Suncrest Home Health

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on medical record (MR) reviews, agency policy, and interviews with staff it was determined the agency failed to ensure the comprehensive assessment, including Occupational Therapy (OT) and Physical Therapy (PT) were started within five days of the Start of Care (SOC). This deficient practice affected two of nine MR reviews with therapy orders including MR # 9 and MR # 10 and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Patient Assessment, Initial and Reassessment Policy Number: 2.1.002 Revised: 9/1/24 ...Policy: All patients admitted to the agency will receive an initial assessment...comprehensive assessments are completed at patient admission on all adult patients. ...the assessing clinician may obtain input from the patient...within the comprehensive 5 (five) day window timeframe...The date assessment completed...will indicate the last day the assessing clinician received input to complete the comprehensive assessment... 2. MR # 10 was admitted on 8/17/24 with diagnoses including Malignant Neoplasm of Prostate and Unspecified Dementia, Unspecified Severity, with other Behavioral Disturbances. Review of the HHC and POC dated 8/17/24 revealed physician’s orders for SN, PT and OT effective 8/18/24. Review of the OT VNR dated 8/24/24 revealed the OT Evaluation was completed seven days after the SOC. An interview was conducted with EI # 2, PCM, who confirmed the comprehensive assessment was not completed within five days of the SOC per agency policy. 1. MR # 9 was admitted on 8/15/24 with diagnoses including Acute Cystitis with Hematuria, and Unspecified Cirrhosis of Liver. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 8/15/24 revealed physician’s orders for Skilled Nurse (SN), PT and OT effective 8/18/24. Review of the OT Visit Note Report (VNR) dated 8/21/24 revealed the OT Evaluation was completed six days after the SOC. Review of the PT VNR dated 8/23/24 revealed the PT Evaluation was completed eight days after the SOC. An interview was conducted with Employee Identifier (EI) # 2, Patient Care Manager (PCM), who confirmed the comprehensive assessment was not completed within five days of the SOC per agency policy.”

“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 observations, medical record (MR) review, agency policy and procedure, and interviews, it was determined the agency failed to maintain a complete and accurate list of all current medications and dosages. This deficient practice affected three of five Home Visits (HV) including HV # 1, HV # 4, HV # 3, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Monitoring Medications Policy Number: 10.008 Revised: 7/1/24 Purpose: To provide a process to ensure continuous monitoring of medications in the patient’s home. Policy: A drug regimen review will be performed on all patients...all clinicians will participate in medication review and reconciliation throughout the episode... Procedure: 1. The discipline responsible for the drug regimen review will: ...b. Review all medications including over the counter (OTC) medications... 2. All clinicians participating in the patient’s care are responsible to assist with the maintenance of accurate patient medication information... a. Through a collaborative process the care team will: ...Compare medications patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies... 1. HV # 1 was admitted on 8/25/24 with diagnoses including COVID-19, and Chronic Obstructive Pulmonary Disease. Review of the Home Health Certifications (HHC) and Plan of Care (POC) dated 8/26/24 revealed physician’s orders for Physical Therapy (PT) two times a week for four weeks then one time a week for five weeks and Occupational Therapy (OT) one time a week for one week, two times a week for three weeks, then one time a week for four weeks. A HV visit was conducted on 9/17/24 at 1:00 PM to observe care provided by Employee Identifier (EI) # 6, OT. During the HV, the surveyor observed an oxygen (O2) concentrator and O2 cylinders in the home. HV # 1’s caregiver stated he/she had been on O2 at 2 liters per minute as needed since returning home from the hospital. Review of the Client Medication Report (CMR) dated 9/17/24 revealed no orders for O2. Further review of the HHC and POC revealed no initial order for O2, but O2 was listed as a DME (Durable Medical Equipment) Supply. An interview was conducted on 9/19/24 at 3:35 PM with EI # 2, Patient Care Manager (PCM), who confirmed the agency failed to reconcile the medications per agency policy. 2. HV # 4 was admitted on 7/5/24 and recertified for home care from 9/3/24 to 11/1/24 with diagnoses including Unspecified Atrial Fibrillation, and Other Fracture of Fifth Lumbar Vertebrae. Review of the HHC and POC dated 9/3/24 revealed physician’s orders for Skilled Nurse (SN) one time a week for nine weeks, PT two times a week for four weeks then one time a week for one week, and Speech Therapy (ST) one time a week for one week. A HV was conducted on 9/18/24 at 11:15 AM to observe care provided by EI # 4, Speech Therapist. A review of current medications was conducted with EI # 4 and the caregiver and compared with the CMR dated 9/17/24. The follow discrepancies were identified. Aspirin 325 mg was observed in the home and not on the CMR. HV # 4’s caregiver stated the patient takes the Aspirin as needed for headaches. The last dose was a couple of months ago. Levetiracetam 250 mg tablets, take two tablets two times a day, was on the CMR. The caregiver stated HV # 4 has been on Levetiracetam 250 mg one time a day for an unknown amount of time. Lisinopril 20 mg tablets, take two tablets daily, was on the CMR. The caregiver stated HV # 4 has been taking Lisinopril 20 mg one tablet daily since his/her doctor changed the dosage a couple of months ago when he/she came out of the hospital. An interview was conducted on 9/19/24 4:00 PM with EI # 2 who confirmed the agency failed to ensure the CMR was updated with the current medications. 3. HV # 3 was admitted on 7/20/24 and recertified for home care from 9/18/24 to 11/16/24 with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Digestive System and Secondary Malignant Neoplasm of Brain. Review of the HHC and POC dated 9/18/24 revealed physician’s orders for SN one time a week for nine weeks, PT one time a week for one week, two times a week for four weeks, then one time a week for four weeks, and OT one time a week for four weeks. A HV was conducted on 9/18/24 at 2:30 PM to observe wound care provided by EI # 5, Licensed Practical Nurse. During the HV a review of the current medications was conducted with EI # 5 and the caregiver. The following discrepancies were identified: Levothyroxine 125 mg, take one capsule daily was listed on the CMR. Levothyroxine 100 mg, take one capsule daily was in the home. The caregiver stated the dosage had been changed by the patient’s physician two weeks prior. Midodrine 5 mg, take one tablet three times a day, was listed on the CMR. The caregiver stated HV # 3 had not been taking the Midodrine for two weeks due to high blood pressure. An interview was conducted on 9/19/24 at 3:35 PM with EI # 2 who confirmed the agency failed to reconcile the current medications per agency policy.”

“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 medical record (MR) reviews, agency policy, and interviews it was determined the agency failed to ensure: 1. Physician’s orders were followed for obtaining body measurements. 2. Physician’s orders for the administration of oxygen (O2) were included in the Plan of Care (POC). This deficient practice affected one of three patients with orders for ankle measurements and one of one patients receiving O2 including MR # 8, Home Visit (HV) # 1, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Physician Orders Policy Number: 2.1.008 Revised: 10/1/23 Purpose: To outline the process of receiving and documenting physician or authorized practitioner orders. Policy: No medications, treatments, ... will be administered without the order of a qualified physician or authorized practitioner... 10. Services are provided according to the most recent orders updating the patient’s Plan of Care... 1. MR # 8 was admitted on 5/11/23 and recertified for home care from 9/2/24 to 10.31.24 with diagnoses including Pressure Ulcer of Other Site, Stage Two, and Other Cerebrovascular Vasospasms and Vasoconstriction. Review of the Home Health Certification (HHC) and POC dated 9/2/24 revealed physician’s orders for Skilled Nurse (SN) two times a week for eight weeks then one time a week for one week. SN to obtain body measurements of ankle every visit and notify physician of two-centimeter (cm) increase. Review of the SN Visit Note Reports (VNR) dated 9/3/24 and 9/9/24 revealed no documentation of ankle measurements. An interview was conducted on 9/19/24 at 3:33 PM with Employee Identifier (EI) # 2, Patient Care Manager, who confirmed the agency failed to ensure the orders for obtaining body measurements were followed. 2. HV # 1 was admitted 8/26/24 with diagnoses including COVID-19, and Chronic Obstructive Pulmonary Disease. Review of the HHC and POC dated 8/26/24 revealed physician’s orders for Physical Therapy (PT) two times a week for four weeks then one time a week for five weeks and Occupational Therapy (OT) one time a week for one week, two times a week for three weeks, then one time a week for four weeks. PT to instruct patient/caregiver regarding O2 management including administration, care of equipment, and safety. Further review of the HHC and POC 8/26/24 and the Client Medication Report dated 9/17/24 revealed no documentation of a physician’s order for O2 therapy. An interview was conducted on 9/19/24 at 3:35 PM with EI # 2 who confirmed there was no documentation of a physician’s order for O2.”