Suncrest Home Health

“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 policy review, medical record review and interview, the facility failed to follow the plan of care (POC) for documenting patient weights for 2 of 12 (Patient #8 and #12) active records reviewed. The findings included: 1. Review of the facility’s “PLAN OF CARE (POC)” policy (3/1/2026) revealed, “…PURPOSE…To ensure that physician/authorized practitioner’s orders are followed…Each patient has an individualized Plan of Care (POC) developed in consultation with the patient, physician or authorized practitioner, and staff that integrates comprehensive assessment findings to address patient problems, needs, and goals, as well as to address specific services being provided…the POC includes…Patient specific interventions…” 2. Medical record review for Patient #8 revealed a Start of Care (SOC) date of 6/15/2026 with diagnoses which included hypertensive heart disease and heart failure. Review of a 6/15/2026 through 8/13/2026 POC revealed Skilled Nurse (SN) orders that stated, “…SKILLED NURSE TO OBTAIN WEIGHT EVERY VISIT AND NOTIFY RN [Registered Nurse]/PHYSICIAN OF WEIGHT GAIN OF 3 lbs [pounds] WITHIN 1 DAY OR 5 LBS WITHIN ONE WEEK…” Review of SN notes beginning 6/15/2026 through 7/13/2026 revealed SN failed to obtain and document Patient’s weight on 6/23/2026. 3. Medical record review for Patient #12 revealed a SOC date of 6/10/2026 with diagnoses which included chronic obstructive pulmonary disease, Type 2 Diabetes and heart failure. Review of a 6/10/2026 through 8/8/2026 POC revealed SN orders that stated, “…SKILLED NURSE TO OBTAIN WEIGHT EVERY VISIT AND NOTIFY RN/PHYSICIAN OF WEIGHT GAIN OF 3 LBS WITHIN 1 DAY OR 5 LBS WITHIN ONE WEEK…” Review of SN notes beginning 6/10/2026 through 7/13/2026 revealed SN failed to obtain and document Patient’s weight on 6/22/2026, 7/7/2026 and 7/13/2026. In an interview on 7/22/2026 at 11:55 AM, the facility’s Executive Director verified Patient weights were not obtained and documented as ordered on the POC.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on policy review, medical record review, and interview, the agency failed to maintain a system of communication and integration in accordance with the home health agency’s own policies and procedures by failing to ensure clinical visit notes were documented in a timely manner for 1 of 12 (Patient #2) patients reviewed. 1. Review of the agency’s policy “…Home Care Record...” last revised 10/1/2025, revealed, “...PURPOSE...the contents and requirements of the clinical home care record…POLICY...medical record is maintained for all patients receiving services and care form the agency…PROCEDURE…Clinical notes for all services the patient has received shall be…Point of Care users, synchronization will occur within 24 hours from visit. 2. Review of the medical record revealed Patient #2, the Start of Care (SOC) to the agency was on 7/7/2026 with diagnoses including Open Wound Right and Left Foot, Diabetes Mellitus, and Cognitive Impairment. Medical Record review for Certification Period 7/7/2026 to 9/4/2026 revealed, “…SN[Skilled Nurse]2WK[Week]9...” (Skilled Nurse 2 times a week for 9 weeks). Review of the Visit Note Report revealed a visit was made on 7/14/2026 at 1:49 PM. The documentation for the visit was completed on 7/17/2026 at 6:51 AM. 3. During an interview on 7/22/2026 at 12:02 PM, the Executive Director stated the time frame for documentation of visit notes for Patient #2 was 24 hours and was not completed timely.”