Every finding on record at Suncrest Home Health of Georgia, Inc

A Recertification and Re-Licensure survey was conducted at Suncrest Home Health on January 6, 2025, and concluded on January 8, 2025. At the time of the survey, the agency was in compliance with 42 CFR Part 418.113, Emergency Preparedness and Covid-19 infection control.

A Recertification survey was conducted at Suncrest Home Health on January 6, 2025, and concluded on January 8, 2025. At the time of the survey, the agency was not in compliance with Chapter 42 CFR Part 418, Rules and Requirements for Home Health and Hospice Agencies. The census was 282. The following deficiency was cited.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on the Centers for Medicare & Medicaid Services (CMS) Home Health Agency (HHA) Error Summary by agency report, agency policy “OASIS Capture, Transmission, Verification, Display, and Reports,” and staff interview, it was determined that the agency failed to electronically transmit monthly Outcome and Assessment Information Set (OASIS) data collected to the CMS system every 30 days. Findings include: Review of the policy titled “OASIS Capture, Transmission, Verification, Display, and Reports,” last revised 03/01/21, revealed the following: 2. Transmittal of OASIS data a. At least monthly, Agency will electronically transmit accurate, completed, encoded, and locked OASIS data to the state agency. All Oasis assessments completed must be transmitted within thirty (30) days of M0090 date. Review of CMS report titled “HHA Error Summary by Agency,” with a run date of 12/31/24, revealed the agency failed to transmit OASIS data to the CMS system within 30 days. An interview on 1/6/2024 at 12:00 p.m., was conducted at the Home Health agency with the Regional Home Health Survey and Performance Improvement Coordinator who confirmed awareness of the 30-day OASIS submission timeframe requirements not met during the time frame of 01/01/2024 through 12/31/2024. The Regional Home Health Survey and Performance Improvement Coordinator admitted the corporate office does OASIS submissions. A plan was recently implemented by the agency to address late submissions, including daily OASIS submissions and review of available reports.

A standard recertification survey was conducted at Suncrest Home Health in Fayetteville, GA on 1/6/21. The survey revealed that the agency was in substantial compliance with 42 CFR 484.22, Emergency Preparedness for Home Health Agencies. A Focused Infection Control Survey was completed at the time of the on-site survey. The census was 243 at the time of the on-site visit. No deficiencies were cited.

A standard recertification survey was conducted at Suncrest Home Health in Fayetteville, GA on 1/6/21. The survey revealed that the agency was in substantial compliance with 42 CFR Part 484, Requirements for Home Health Agencies. The census was 243 at the time of the on-site visit. The following deficiencies were cited:

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 home visit observations, clinical record review and staff interview it was determined that the home health agency failed to ensure that the medication profile was updated in to reflect current medications at the time of the comprehensive assessment for one of six sampled patients (P) (P#12) observed during home visits. The findings include: P#12 was admitted to the agency on 3/1/21 with the diagnosis of wedge compression of the first lumbar vertebrae. The clinical record was reviewed for certification period 12/26/21 to 2/23/22. A home visit was conducted at 1/4/22, at 1:40 p.m. During the visit medications were reviewed by this surveyor and registered nurse (RN) #ZZ. During the visit it was revealed that P#12 had multiple medications in the home that did not match the medications listed on the agency electronic medical record (EMR). Pt#12 informed RN #ZZ that the medication Tramadol 50 mg (milligrams) and Tramadol 100 mg listed on the agency EMR were no longer being used for pain management. P#12 stated acetaminophen 500 mg was started for pain management “some time ago”. Additionally, the simvastatin, a medication used to lower cholesterol, located at the home was 5 mg per day. The home health agency has simvastatin 20 mg per day listed in its EMR. Finally, P#12 had the dietary supplement Zinc 220 mg once daily in the home. The agency EMR did not have this dietary supplement listed. During the home visit, RN#ZZ confirmed the agency’s medication profile had not been updated to reflect the current medications in the home. In an interview via Microsoft Teams at 9:15 a.m. on 1/6/21, the agency Administrator was informed of this finding

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 clinical record review, observation and staff interview it was determined that the agency staff failed to ensure the plan of care contained all the treatments necessary to provide care to four of 17 sampled patients (P) (P#1, P #12, P#13 and P#17). Findings include: Review of clinical record for P #1 revealed the patient was admitted on 11/12/21 with diagnosis of acute cystitis without hematuria and encounter for fitting and adjustment of urinary device. Review of the plan of care for P #1 with a certification period of 11/12/21 to 1/10/22 required a skilled nurse( SN) to change the indwelling Foley catheter with a 16 – 18 French with 5- 10 cubic centimeter (cc) balloon monthly and as needed for dislodgment or blockage. However, the Foley catheter order lacks the type and the amount of solution to inflate the balloon. The agency failed to ensure the plan of care was complete and consistent to include the specific steps and supplies used to change the Foley catheter monthly and on as needed basis. During an interview on 1/6/22 at 9:30 a.m., the Executive Director and the clinical manager confirmed that the plan of care lacked a complete Foley catheter order. Review of clinical record for P #13 revealed the patient was admitted on 10/19/21 with diagnosis of malignant of rectum and malignant neoplasm of bone. Review of the plan of care for P #13 with a recertification period of 12/18/21 to 2/15/22 required the SN to change the indwelling Foley catheter with a 16 French with 10 cubic centimeter (cc) balloon monthly and as needed for dislodgment or blockage. However, the Foley catheter order lacks the type and the amount of solution to inflate the balloon. The agency failed to ensure the plan of care was complete and consistent to include the specific steps and supplies used to change the Foley catheter monthly and on as needed basis. During an interview on 1/6/22 at 9:30 a.m., the Executive Director and the clinical manager confirmed that the plan of care lacked a complete Foley catheter order. 3. P#12 was admitted to the home health agency on 3/1/21, with the diagnosis of wedge compression fracture of the first lumbar vertebrae. The clinical record was reviewed for the certification period 12/26/21 to 2/23/22. The clinical record contained a physician’s order dated 12/21/21, “Skilled nurse to perform/instruct/reinforce patient/ caregiver procedure of wound care to coccyx. Cleanse with wound cleaner, apply Medihoney to wound bed and cover with Optifoam gentile boarder using clean technique. Instruct patient/ caregiver signs/ symptoms of wound infection and proper disposal of dressings.” The order lacked specific information on how often the wound was to be cleaned. During a home visit with P#12 and registered nurse (RN)#ZZ at 1:40 p.m. on 1/4/22, RN #ZZ stated the wound care was to be provided by the agency or the caregiver two times per week and as needed for soiled dressing. RN #ZZ acknowledged the order present in the plan of care did not specify the frequency of wound care. In an interview via Microsoft Teams on at 9:15 a.m. on 1/6/22, the agency Administrator was informed of this finding. 4. P#17 was admitted to the home health agency on 11/30/21, with the diagnosis of hypertensive heart disease with heart failure. The clinical record was reviewed for the certification period 11/30/21 to 1/28/22. The clinical record contained physician’s orders for the medications metformin and Lantus insulin. Both medications are used to lower blood sugar in patients with diabetes. However, the plan of care lacked any physician’s orders to monitor P#17’s blood sugar levels nor did it include interventions for teaching diabetic care and blood sugar control. The clinical record also contained physician’s orders for Eliquis, which is used for anticoagulation of the blood and prevention of blood clots. However, the plan of care lacked interventions for teaching bleeding precautions. In an interview via Microsoft Teams at 9:15 a.m. on 1/6/21, the agency Administrator was informed of this finding.