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

A recertification survey was conducted at CHSGA Home Health on May 13, 2024, and concluded on May 15, 2024. 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 CHSGA Home Health on May 13, 2024, and concluded on May 15, 2024. At the time of the survey, the agency was not in compliance with compliance with Chapter 42 CFR Part 418, Rules and Requirements for Home Health and Hospice Agencies. The census was 39. 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 Centers for Medicare & Medicaid Services (CMS) Home Health Agency (HHA) Error Summary by agency report, agency policy, and staff interview, it was determined that the agency failed to electronically transmit monthly Outcome and Assessment Information Set (OASIS) data collected to the State Agency every 30 days. Findings include: Review of the policy titled “Reporting OASIS Information,” undated, revealed the following: Policy The Agency will report required data collected for the Outcome and Assessment Information Set (OASIS) items. Procedure The Home Health Agency (HHA) should encode and electronically transmit each completed OASIS assessment to the State agency or the CMS OASIS contractor, regarding each beneficiary with respect to which such information is required to be transmitted, within 30 days of completing the assessment of the beneficiary. Review of CMS report ran on 5/1/24 for period 2/6/23 to 1/23/24 titled “HHA Error Summary by Agency”, revealed the agency failed to transmit OASIS data to the State Agency within 30 days. An interview was conducted with the Administrator on 5/13/2024 at 1:00 p.m. The Administrator confirmed OASIS reports had not been submitted to CMS within 30 days of completing the assessments.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interview, it was determined the agency failed to provide services as ordered by the physician in the plan of care for three patients (P) (P#4, P#5, P#6) of three sampled patients with wound care management. Findings include: 1. Review of clinical record revealed that P#5 was admitted on 4/23/2024 with diagnosis of pressure ulcer (an open wound on your skin caused by a long period of constant pressure to a specific area of the body) to buttock, congestive heart failure (heart can’t pump blood well), and type 2 insulin dependent diabetes mellitus (high blood sugar). Plan of care dated 4/23/2024 revealed skilled nurse (SN) to perform the following: SN: assessment and wound care to the wound on buttock as follows: cleanse wound with soap and water, pat dry, cover with bordered foam dressing. Change dressing twice a week and as needed. May refer to wound care center if wound shows little or no improvement within 30 days. SN: review patient’s blood sugar log at every visit and notify Primary Care Provider (PCP) with blood sugar less than 60 or greater than 300. SN: monitor patient’s weight gain if able to balance on scale of 2-3 pounds in one week or 5 pounds in one day. Review of the SN visit notes dated 4/23, 4/25, 4/30, and 5/3/2024 failed to reveal wound measurements and progress or lack of progress of wound status, blood sugar level, and patient’s weight. 2. Review of clinical record for P#6 revealed that patient was admitted on 4/4/2024 with diagnosis of chronic venous stasis ulcer to right ankle (open wounds on the legs or ankles that don't heal easily due to poor blood circulation in the veins). Plan of care dated 4/4/2024 revealed the skilled nurse (SN) to provide assessment and wound care to right ankle as follows: cleanse right ankle wound with sterile saline, use exufiber AG (a sterile non-woven gelling fibre design with an antimicrobial action against a broad range of wound relevant pathogens) as primary dressing, oil emulsion dressing, apply 4x4's ABD pad and wrap with Unna boot, Change dressing twice a week. Review of SN visit notes dated 4/16, 4/19, 4/24, and 4/26/2024 failed to reveal wound measurements and progress or lack of progress of wound status. 3. Review of clinical record for P #4 revealed that patient was admitted on 4/12/2024. Review of the Resumption Of Care (ROC) orders dated 4/26/24 revealed that patient has a wound to right lateral left toe. SN to assess and provide wound care as follows: cleanse wound with normal saline or wound cleanser, pat dry, cover with dry gauze, and bordered foam dressing. Change dressing twice a week. Review of SN visit notes dated 4/25, 4/30, 5/2 and 5/8/24 failed to reveal wound measurements and progress or lack of progress of wound status. An office interview was conducted on 5/14/2024 with the Administrator at 1:00 p.m., the Administrator verbalized that wound measurements are performed on weekly basis and confirmed that visit notes for P#4 and P#6 lacked wound measurements and visit notes for P#5 lacked wound measurements, blood sugar level, and patient’s weight.

CHSGA home health Albany, Georgia was in compliance with 42 CFR Part 418.113, Emergency Preparedness and Covid-19 infection control for HHA, as a result of an onsite survey conducted on 5/20/21 by Qualified Nurse Surveyor.

An unannounced recertification survey was conducted at CHSGA home health Albany, Georgia, on 5/20/21 by Qualified Nurse Surveyor. It 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 51. The following deficiencies were cited.

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 observations, clinical record reviews, interviews with agency staff and patients, the agency failed to ensure medication profiles for three (3) of three (3) patients (P#1, P#2 and P#3) were updated to reflect current medications at the time of the comprehensive assessments. The findings include: During a home visit on 5/18/21, at approximately 9:30 a.m., with Licensed Practical Nurse (LPN) AA, the surveyor reviewed P#1’s clinical record for the certification period of 5/5/21 to 7/3/21. Review of the medical record revealed diagnoses that include hypertension, congestive heart failure. When comparing the medications P#1 is taking at home to the agency’s current medication profile it was determined that P#1’s medications did not match the agency’s medication profile. Patient #1 is taking Lasix 20milligrams (MG) take one tablet oral daily for fluid retention since 3/25/20, Tizanidine hydrochloride 2mg take one tablet every eight hours as needed for back stiffness (skeletal muscle relaxants), and Levothyroxine Sodium 150 microgram (MCG) take one tablet oral daily for thyroid hormones since 3/26/21. The medications listed above was not listed in the home health agency’s medication profile and plan of care. On 5/18/21 at 10:15 a.m., the surveyor visited P#2 with Registered Nurse BB. Review of P#2’s medical record revealed diagnoses that include shortness of breath. The medications P#2 is taking the included Albuterol Sulfate (beta-adrenergic agonist) and Ipratropium Bromide (anticholinergic) 0.5-0.3milliliters (ML) by nebulizer treatment every four hours as needed for shortness of breath. The medications listed were not on the agency’s medication profile. During an interview on 5/18/21 at 10:28 a.m., with P#2 she stated that she has been taking Albuterol Sulfate (beta-adrenergic agonist) and Ipratropium Bromide (anticholinergic) 0.5-0.3milliliters (ML) by nebulizer treatment every four hours as needed for shortness of breath since 4/9/21, and when she visited her primary physician on 5/6/21, her doctor wants her to continue the medication. P#2 said that she told the home health agency nurse upon admission. On 5/18/21 at 11:00 a.m., an interview was conducted with RN BB who stated, “I admitted P#2 but, I do not know how I missed and did not record”. RN BB was referring to Albuterol Sulfate (beta-adrenergic agonist) and Ipratropium Bromide (anticholinergic) 0.5-0.3milliliters (ML) by nebulizer treatment every four hours as needed for shortness of breath in the home health medication profile. On 5/18/21 at 12:20 p.m., the surveyor accompanied by RN CC visited P#3 at home. Review of the medical record revealed diagnoses that include cellulitis of lower leg. P#3 was taking Tramadol-Acetaminophen 37.5mg-325mg take two tablets oral twice daily for pain. B12 1000mcg take one tablet oral daily, Docusate sodium100mg (stool softeners) take one capsule oral daily for constipation, and Centrum Multivitamins-Multimineral for men take on tablet oral daily. These medications were not listed on the home health agency medication profile. On 5/18/21 at 12:37 p.m., an interview was conducted with P#3 she stated that she was a retired nurse from Georgia State Public Health, and she has been taking the above medication for long- term. P#3 stated that she was surprised that the home health agency medication profile was missing the four medications. On 5/18/21 at 1:00 p.m., an interview was conducted with RN CC, stated that she was not an assigned nurse to P#3. RN CC said that this was the first time that she visits P#3. RN CC said that she did not know why the assigned nurse missed to record all the medications in home health agency medication profile. On 5/18/21 at 3:40 p.m., an interview was conducted with Director of Nursing (DON), stated that home health nurses communicated with her often and during the interdisciplinary team meeting (IDTM). The DON verbalized that she did not know how the patients’ home medications did not match home health agency’s medication profile.