Suncrest Home Health

“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 policy review, medical record review, and interview, the agency failed to ensure the Plan of Care for wound assessments was followed for 1 of 2 (Patient # 8) sampled patients with wounds. The findings included: 1.Review of the agency’s “Wound Assessment, Documentation, and Photography,” policy dated 9/1/2024, revealed “…To ensure the accurate and consistent assessment and documentation of wounds…The assessment will be documented on the Wound Assessment Tool. The assessment includes measurement of the length, width, and depth…” 2.Medical record review for Patient # 8 revealed a Start of Care date of 11/1/2024 with diagnoses which included Stage 3 Pressure Ulcer of the Sacral Region, Malignant Neoplasm of Bone, Malignant Neoplasm of Uterus, Hypertension, Diabetes Mellitus, and Obesity. Review of the Plan of Care dated 1/10/2025 through 3/10/2025 revealed, “…Skilled nurse to evaluate patient and develop plan of care (POC) in coordination with physician…to provide services as necessary and appropriate…Goals/Rehabilitation Potential Discharge Plans…Patient/Caregiver will demonstrate improved wound status as evidenced by decrease in size/drainage of wound…” Review of the Wound Record Reports dated 1/17/2025, 1/24/2025, 1/31/2025, 2/7/2025, 2/14/2025, 2/21/2025, 2/28/2025, and 3/7/2025 revealed Patient #8 had a Stage 3 pressure wound on the sacrum. There were no wound measurements documented. During an interview on 4/22/2025 at 3:35 PM, the Administrator confirmed there were no wound measurements documented on the dates listed above.”

“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 policy review, medical record review, observation, and interview, the agency failed to ensure an accurate Patient Medication Record for 3 of 7 (Patient #11, #15, and #16) sampled patients with home visits. The findings included: 1. Review of the agency’s “Monitoring Medications” policy revised 7/1/2024 revealed, “...All clinicians participating in the patient’s care are responsible to assist with the maintenance of accurate patient medication information throughout the episode of care...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...” 2. Medical record review for Patient #11 revealed a Start of Care date of 1/25/2021 with diagnoses which included Multiple Sclerosis, Chronic Pain Syndrome, and Migraines. Observations in Patient #11’s home on 4/22/2025 at 10:05 AM, revealed the Patient was taking the following medications which were not included on the Medication Profile: Omeprazole (used to treat frequent heartburn) 40 milligrams (mg) 1 tablet by mouth daily for acid reflux Rosuvastatin (used to reduce the amount of cholesterol in the blood) 5 mg by mouth daily for high cholesterol Prazosin (used to treat high blood pressure) 1 mg 1 to 2 tablets by mouth 1 to 2 hours before bedtime for high blood pressure Observations revealed there were no Nurtec (used to treat migraine headaches) 75 mg tablets in Patient #11’s medications which were listed on the Medication Profile. During an interview on 4/22/2025 at 10:08 AM, Patient #11 verified she had been taking the Omeprazole, Rosuvastatin, and Prazosin for several months. Patient #11 stated her physician discontinued the Nurtec and wrote a new order for the Rizatriptan Benzoate tablets to treat her migraines because her insurance didn’t pay for the Nurtec. Patient #11 stated the Nurtec was discontinued in January of 2025. 3. Medical record review for Patient # 15 revealed a Start of Care date of 3/22/2025 with diagnoses which included Fracture of Upper End of Left Humerus, and History of Falling. Review of Patient #15’s Medication Profile dated 3/22/2025 through 5/20/2025 revealed the following medications were ordered: Furosemide, used to treat excess fluid, 20 mg by mouth every day Magnesium Glycinate, a dietary supplement, 100 mg by mouth every day Vitamin B-12, a dietary supplement, 1,000 micrograms (mcg) by mouth every day Observations in Patient #15’s home on 4/14/2025 at 2:00 PM, revealed no Magnesium Glycinate or Vitamin B-12 supplements were found in the Patient’s home. Additionally, a bottle of Triple Magnesium Complex 400 mg tablets, a dietary supplement was found in the home but was not included on the Medication Profile. During an interview on 4/22/2025 at 10:40 AM, Patient #15 stated she was no longer taking the Furosemide tablets every day because her physician had instructed her 4 weeks ago to only take them when needed for excess fluid. Patient #15 stated she substituted the Magnesium Glycinate tablets with the Triple Magnesium Complex supplements, and she hadn’t taken the Vitamin B-12 supplements in over 3 years. 4. Medical record review for Patient #16 revealed a Start of Care date of 1/9/2025 with diagnoses which included Chronic Pain Syndrome, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Heart Failure, Anxiety, and Depression. Review of Patient #16’s Medication Profile dated 3/10/2025 through 5/8/2025 revealed the following medications were ordered: 9/17/2024 Cyclobenzaprine, used to treat muscle spasms, 200 mg by mouth every day 9/17/2024 Furosemide 40 mg by mouth every day 2/28/2025 Wellbutrin, used to treat depression, 150 mg by mouth every day Observations in Patient #16’s home on 4/22/2025 at 9:38AM, revealed no Cyclobenzaprine, Furosemide, or Wellbutrin were present in the Patient’s home. Additionally, the following medications which were not included on the Medication Profile were observed in the Patient’s home: 2/13/2025 Vitamin D (Ergocal), a dietary supplement, 1.25 mg by mouth one time a week 4/5/2025 Myrbetriq ER (extended release) (treats over-active bladder) 50 mg by mouth daily 3/4/2025 Rosuvastatin Calcium (treats high cholesterol) 40 mg by mouth every daily 3/3/2025 Qulipta (treats migraines) 60 mg by mouth every day 3/31/2025 Potassium Chloride, a dietary supplement, 20 milli-equivalent (meq), 2 tablets by mouth twice a day 4/7/2025 Trazadone, used to treat depression, 150 mg, 2 tablets at night During an interview on 4/22/2025 at 9:38 AM, Patient #16 stated she was no longer taking the Furosemide, Wellbutrin, or Cyclobenzaprine. Patient #16 continued and stated she was taking the Vitamin D supplements, Myrbetriq, Rosuvastatin Calcium, Qulipta, Potassium Chloride, and Trazadone. 5. During an interview on 4/22/2025 at 4:15 PM, the Clinical Manager verified the Medication Profiles should match what medications the patients were actually taking.”