancies were found. Patient #10 was admitted to the home health agency on 8/23/22, diagnosed with Periprosthetic fracture around internal prosthetic right hip joint subsequent encounter. According to agency medication profile for P#10, physician’s order dated 7/25/22, revealed Fluticasone propionate 50 microgram (MCG) spray, spray one spray in each nostril twice a day. The above medication was not listed in the home health agency medication profile and plan of care. Nature Made Vitamin D3 1000 International Unit (IU), a dietary supplement, one tablet oral daily at bedtime. The above medication was not listed in the home health agency medication profile and plan of care. Kroger All Day Allergy tablets 10 milligrams (MG) for allergies only tablet oral daily. The above medication was not listed in the home health agency medication profile and plan of care. Centrum Silver Adults 50 plus Multivitamin one tablet oral daily, a dietary supplement. The above medication was not listed in the home health agency medication profile and plan of care Nature Made Vitamin C 1000 (MG) one tablet oral daily, a dietary supplement. The above medication was not listed in the home health agency medication profile and plan of care. Nature Made Turmeric Curcumin 500 (MG) one capsule oral daily, a dietary supplement. The above medication was not listed in the home health agency medication profile and plan of care. On 8/30/22 at 2:10 p.m., an interview was conducted with PT (CC) with PT (CC) who confirmed she was not aware of medication in home was not listed on the agency’s medication profile.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record reviews, observations, and staff interviews, it was determined that the agency failed to follow physician’s order for P#1’s right great toe open wound care for one (1) of eighteen (18) patients (P) sampled. The Findings include: Patient #1 was admitted to agency on 3/28/22, with a diagnosis of type 2 diabetes, end stage renal disease, and right great to amputation. Physician order dated 7/29/22, revealed that skilled nurse should clean right foot skin intact with soap and water, pat dry, cleanse wound with vashe, pat dry with gauze, apply endoform or equivalent to wound bed, cover with Alginate, 4x4 gauze and ABD, secure with kerlix and Medi pore tape apply Spand grip size to right lower leg for mild edema management using clean and aseptic technique. On 8/31/22, at 9:20 a.m., surveyor observed Licensed Practical Nurse (LPN) AA, clean P#1 skin intact around right great toe with wound cleanser. (LPN) AA, failed to follow physician’s order by choosing not to use soap and water as ordered by physician. During the interview with (RN) AA, on 8/31/22 at 9:35 a.m., she confirmed that she did not follow physician’s order for P#1’s right great toe wound care.

Documentation of competency evaluation CFR(s): 484.80(c)(5) The HHA must maintain documentation which demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on employee record review and staff interview it was determined the agency failed to ensure a licensed professional participated in the 90-day performance appraisal. The finding include: The office manager who was also Licensed Practical Nurse (LPN) (DD) with a hire date 9/16/21, however administrator failed to complete 90-day performance appraisal on 12/16/21. During an interview on 9/1/22, at 11:50 a.m., the Administrator stated I don’t know why, I forgot to complete 90-day performance appraisal for office manager also LPN. The Administrator did not provide documentation of 90-day performance assessment for office manager.