Pruitthealth @ Home - Valdosta

“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, policy “Oasis Data Transmission (Policy No. 3-020),” 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. Failure to submit OASIS within 30 days has the potential to cause delay in care and affect quality of care for all patients with late OASIS submission. Findings include: Review of the policy titled “Oasis Data Transmission (Policy No. 3-020),” revised 03/23/2018, revealed the following: 1. “The organization will encode and transmit completed OASIS data for each applicable patient within thirty (30) days of the M0090 date, date assessment completed.” Review of CMS report ran on 1/10/25 for period 01/01/2024 to 12/31/2024 titled “HHA Error Summary by Agency,” revealed the agency failed to transmit OASIS data to the CMS system within 30 days. On 2/3/2025 at 12:20 p.m., during an in-office interview, the Human Resource (HR) in charge of OASIS transmission confirmed awareness of the 30-day OASIS submission time frame requirements not met during the time frame of 01/01/2024 to 12/31/2024.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record reviews, and staff interviews, and agency policy “Monitoring Patient’s Response/Reporting to Physician,” it was determined the agency failed to perform blood sugar for one patient (P) (P#16) of 18 sampled patients. Findings include: Review of the policy titled “Monitoring Patient’s Response/Reporting to Physician,” Policy No. 4-012, revised 03/23/2018, reveals the following: Policy: Clinicians will monitor, document, and report the patient’s response to care and treatment provided on each home visit. Progress of goals will be measured at regular intervals. PROCEDURE: 3. The patient’s physician will be contacted on the same day when any of the following occur: E. Changes that occurred regarding diagnosis, prognosis, or treatment (including procedures, medications, precautions, and limitations). F. When there is any problem implementing the plan of care. Review of the plan of care (POC) for P#16 (certification period (start of care) of 9/8/2024 to 11/6/2024) revealed P#16 was admitted to the Home Health agency on 9/8/2024, with a diagnosis of type 2 diabetes mellitus with hyperglycemia (inability to produce enough insulin results in high blood sugar). The agency failed to perform blood sugar as ordered by physician on Plan of Care (POC). The skilled nurse visited P#16 on 11/22/2024, she was unable to do blood sugar due to glucometer is not working. The Licensed Practical Nurse (LPN) AA failed to notify physician. During an interview on phone with LPN AA on 2/4/2025 at 3:49 p.m., LPN AA confirmed that the agency failed to notify the physician regarding inability to perform P#16, blood sugar on 11/22/2024. On 2/4/2024 at 4:20 p.m., an interview conducted with the Administrator who acknowledged that LPN AA failed to notify the physician.”

“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, and staff interviews, and agency policy “Care Planning Process (Policy No. 4-001),” it was determined the agency failed to include goals, interventions and parameters with a diagnosis of heart failure (when your heart doesn’t pump enough blood for your body’s needs) for one patient (P) (P#17) of 18 sampled patients. Findings include: Review of the policy titled “Care Planning Process,” (Policy No. 4-001), revised 03/23/2018, reveals the following: Definitions: The Plan of Care (POC) includes: 1. D. Pertinent primary and secondary diagnoses. PROCEDURE: 1. At the time of the initial assessment, the clinician, along with other involved disciplines, will develop the patient plan of care based upon the patient’s identified needs and will review it with the patient and family/caregiver. 2. G. Patient and caregiver education and training that the organization will provide specific to the patient’s care needs. 3. Based on the assessment and conclusions, the plan of care will include, but will not be limited to: A. Patient specific interventions and education. B. Identified patient problems and needs, including functional limitations, activities permitted, nutritional requirements. C. Reasonable, measurable, and individualized goals and outcomes identified by the organization and the patient. Review of the plan of care (POC) for P#17 (certification period (start of care) of 2/28/2024 to 4/27/2024) revealed P#17 was admitted to the Home Health agency on 2/28/2024, with a diagnosis of heart failure. The agency failed to address goals, interventions, and parameters on the POC to monitor fluids retentions, weight, or calf measurement. During a telephone interview with Registered Nurse (RN) BB on 2/4/2025 at 12:25 p.m., RN BB confirmed that the agency failed to address intervention on diagnosis of heart failure on P#17 POC because her focus was to treat P#17 with wound care. During a telephone interview with Licensed Practical Nurse (LPN) CC on 2/4/2025 at 12:30 p.m., LPN CC confirmed that the agency failed to address intervention on diagnosis of heart failure on P#17, POC, because her focus was to treat P#17 with wound care. On 2/4/2025 at 3:38 p.m., an interview conducted with the OASIS Quality Assurance (QA), who acknowledged that she failed to correct or include intervention for the diagnosis of heart failure for P#17.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on record review, staff interview, and policy “Physician Participation in Plan of Care (Policy No. 4-002),” it was determined that the agency failed to have physician sign patient plan of care (POC), and verbal orders timely for three Patients (P) (P#15, P#16, P#18) of 18 sampled patients. The findings include: Review of policy titled “Physician Participation in Plan of Care (Policy No. 4-002),” revised 03/23/2018, reveals the plan of care, telephone and or verbal orders must be signed and dated by the physician or authorized practitioner within a timely manner per state regulation of 30 days. 1. Review of clinical record for P#15, revealed that verbal order received from physician on 8/15/2024 for skilled nurse to “assess right foot 2nd digit diabetes mellitus ulcer each skilled nurse visit. Teach and perform the following care: Clean with normal saline, pat dry applies calcium alginate or equivalent, apply dry gauze wrap tape or Coban to secure. Change daily and prn (as needed) when soil. Discontinued when the P#15’s wound is healed, effective date 8/15/24. The physician signed the verbal order on 10/9/2024. 2. Review of clinical record for P#16, certification period dated 11/7/2024 to 1/5/2025, revealed that P#16 was admitted to the home health agency on 9/8/2024. The physician’s verbal order was to recertified P#16 on 11/5/2024. The physician signed the POC on 12/10/2024. 3. Review of clinical record for P#18, revealed that verbal order received from physician on 9/25/2024 to discharge P#18 from home care related to transition to hospice care a as of 9/25/24. The physician signed a verbal order on 11/13/2024. On 2/4/2025 at 1:25 p.m., an interview was conducted with the Administrator who acknowledged that the physician failed to sign POC and verbal orders within 30 days. The Administrator additionally revealed that it was a struggle for two of their physicians to sign patients’ plan of care or verbal orders on time, but the company is working to solve the problem.”