Suncare Home Health

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an Emergency Preparedness training and testing program that is reviewed and updated at least every two years. This deficient practice could affect the health and safety of all agency patients in the event of a natural, man-made, or facility-based emergency. Findings include: During review of the agency’s emergency preparedness program on 6/10/26, it was discovered that there was no evidence the agency had documented the content of their exercises for 2024 and 2025, to evaluate the effectiveness of the training, any gaps in the procedures, areas for improvement, after action reports, and the overall emergency preparedness program. The agency documented that employees attended a drill, but there were no details of the drill. During an interview on 6/10/26 at 10:00 a.m., the administrator (Staff-A) acknowledged the above findings.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to provide evidence that initial infection control education was provided for 1 (Staff-E) of 11 staff records reviewed. Findings include: The personnel records for 10 agency employed staff and 1 contracted staff (employed under arrangement) were reviewed on 6/10/26 at 9:25 AM. The review revealed that that agency provided initial and ongoing annual infection control education for the 10-agency staff. The agency did not provide documented evidence that the contracted staff (Staff-E) received initial infection control education at the time of hire (3/15/26). During an interview with the Administrator (Staff-A) and the Alternate Administrator (Staff-C) on 6/10/26 at 10:58 AM, the findings above were reviewed. Staff-C explained that this education is provided electronically and should be documented in the personnel file for all contracted staff. Staff-A and Staff-C acknowledged findings during the interview.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Home Health Aide provided care and services as ordered in the plan of care for 1 (P-6) of 1 patient records reviewed in which Home Health Aide services were provided, resulting in the potential of unmet patient needs. Findings include: Patient #6 (P-6): During the record review on 6/8/26 at 12:48 PM, it noted that Home Health Aide (HHa) services were ordered at a frequency of one day a week for 6 weeks. The review of the HHa plan of care dated 4/6/26, found that the HHa was ordered to report if the patient experienced, “No Bowel Movements in 3 Days.” The review of the HHa visit notes for services provided 4/9/26 through 5/4/26, noted that the field, “Last Bowel Movement” was left blank for 6 out of 6 visits. The HHa did not provide care as ordered by documenting the last bowel movement to determine the need to report if the patient had no bowel movement in 3 days. The Administrator (Staff-A), the Director of Nursing (Staff-B), and the Alternate Administrator (Staff-C) reviewed and acknowledged the findings during an interview on 6/10/26 at 10:58 AM.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical notes were maintained for 4 (P-3, P-4, P-5 and P-6) of 7 records reviewed, resulting in the potential to negatively affect the health and well-being of these patients. Findings include: Patient #6 (P-6) was admitted to the agency 4/6/26 after being discharged from a skilled nursing facility for continuation of care, for the diagnosis of a hemorrhagic stroke (bleeding in the brain caused by a blood vessel leak) with left side body weakness and neglect. During the record review on 6/9/26 at 12:48 PM, the SN discharge summary visit note dated 4/22/26, noted that the physical therapist was informed that “…patient fell on 4/22/26. Patient sore, no physical injury noted…” and under, “Coordination Plan Regarding (Continued)” it noted a message will be communicated to the provider through the in agency electronic medical record. Further review revealed that SN documented a message in the “Patient Communication” dated 4/22/26 addressed to the physician that stated, “During nursing visit with patient on April 22, 2026, patient and husband reported that patient fell that morning. It was reported that she was standing at the bedside and fell onto her right side. No physical injury noted other than patient being sore on her right side.” Review of the “FAX Transmission Status” attached to the “Patient Communication”, documented the fax was sent 5/1/26 (9 days) after the reported fall, with the message,“Communication note 4/22/26 for your records. Thank you.” The agency failed to accurately document timely physician communication of the patient’s fall. During an interview with the Administrator (Staff-A), the Director of Nursing (Staff-B), and the Alternate Administrator (Staff-C) on 6/10/26 at 10:58 AM, the findings were reviewed. Staff-B explained that the staff call the physician and document the “Patient Communication” that is then faxed to the physician. Staff-A, Staff-B and Staff-C acknowledged the findings and confirmed that SN did not document that the physician was called to communicate the fall. Patient #3’s (P-3) Start of Care (SOC) was dated 1/15/26. The Plan of Care (POC) identified diagnoses of Laceration of Head, Concussion, Fall and Muscle Weakness. During record review on 6/8/26, it was noted the Skilled Nurse (SN) stated, “Vital Signs: BP (Blood Pressure): 166/74. Comments: BP taken later by therapist at next visit: 119/73… Coordination Plan: Physician Contacted Re: Pt (Patient) status, POC…” The vital sign of 166 was highlighted in red, representing an elevated value over the POC parameter stating, “Notify physician of: … Systolic BP greater than (>) 160…” The agency failed to accurately document the physician contact and follow-up. Furthermore, the Physical Therapy Assistant (PTA) documented the following on 4/14/26, 4/21/26 and 4/28/26, “Care Coordination: Conference with: PT (Physical Therapist), SN. Regarding: pt status and POC.” On 4/28/26, the PTA also documented, “Assessment: Summary of Patient Overall Performance on this Visit: … she reported that she had a fall the night before…” An incident report was completed, and the physician was notified on 4/28/26. The PTA failed to accurately document the “Care Coordination” status regarding the fall. Patient #4’s (P-4) Start of Care (SOC) was dated 12/3/25. The Plan of Care (POC) identified diagnoses of Vascular Dementia, Osteoarthritis and Chronic Pain. During record review on 6/9/26, it was noted that the POC ordered Physical Therapy (PT) to “Evaluation and treat”. On 12/5/25, the PT documented a missed visit stating, “Reason: No answer to phone call. Comments: Attempted multiple times to contact pt (patient) - no call back.” On 12/12/26, the PT documented a missed visit stating, “Reason: No answer to phone call. Comments: Attempted multiple times to contact pt and emergency contact – no response.” On 12/12/26 the PT completed an order stating, “Orders: pt/CG (Care Giver) has refused PT services at this time. No PT visit made. Pt with continue with SN and OT (Occupational Therapy).” There is no documented evidence in the EMR (Electronic Medical Record) that a return call was received refusing the PT services. Patient #5’s (P-5) Start of Care (SOC) was dated 5/29/26. The Plan of Care (POC) identified diagnoses of Hemiplegia, Hypotension and Diabetes Type 2. During record review on 6/9/26, it was noted that the PT completed an evaluation on 5/29/26 and stated, “Clinical Statement of Assessment Findings and Recommendations: … Pts BP is low and PCP (Primary Care Physician) notified… Care Coordination: Physician Notified Re: Plan of Care, Goals, Frequency, Duration and Direction.” There is no documented evidence of the physician being notified of the low BP and the response. Furthermore, the POC stated, “Other: Has wound on sacral area… Assessment of patient … Has sacral wound that is at risk for complication/infection…” During a joint home visit survey with Staff-D (Registered Nurse), she was questioned on 6/9/26 at 1:15pm regarding the sacral wound and stated, “P-5 does not have a sacral wound. She had a wound during her last admission.” The agency failed to accurately document within the POC. A review of the agency policy occurred on 6/10/26 titled “Clinical Record Contents and Maintenance” (Undated). The policy states, “The Agency will maintain a clinical record for all patients, initiated during the initial visit from data collected during the assessment process. The record will contain pertinent past and current medical, nursing, social and other information as appropriate to the care and treatment of the patient. The patient’s clinical record will contain data including but not limited to: - Clinical progress notes / visit notes, detailing services rendered and patient response to services.” The Administrator (Staff-A), Clinical Manager (Staff-B) and Alternate Administrator (Staff-C) reviewed and acknowledged the findings listed above in an interview on 6/10/26 at 11:20 am.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview, the agency failed to submit the discharge summary to the physician within 5 days of the patients discharge from the agency for 1 (P-1) of 2 discharged records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: Patient#1 (P-1): The start of care was dated 3/13/26, with diagnoses of hypertension, congestive heart failure, and chronic kidney disease. During record review on 6/8/26, it was discovered that the discharge summary dated 4/24/26 had a fax transmittal date of 5/7/26, 13 days after the patient’s discharge. During an interview on 6/10/26 at 10:00 a.m., the Administrator (Staff-A) agreed that the discharge summary should have been sent within 5 days of the patient’s discharge.”