Pruitthealth at Home - Atlanta

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on policies and procedures and clinical records review, it was determined the agency failed to manage and provide home health care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness and related conditions. Specifically the facility failed to: • electronically transmit monthly Outcome and Assessment Information Set (OASIS) data collected to the CMS system every 30 days. • failed to provide a written schedule for seven patients (P) P11, P12, P13, P14, P15, P16, and P17 of seven home visits made. • failed to provide a medication profile in the home for seven patients (P) P11, P12, P13, P14, P15, P16, and P17 of seven home visits made. • failed to provide weekly central venous access dressings changes for one patient (P) P11 of 17 patient record reviews which required dressing changes • failed to complete an Emergency Preparedness post assessment as required • complete visits as ordered for nine patients (P) P2, P3, P4, P5, P6, P7, P8, P9, P10 of 17 patients reviewed. Findings included: Review of policy titled “Governing Body- Home Health,” revised date 2/16/23 revealed the following: “POLICY” The Governing Body assumes full legal authority and responsibility for the overall management and operations of the Home Health Agency (HHA). Procedure: The scope of the responsibilities of the governing body/owner includes but is not limited to • Decision making • Overseeing management, operational plans, fiscal operations, and budget review for the HHA • Annual review of policies and procedures Cross Reference to E006 related to incomplete Emergency Preparedness Preparations. Cross Reference to G0372 related to failure to transmit OASIS (Outcome and Assessment Information Set) data in a timely manner Cross Reference to G0572 related to missed skilled nurse visits without physician notification Cross Reference to G0614 related to failure to provide home visit schedules for home visit observations Cross Reference to G0616 related to failure to provide current medication profiles for home visit observations Cross Reference to G 0710 related to failure follow the physician’s ordered plan of care”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on policy titled “Emergency Preparedness Plan/Policy - Home Health,” facility document review and staff interview, it was determined that the agency failed to maintain documentation of all the components of drills, tabletop exercises, and emergency events, after action review and revise the hospice’s emergency plan, as needed. Findings included: Review of policy titled “ Emergency Preparedness Plan/Policy - Home Health,” with revised date 02/20/2024, reveals the following: Policy Statement: The agency will comply with federal, state, and local emergency preparedness requirements and will establish and maintain an Emergency Preparedness Plan (EPP). The agency will ensure the EPP outlines the process for meeting patient and personnel needs in a disaster or crisis. The EPP and policies and procedures will be reviewed and updated at least every two years. The agency will conduct testing of the emergency plan at least annually. The agency will conduct an additional exercise every two years, opposite the year the full-scale or functional exercise is conducted, that may include but is not limited to the following: A full-scale exercise that is community-based or an individual facility based functional exercise; or a mock disaster drill; or a tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. Testing Agency will conduct testing of the emergency plan at least annually. 3. Analyze the agency’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the EPP as needed. Review of the agency’s binder titled “Emergency Preparedness,” failed to reveal documentation of the components of the tabletop drills and after-action review. The binder failed to reveal a group discussion using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. On 05/26/2026 at 11:30 AM, an office interview was conducted with the Regional Administrator, who acknowledged responsibility for the agency’s disaster plan. The Regional Administrator confirmed the agency failed to document the required components of the tabletop drills and after-action reviews of drills.”

“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 review of policy titled “Oasis Outcome and Information Set,” review of 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 included: Review of the policy titled “Oasis Data,” reviewed 11/17/2025, revealed that the HHA will encode and electronically transmit each completed OASIS assessment to the CMS OASIS contractor regarding each beneficiary within 30 days of completing the assessment of the beneficiary. Review of CMS report titled “HHA Error Summary by Agency,” with report period of 10/01/2025 – 05/26/2026 ran on 05/26/2026 revealed the agency failed to transmit OASIS data to the CMS system within 30 days. An interview was conducted with the Regional Administrator at 05/26/2026 at 1:00 PM. The Regional Administrator confirmed OASIS reports had not been submitted to CMS within 30 days of completing the assessments. The Regional Administrator revealed the agency changed their system of submitting OASIS and it contributed to late submissions.”

“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 review of policy titled “Attempted Visits/Missed Visits Policy for Home Health,” review of records, and staff interview, it was determined the agency failed to meet all scheduled and ordered clinical visits to provide home health services as written in the individualized plan of care. Specifically, the agency had missed visits for nine patients (P2, P3, P4, P5, P6, P7, P8, P9, P10) of 17 patients reviewed. Findings included: Review of the policy titled “Attempted Visits/Missed Visits Policy for Home Health,” reviewed 06/22/2023, reveals the following: “Policy statement: It is the policy of [Agency Name] through coordination of care to meet all scheduled and ordered clinical on-site visits. Procedure: 4. If a partner attempts to make a visit to the patient’s home and for any reason the partner is unable to make contact with the patient/caregiver, the following steps should be followed in order to promote the safety and well-being of the patient. The partner should document in a coordination note what occurred and attempt to reschedule the visit for another day in the week. 5. Every effort should be made to reschedule missed visits.” Review of clinical records of P2, P3, P4, P5, P6, P7, P8, P9, P10 failed to reveal visits as ordered in the patient’s plan of care. On 05/27/26 during an office interview at 3:00 PM, the Regional Administrator confirmed the records did not reveal scheduled visits as required and did not reveal missed visit notes for the missed visits.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on home visits, patient and staff interviews, it was determined that the agency failed to provide the patient and caregiver with a written visit schedule. Specifically, the agency failed to provide a written schedule for seven patients (P) (P12, P11, P16, P13, P15, P17, P14) of seven home visits made. Findings included: 1. On 05/27/2026 at 9:00 AM during a home visit for P12, the caregiver stated that no written schedule is provided by the agency. The caregiver stated the family is notified by text or telephone call the night before a visit is going to be made. 2. On 05/27/2026 at 10:00 AM during a home visit for P11 confirmed that no schedule is provided by the agency. Review of records during home visit failed to reveal a written schedule provided by the agency. 3. On 05/27/2026 at 10:30 AM during a home visit, P16 confirmed that no schedule is provided by the agency. Review of records during home visit failed to reveal a written schedule provided by the agency. 4. On 05/27/2026 at 11:15 AM during a home visit P13 confirmed that no written schedule is provided by the agency. P13 stated ” I never know when the nurse is coming until she shows up, we have to go by her schedule when she is able to come.” Review of records during home visit failed to reveal a written schedule provided by the agency. 5. On 05/27/2026 at 11:45 AM during a home visit P15 confirmed that no written schedule is provided by the agency. Review of records during home visit failed to reveal a written schedule provided by the agency. 6. On 05/27/2026 at 12:30 PM during a home visit P17 confirmed that no written schedule is provided by the agency. Review of records during home visit failed to reveal a written schedule provided by the agency. 7. On 05/27/2026 at 1:30 PM during a home visit with P14, family confirmed that no written schedule is provided by the agency. Family stated that the clinician will call or text them the day before they are going to make a visit. Review of records during home visit failed to reveal a written schedule provided by the agency. On 05/27/2026 at 9:10 AM during an in-person interview with Occupational Therapist (OT), OT confirmed that a text or call is made the evening prior to making a visit the next day. OT stated” I have been doing home health for 20 years and we have never given them a schedule; schedules are subject to change.” On 05/28/2026 at 9:00 AM during an in-office interview, the Administrator confirmed that patients and caregivers are notified the day before a visit is going to be made.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on home visits, record reviews, and patient and staff interviews, it was determined that the agency failed to provide the patient and caregiver with a written medication schedule/instructions. Specifically, the agency failed to provide a written medication profile for seven patients (P) (P12, P11, P16, P13, P15, P17, P14) of seven home visits made. Findings included: 1. On 05/27/2026 at 9:00 am, during a home visit for patient (P) 12, the caregiver stated that no written medication profile is provided by the agency. Review of records during home visit failed to reveal a written medication schedule/instructions. 2. On 05/27/2026 at 10:00 am, during a home visit with P11, failed to reveal a written medication profile in the home. P11 confirmed that no written medication profile is provided by the agency. Review of records during home visit failed to reveal a written medication schedule/instructions. 3. On 05/27/2026 at 10:30 am, during a home visit P16 confirmed that no medication list is provided by the agency. Review of records during home visit failed to reveal a written medication schedule/instructions. 4. On 05/27/2026 at 11:15 am, during a home visit P13 confirmed that no written medication profile is provided by the agency. Review of records during home visit failed to reveal a written medication schedule/instructions. 5. On 05/27/2026 at 11:45 am, during a home visit P15 confirmed that no written medication profile is provided by the agency. Review of records during home visit failed to reveal a written medication schedule/instructions. 6. On 05/27/2026 at 12:30 pm, during a home visit P17 confirmed that no written medication profile is provided by the agency. Review of records during home visit failed to reveal a written medication schedule/instructions. 7. On 05/27/2026 at 1:30 pm, during a home visit with P14, family confirmed that no written medication profile is provided by the agency. Review of records during home visit failed to reveal a written medication schedule/instructions. On 05/28/2026 at 9:00 AM during an in-office interview, the Administrator confirmed that the agency does not provide medication profiles to the patient. Administrator stated that due to the changes in the Electronic Medical Record (EMR), they are not able to only print out a medication list.”

“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 review of policy titled “Physician Orders for Home Health Patients,” record review, and staff interviews, it was determined that the agency failed to provide weekly central venous access (catheter inserted into a large central vein that leads to the heart) dressings changes for one patient (P) (P11) of 17 patient record reviews. Findings included: Review of the policy titled “Physician Orders for Home Health Patients,” reviewed date 11/17/2025, reveals the following: “Policy Statement: It is the policy of [Name] in accordance with program regulations that all medications and treatments are administered upon the clear, complete, and signed order of a person lawfully authorized to prescribe.” Review of clinical record for P11 revealed orders/treatments: skilled nursing: Change central venous access dressing weekly and as needed (PRN). Review of clinical record for P11 failed to reveal documentation of the central venous access weekly dressing change. During an interview on 05/28/2026 at 9:30 AM, the Regional Administrator confirmed that the clinical record failed to reveal documentation of the central venous access weekly dressing changes.”