Every finding on record at Sun Home Health Care at Columbus, Inc

Emergency Preparedness Survey At the time of the emergency preparedness survey completed on 02/22/23, Sun Home Health Care at Columbus, Inc is in compliance with the provisions of 42 CFR Part 484.102, Conditions of Participation for Home Health Agencies.

Partial Extended Recertification Survey An entrance conference was conducted on 02/16/23 at 11:55 A.M. with administrative staff and an exit conference was conducted on 02/22/23 at 3:30 P.M. with administrative staff. The following deficiency is based on the Partial Extended Recertification Survey completed on 02/22/23. Sun Home Health Care at Columbus, Inc 368203, is not in compliance with the requirements at 42 CFR Part 484, Subpart B, C for Home Health Agencies.

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 record review and interview, the agency failed to ensure the individualized plan of care included the frequency and duration of visits to be made for three of seven patients reviewed (Patient #1, #3, and #4). This could affect all patients receiving care from the agency. The current total census was 10. Findings include: 1. Medical record review for Patient #1 revealed the physician ordered plan of care for the certification period dated 12/05/22 through 02/02/23 included orders for skilled nursing (SN) services one time per week for nine weeks and home health aide (HHA) services “up-to” 14 hours. There was no frequency or duration listed for the HHA services. On 02/21/23 at 2:22 P.M. an interview with Staff A revealed the HHA orders were frequently written as “up-to” orders at this agency. Further interview with Staff A confirmed the facility orders were written as “up-to” 14 hours for Patient #1 without a specific range and frequency, but Staff A stated that the order implies that the patient would get 14 hours of HHA care every week. 2. Medical record review for Patient #3 revealed the physician ordered plan of care for the certification period dated 12/11/22 through 02/08/23 included orders for skilled nursing (SN) services three times per week for nine weeks and HHA services “up-to” 14 hours. There was no frequency or duration listed for the HHA services. 3. Medical record review for Patient #4 revealed the physician ordered plan of care for the certification period dated 01/21/23 through 03/21/23 included orders for HHA services “up-to” 14 hours. There was no frequency or duration listed for the HHA services. Staff A confirmed the findings for Patient #3 and #4 in an interview on 02/21/23 at 2:52 P.M.