Suncrest Home Health

“Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This Standard is not met as evidenced by: Based on agency policy, clincal record review, and staff interviews the SN [skilled nurse] failed to obtain PICC [peripherally inserted central catheter, is a long, thin tube inserted into a vein and guided to a central vein in the chest, allowing for long-term access to the bloodstream] line measurements for 1 of 1 patient with a PICC line [#13]. The findings included: The policy, Dressing Change Procedure for Central Venous, Midline and Peripherally Inserted Central Catheters [10/1/16], was provided by the agency director on 6/11/25 at 11:55 am. The policy stated, “...Inspect catheter, catheter exit site...Obtain upper arm circumference (approximately 5 cm above exit site) ...Measure external length of catheter from the insertion site to the catheter hub...” Patient # 13 had a start of care date [SOC] of 4/15/25 with admitting diagnoses of type 2 diabetes mellitus with foot ulcer and encounter for adjustment and management of VAD [vascular access device is a medical device that provides access to the bloodstream, allowing for repeated or long-term infusion of medications, fluids, or blood products, or for blood sampling]. The Plan of Care [POC] for the certification period 4/15/25-6/13/25 included orders for SN [skilled nursing] 3 times a week for 1 week and “...Skilled nurse to perform site care for infusion access device PICC [peripherally inserted central catheter, is a long, thin tube inserted into a vein and guided to a central vein in the chest, allowing for long-term access to the bloodstream] to RUE [right upper extremity] with transparent dressing changes a week [sic] and PRN...” Review of the clinical record revealed RN # 14 completed the SOC assessment on 4/15/25. Review of RN # 14’s documentation revealed the OASIS [Outcome and Assessment Information Set- It is a standardized data set used by home health agencies to collect and report information about their patients, including their clinical conditions, functional status, and other relevant details] question “does the patient have infusion access” was answered No. Further review of the documentation on 4/15/25 revealed no assessment/measurement of the PICC line site. Further review of the clinical record revealed RN #16 conducted a visit on 4/16/25 and documented, “PICC line dressing intact...” There was no evidence that the PICC line or arm circumference was measured. The patient received 12 nursing visits from SOC until the PICC line was discontinued and removed on 5/23/25. There was no evidence of PICC line/arm circumferences in 12 of 12 SN visits. During an interview with the director on 6/11/25 at approximately 2 pm, the director confirmed the PICC line/arm circumference should have been measured weekly with dressing changes.”

“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 agency policy, direct observation, clinical record review, patient/caregiver interviews, and staff interviews the Plan of Care [POC] failed to included all the medications/correct medications the patient was taking for 5 of 7 patients who recieved home visits [#6, 11, 12, 7 and 8]; and the POC failed to include any vital sign parameters for 1 of 5 discharged records [# 5]. The findings included: 4. Patient # 7 had a start of care date of 5/24/25 with an admitting diagnosis of emphysema [a form of COPD [chronic obstructive pulmonary disease] characterized by damage to the tiny air sacs in the lungs, making it harder to breathe]. Review of the Plan of Care [POC] for the certification period 5/24/25-7/22/25 included orders for SN [skilled nursing] 1 time a week for 2 weeks, 2 times a week for 2 weeks, 1 time a week for 6 weeks and “...Skilled nurse to instruct on new and changed medications...” On 6/10/25 at approximately 12:30 pm a joint visit was made with RN # 18. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: Oxygen 2 liters continuously via nasal canula was listed on the medication profile with a date of 6/9/25. During an interview with patient # 7 he reported, “I haven’t used the oxygen unless I felt short of breath. I never did use it 100% of the time.” Oxycodone [pain medication] 5 mg – take 1 tablet by mouth every 4 hours as needed for pain level 4-6 or continuous pain level of 3-4. During the interview with the patient he reported he no longer uses the oxycodone. “I probably only took those pills for the first day or two after I came home.” Aspirin [anti-inflammatory medication] 81 mg daily was not listed on the medication profile. The patient reports taking this medication for “a long time”. During an interview with the director on 6/11/25 at approximately 11 am, the director confirmed the POC did not include all the correct/current medications. 5. Patient # 8 had a start of care 2/22/25 with an admitting diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease. Review of the Resumption of Care [comprehensive assessment completed after in-patient stay] Plan of Care [POC] for the certification period 5/7/25-6/21/25 included orders for SN [skilled nursing] 1 time a week for 7 weeks. On 6/10/25 at 9:45 am a joint visit was conducted with RN # 5. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile included losartan [blood pressure medication] 100 mg each day. The patient had prepackaged medications in the home. RN # 5 advised the patient’s daughter used the prepackaged medications to prefill the medication planner. The prepackaged losartan was 50 mg daily. The patient had paroxetine [anti-depressant] 20 mg daily in the prepackaged medications and aspirin [anti-inflammatory] 81 mg daily in the prepackaged medications. During an interview with the patient, the patient advised she used the medications which were prepackaged. During an interview with the agency director on 6/11/25 at 11 am, the director confirmed the POC did not include all the correct/current medications. 6. Patient # 5 had a start of care date of 3/14/24 with an admitting diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease. Review of the Plan of Care [POC] for the certification period 5/13/24-7/11/24 included orders for PT [physical therapy] 1 time a week for 6 weeks and OT [occupational therapy] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 4 weeks. Review of the patient’s expressed goals on the plan of care revealed “Right shoulder to stop hurting and blood sugar fairly stable, blood pressure down.” The POC did not include any vital sign/pain/blood sugar parameters. During an interview with the agency director on 6/11/25 at 2 pm, the director confirmed the POC should have included certain parameters. A policy, Monitoring Medications, (revised 07/1/2024), was presented by the agency director on 6/11/2025 at 11:55 am. The policy stated, “...all clinicians will participate in medication review and reconciliation throughout the episode.” A policy, Plan of Care (POC)(4/1/25), was provided by the agency director on 6/11/25, at 8:49 am. The Policy stated, “...The POC includes medications and treatments...” 1. Patient #6 was admitted on 5/5/2025 with a diagnosis of type 2 diabetes (adult onset) with foot ulcer (a pressure wound on foot that is common with diabetes). The plan of care for 5/5/2025-7/3/2025 included orders for SN (skilled nursing) 2 times a week for 1 week, 3 times a week for 7 weeks, 2 times a week for 1 week. During a home visit on 6/9/2025 at approximately 9:30 am with registered nurse (RN) #7, a medication review was conducted using a medication list provided by the agency and the following discrepancy was noted: Gabapentin (used to treat nerve pain) was listed on the medication list as 400 mg 3 times a day, the prescription bottle directions read 800mg 2 times a day and the patient revealed that he took this medication as prescribed on bottle. During an interview on 6/9/2025 at 12:45 pm, when asked “how often do you do a complete medication review?” RN #7 stated that she checks the meds at each visit and RN #7 confirmed that the medications on the plan of care were incorrect. 2. Patient #11 was admitted on 5/22/2025 with a diagnosis of chronic right heart failure (the right side of the heart does not pump effectively, leading to a buildup of fluid and pressure). The plan of care for 5/22/2025 - 7/20/2025 included orders for PT (physical therapy) 1 time a week for 1 week, 2 times a week for 2 weeks, and 1 time a week for 4 weeks. During a home visit on 6/10/2025 at approximately 2:00 pm with PT #9, a medication review was conducted using a medication list provided by the agency and the following discrepancies were noted: The medication list did not include Tylenol (used for pain or fever) 500mg 2 tablets every 6 hours as needed for pain. Lasix (used to treat fluid retention) 40mg was listed on the medication list as 2 times a week as needed. The prescription bottle directions read daily as needed. The patient stated he took Lasix daily. Gabapentin (used to treat nerve pain) was listed on the medication list as 300 mg 3 times a day, the prescription bottle directions read 3 times a day as needed, and the patient stated he took 2 tabs at bedtime and sometimes another tab during the night. Pramipexole (used to treat restless legs) 0.5mg was listed on the medication list as 1 tablet daily. The prescription bottle directions read 2 tablets as needed at bedtime. May take up to 4 tablets daily. The patient revealed that he took 2 tablets at about 8:30pm and then he took another tablet when he was going to sleep, and sometimes another tablet during the night if his “legs are jumping”. During an interview on 6/10/2025 at 2:32 pm, when asked “how often do you do a complete medication review?” PT #9 stated,“I do a med review each visit”. PT #9 confirmed that the medications on the plan of care were incorrect. 3. Patient #12 was admitted on 4/14/2025 with a diagnosis of pressure ulcer right heel stage 3 (a wound caused by pressure that extends through the full thickness of the skin and into the fat layer). The plan of care for 4/14/2025-6/12/2025 included orders for SN (skilled nursing) 3 times a week for 6 weeks, 2 times a week for 1 week, 3 times a week for 1 week, and 2 times a week for 1 week. During a home visit on 6/11/2025 at approximately 9:30 am with registered nurse (RN) #16, a medication review was conducted using a medication list provided by the agency and the following discrepancy was noted: Gabapentin (used to treat nerve pain) was listed on the medication list as 600 mg 2 times a day, the prescription bottle directions read 4 times a day as needed, and the patient revealed that she took this medication as prescribed on bottle. During an interview on 6/11/2025 at 9:42 am, when asked “how often do you do a complete medication review?” RN #16 stated, “I check the meds each visit” and RN #16 confirmed that the medications on the plan of care were incorrect.”

“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 agency policy, clinical record review, and staff interviews, the agency failed to obtain a physician’s order for a urine specimen obtained via in and out catheterization for 1 of 1 patients with an indwelling catheter [#15]; and failed to obtain a physician’s order to increase the bulb size of an indwelling catheter for 1 of 1 patients with an indwelling catheter [#15 ]; and failed to change an dwelling catheter in four weeks for 1 of 1 patients with an indwelling catheter [#15 ]. The findings included: The policy, Physician Orders [10/1/ 23], was received on 6/11/25 at 9:49 am from the director. The policy stated...” No medications, treatments...studies...will be administered without the order of a qualified physician...” 1A. Patient # 15 had a start of care date of 2/12/25. Review of the Plan of Care [POC] for the certification period 4/13/25-6/11/25 included a diagnosis of hypo-osmolality [low blood osmolality- the concentration of dissolved substances in the blood is low and is usually caused by an excess of water relative to sodium] and hyponatremia [low sodium in the blood] and encounter for fitting and adjustment of urinary device. Further review of the POC revealed orders for SN [skilled nursing] visits 2 times a week for 3 weeks, 1 time a week for 6 weeks and “...Clinician to obtain urine and test via reagent strip. If results are positive, urine to be sent to lab for UA [urinalysis]...” Review of the clinical record revealed RN # 17 conducted a visit on 4/14/25 and documented, “...16-french foley catheter inserted...Upon insertion urine specimen was collected and given to ________ [ALF name] staff for UTI [urinary tract infection] testing. There was no evidence that the RN followed the physician’s order related to testing via reagent strip. During an interview with the agency director on 6/11/25 at 2 pm, the director confirmed the RN failed to follow the physician’s order related to testing urine via reagent strip and did not obtain an order for an urine specimen obtained by in and out catheterization. 1B. Patient # 15 had a start of care date of 2/12/25. Review of the Plan of Care [POC] for the certification period 4/13/25-6/11/25 included a diagnosis of hypo-osmolality [low blood osmolality- the concentration of dissolved substances in the blood is low and is usually caused by an excess of water relative to sodium] and hyponatremia [low sodium in the blood] and encounter for fitting and adjustment of urinary device. Further review of the POC revealed orders for SN [skilled nursing] visits 2 times a week for 3 weeks, 1 time a week for 6 weeks and “...Skilled nurse for insertion of 16 fr [French] 10 cc balloon indwelling catheter....” Review of the clinical record revealed RN # 17 conducted a visit on 4/14/25 and documented, “...16 french foley catheter inserted...with 30-cc balloon...” Further review revealed no evidence that the RN obtained an order for a 30-cc balloon. During an interview with the agency director on 6/11/25 at 2 pm, during the interview the director confirmed the physician’s order was for a 10-cc balloon. 1C. Patient # 15 had a start of care date of 2/12/25. Review of the Plan of Care [POC] for the certification period 4/13/25-6/11/25 included a diagnosis of hypo-osmolality [low blood osmolality- the concentration of dissolved substances in the blood is low and is usually caused by an excess of water relative to sodium] and hyponatremia [low sodium in the blood] and encounter for fitting and adjustment of urinary device. Further review of the POC revealed orders for SN [skilled nursing] visits 2 times a week for 3 weeks, 1 time a week for 6 weeks and “...Skilled nurse for insertion of 16 fr [French] 10 cc balloon indwelling catheter...change every 4 weeks and PRN [as needed]. Review of the clinical record revealed RN # 17 changed the foley catheter on 4/14/25. RN # 17 conducted a routine visit on 5/15/25 and documented, “Patient has indwelling foley catheter...catheter will be changed next visit...” Further review of the clinical record revealed RN # 17 changed the foley catheter during the 5/23/25 visit. During an interview with the agency director on 6/11/25 at 2 pm, the director confirmed the foley should have been changed on 5/12/25.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the agency failed to notify the physician of changes in patient condition for 3 out of 12 patients current on service [#12, #16, #17]. The findings included: 2. Patient # 16 had a Start of Care date of 4/17/25 with an admitting diagnosis of multiple fracture of ribs, right side. Review of the Plan of Care for the certification period 4/17/25-6/15/25 revealed supplemental orders dated 4/20/25 for SN [skilled nursing] 3 times a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 4 weeks. Review of the clinical record revealed LPN # 1 conducted a routine visit on 5/14/25 and documented the following information, “...SN reviewed change to magnesium with Pt [patient] and caregiver [wife]. Pt was taking one tablet. Instructions are to take 2 tabs daily...” Review of the clinical record revealed no evidence that LPN # 1 notified the physician that the patient was taking the wrong dose of medication. During an interview with the agency director on 6/11/25 at approximately 2 pm, the director confirmed the physician should have been notified. 3. Patient 17 had a Start of Care [SOC] date of 5/13/25 with admitting diagnoses of encounter for change or removal of surgical wound dressing, and malignant neoplasm [cancer] of right main bronchus [lung]. Review of the Plan of Care [POC] for the certification period 5/13/25-7/11/25 included orders for SN [skilled nursing] 4 times a week for 1 week, 3 times a week for 3 weeks, 2 times a week for 4 weeks, 1 time a week for 1 week; PT [physical therapy] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 4 weeks; OT [occupational therapy] 1 time a week for 4 weeks and “...When vital signs are obtained licensed professional to report vital signs falling outside the following established parameters...systolic [top number of blood pressure] less than 90 or greater than 150, diastolic [bottom number of blood pressure] less than 60 or greater than 110, pain level greater than 7...” Review of the clinical record revealed OT # 8 documented a blood pressure of 92/42 on 5/14/25. There was no evidence that the physician was notified. RN # 18 documented a visit on 5/31/25 and recorded a pain level of 10. There was no evidence that the physician was notified of the pain level. A policy, Coordination of Care, From Admit Through Discharge (revised 9/1/2024), received from the agency director on 6/11/2025 at 8:49 am states “At admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient’s physician…when changes occur in the patient’s condition or response to treatment…” 1. Patient #12 was admitted on 4/14/2025 with a diagnosis of pressure ulcer right heel stage 3 (a wound caused by pressure that extends through the full thickness of the skin and into the fat layer). The plan of care for 4/14/2025-6/12/2025 included orders for SN (skilled nursing) 3 times a week for 6 weeks, 2 times a week for 1 week, 3 times a week for 1 week, and 2 times a week for 1 week. Review of the clinical record revealed that on the 5/27/2025 nursing visit, the patient’s right heel wound was measured at 0.6 x 2 x 0.2 by RN #16. On the 6/2/2025 nursing visit, the right heel wound was measured at 1.2 x 1.9 x 0.2 by RN #16. There was no documentation that the physician had been notified of the increase in wound size. During an interview with the agency director on 6/11/25 at approximately 1:30 pm, the director confirmed that no documentation was in the record that the physician was notified.”

“Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This Element is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the skilled nurse failed to include specific items on the Plan of Care related to caring for 1 of 1 patient with a PleurX drainage system [a type of indwelling catheter used to drain excess fluid from the chest or abdomen] [#17]. The findings included: A policy, Plan of Care (POC) [4/1/25] was provided by the agency director on 6/11/25, at 8:49 am. The Policy stated, “...Each patient has an individualized Plan of Care developed in consultation with the patient, physician...that integrates comprehensive assessment findings to address patient problems, needs...” Patient # 17 had a Start of Care date of 5/13/25 with admitting diagnoses of encounter for change or removal of surgical wound dressing, and malignant neoplasm [cancer] of right main bronchus [lung]. Review of the Plan of Care [POC] for the certification period 5/13/25-7/11/25 included orders for SN [skilled nursing] 4 times a week for 1 week, 3 times a week for 3 weeks, 2 times a week for 4 weeks, 1 time a week for 1 week and “Skilled nurse may perform up to 3 PRN [as needed] visits for...need for additional pleurx catheter drainage...” Review of the clinical summary found on the POC revealed the following documentation by RN # 5, “SOC [start of care] clinical summary- The patient was recently hospitalized Dx [diagnoses] of lung cancer with metastatic disease. He was dc’d [discharged] 5/9/25. The patient’s primary focus of care is pleurx cath [PleurX drainage system is a type of indwelling catheter used to drain excess fluid from the chest or abdomen] drainage and teaching...”Further review of the POC revealed no specific physician’s order related to drainage of the PleurX , no order related to PleurX drainage dressing changes, and no specific order related to the amount of fluid that could safely be removed each time. During an interview with the agency director on 6/11/25 at approximately 3 pm, the director confirmed the POC should have included specific orders related to the PleurX drainage system.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on clinical record review and staff interviews, the skilled nurse failed to document information related to the drainage [amount of drainage/appearance of drainage] obtained when accessing a PleurX [type of indwelling catheter used to drain excess fluid from the chest or abdomen] for 1 of 1 patient with a PleurX [#17]. The findings included: Patient #17 had a Start of Care [SOC] date of 5/13/25 with admitting diagnoses of encounter for change or removal of surgical wound dressing, and malignant neoplasm [cancer] of right main bronchus [lung]. Review of the Plan of Care [POC] for the certification period 5/13/25-7/11/25 included orders for SN [skilled nursing] 4 times a week for 1 week, 3 times a week for 3 weeks, 2 times a week for 4 weeks, 1 time a week for 1 week and “Skilled nurse may perform up to 3 PRN [as needed] visits for...need for additional pleurx [sic] catheter drainage [PleurX drainage system is a type of indwelling catheter used to drain excess fluid from the chest or abdomen]...” Review of the clinical record revealed RN # 5 conducted the SOC visit on 5/13/25. Review of the documentation revealed the amount of drainage/appearance of drainage was not documented. RN # 16 conducted a routine visit on 6/2/25. There was no documentation of the amount of drainage removed by the PleurX and the appearance of the drainage. During an interview with the agency director on 6/11/25 at approximately 2 pm, the director confirmed she would expect to see the amount of drainage/appearance documented each time the PleurX was drained.”