Every finding on record at Suncrest Home Health of South Ga, Inc.

A Recertification survey was conducted at SunCrest Home Health on March 24, 2025, and concluded on March 26, 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 March 24, 2025, and concluded on March 26, 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 291. The following deficiencies were 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, policy titled “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 CMS report titled “HHA Error Summary by Agency,” with report period of 02/01/2024 - 02/01/2025 and run date of 2/17/2025, revealed the agency failed to transmit OASIS data to CMS system within 30 days. Review of the policy titled “OASIS Data Capture, Transmission, Verification, Display and Report” 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. During an in-office interview on 3/26/2025 at 10:00 am, the Executive Director (ED) revealed that she was aware that the 30-day OASIS submission timeframe requirements were not met during the time frame of 02/01/2024 - 02/01/2024 and that the agency has experienced issues with nursing staff submitting OASIS reports on time. The ED stated the agency has submitted the late submission concerns in their Quality Assurance meeting for discussion and a plan of correction has been started.

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 record reviews, observation, staff and patient interviews, and policy titled “Plan of Care (POC).” it was determined that the agency failed to obtain a physician order for an indwelling catheter (a flexible tube placed in the bladder for drainage) for one patient (P) (P#4) of 17 patients sampled. Findings include: Review of policy titled “Plan of Care (POC),” Policy Number: 2.1.007, revised date: 09/01/24, revealed the following: Policy: 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’s problems, needs, and goals, as well as to address specific services being provided. PROCEDURE: 2. The POC includes: n. all patient care orders During a home visit observation with P#4 on 3/25/25 at 10:00 a.m., observed a urinary catheter with tubing draining urine attached to P#4’s walker. The occupational therapist (OT) OT CC did not address the catheter. The OT CC instructed P#4 to be careful with the urinary catheter tubing as not to dislodge it. In an interview on 3/25/25 at 10:30 a.m., P#4 stated that the catheter was placed on 3/18/25 by the urologist. P#4 stated that she was unable to urinate. In an interview on 3/25/25 at 10:50 a.m., OT CC confirmed that the P#4 is wearing a catheter, but she is not aware that nurse did not obtain physician order for indwelling catheter. OT CC confirmed that the physicians order was not included on the care plan. During an interview on 3/25/25 at 2:45 p.m., the Administrator confirmed there was no physician order for an indwelling catheter for P#4.

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 reviews, staff interviews, and policy titled “Plan of Care (POC),” it was determined the agency failed to include goals, and interventions with primary diagnosis and comorbidity for three patients (P) (P#2, P#7, P#8), of 17 sampled patients. The findings include: Review of the policy titled “Plan of Care (POC),” Policy Number: 2.1.007, revised 09/01/24, reveals the following: Policy: “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’s problems, needs, and goals, as well as to address specific services being provided." PROCEDURE: 2. The POC includes: h. Pertinent diagnosis (es). i. Patient specific interventions and education; measurable outcomes and goals identified by the agency and patient. 1. Review of the plan of care (POC) for P#2 (certification period (start of care) of 3/4/2025 to 5/2/2025) revealed P#2 was admitted to the Home Health agency on 11/4/2024, with a diagnosis of end stage renal disease (a condition where the kidney reaches advanced state of loss of function). The agency failed to address goals, and interventions on the POC to assess and monitor the fistula (connection that a surgeon makes between an artery and a vein to make it possible for patient to receive hemodialysis) on left upper arm site for dialysis for bleeding and signs of infection. 2. Review of the POC for P#7 (certification period (start of care) of 2/18/2025 to 4/18/2025) revealed P#7 was admitted to the Home Health agency on 2/18/2025, with a diagnosis of congestive heart failure (a medical condition where the heart muscle is unable to pump blood effectively, leading to fluid buildup in the body). The agency failed to address goals, and interventions, on the POC to assess and monitor the weight or parameter to measures the calf for edema. 3. Review of the POC for P#8 (certification period (start of care) of 1/6/2025 to 3/6/2025) revealed P#8 was admitted to the Home Health agency on 1/6/2025, with a diagnosis of type 2 diabetes (a medical condition in which your body cannot use insulin correctly and sugar builds up in the blood). The agency failed to address goals, and interventions, on the POC to obtain physician’s order to monitor blood glucose. During a telephone interview with Registered Nurse (RN) AA on 3/25/2025 at 1:15 p.m., RN AA confirmed that the intervention on diagnosis of end stage renal disease on P#2’s POC was not addressed because she was not aware that she had to obtain order to assess and monitor for bleeding and infection at fistula site. During an interview on phone with RN BB on 3/25/2025 at 2:40 p.m., RN BB confirmed that the agency failed to address intervention on diagnosis of end stage renal disease on P#2 POC, because she was not aware that she had to include it (intervention). On 3/25/2025 at 4:15 p.m., an interview conducted with the Administrator, who acknowledged that she failed to correct or include intervention for the diagnosis of end stage renal disease for P#2, congestive heart failure for P#7, and Type 2 diabetes for P#8.

Suncrest Home Health Adel, Georgia, was in compliance with 42 CFR Part 418.113, Emergency Preparedness and Covid-19 infection control for Hospice as a result of an onsite survey conducted on 4/8/22.

A Recertification survey was conducted at Suncrest Home Health Adel, Georgia, on 4/8/22, by Surveyor. It was revealed that the agency was in compliance with Chapter 42 CFR Part 418, Rules and Requirements for Home Health and Hospice Agencies. The census was 240. The 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 observation, clinical record review, and staff interviews, it was determined that the agency failed to ensure that patient medication profiles were updated to reflect current medications at the time of the comprehensive assessment for one (1) of nineteen (19) sampled patients (P#1). The Findings include: During a home visit observation conducted on 4/6/22 at approximately 9:30 a.m., with Registered Nurse (RN) AA, for P#1, it was revealed that P#1 was admitted on 11/17/20, with a diagnosis of Sepsis, hypertension, burn of third degree of left thigh, presence of coronary angioplasty implant and graft. The surveyor compared P#1's current medication list at home to the hospice agency's medication profile discrepancies were found. Tramadol 50 milligrams (MG), take one tablet oral daily for pain, filled on 12/22/21, was missing from medication profile and plan of care. On 4/6/22 at 10:13 a.m., an interview was conducted with RN AA, who stated, “I am not aware that P#1, was taking the above medications.”

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 observation, clinical record review, and staff interviews, it was determined that the agency failed to ensure that patient plan of care was updated to reflect current medications at the time of the comprehensive assessment for one (1) of nineteen (19) sampled patients (P#1). The Findings include: During a home visit observation conducted on 4/6/22 at approximately 9:30 a.m., with Registered Nurse (RN) AA, for P#1, it was revealed that P#1 was admitted on 11/17/20, with a diagnosis of Sepsis, hypertension, burn of third degree of left thigh, presence of coronary angioplasty implant and graft. The surveyor compared P#1's current medication list at home to the hospice agency's plan of care discrepancies was found. Tramadol 50 milligrams (MG), take one tablet oral daily for pain, filled on 12/22/21, was missing from plan of care. On 4/6/22 at 10:13 a.m., an interview was conducted with RN AA, who stated, “I am not aware that P#1, was taking the above medications.”

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 observation, record reviews, and staff interviews, it was determined that the agency failed to follow physician’s order to weigh P#13 and P#15. The physician’s order revealed: if unable to weigh patient, may measure body calf two inches below the knee each home visit. Also agency failed to follow wound care dressing order for P#3, three (3) of nineteen (19) patients sampled. (P#3, #13, and #15). The Findings include: 1. Patient #3 was admitted to agency on 11/4/21, with a diagnosis of hypertensive heart disease with heart failure, congestive heart failure, type 2 diabetes, and pressure induced deep tissue damage of right heel. Physician order dated 3/15/22: Skilled Nurse (SN) to instruct patient and caregiver on procedure of wound care to right heel unstageable pressure ulcer; Skilled Nurse to perform wound care using aseptic technique daily, clean wound with soap and water, apply nickel thick layer of Santyl to the wound bed; apply a saline moistened gauze to the wound bed; cover with dry gauze, and secure with kerlix and tape. On 4/6/22 at 11:20 a.m., Registered Nurse (RN) AA, used the physician’s previous order dated 3/10/22, for wound care. The previous order was: skilled nurse to cleanse right heel wound cleanser and patted dry dime size amount of Santyl del applied to black area of wound; cover with gauze and secure with kerlix and tape. During the interview with (RN) AA, on 4/6/22 at 11:49 a.m., she confirmed that she was not aware that the wound care order had changed. 2. Patient #13 was admitted to agency on 12/18/21, with a diagnosis of congestive heart failure, type 2 diabetes, chronic obstructive pulmonary disease, chronic kidney disease, atrial fibrillation, and cardiac arrhythmia. Physician order dated 3/2/22: skilled nurse to assess, measure edema every visit, and to notify physician with three plus pitting edema or greater. It was revealed that (RN) AA, did not measure and record edema during the visits as physician had ordered. On 4/8/22, at 9:50 a.m., an interview was conducted with (RN) AA, stated that P#13 refused and did not allow her to measure pitting edema. (RN) AA, also confirmed that she did not notify physician of P#13’s refusal. 3. Patient #15 was admitted to agency on 3/7/22, with a diagnosis of hypertensive heart disease with heart failure, congestive heart failure, atrial fibrillation, Parkinson’s disease, and peripheral vascular disease. Physician’s order dated 3/20/22: skilled nurse to assess, monitor weight gain of three pounds overnight or five pounds over one week; if patient unable to stand, perform body measurement of calf two inches below the knee; notify physician of two centimeters increase. No record indicates that (RN) BB, measured P#15’s weights or performed body measurement of calf; also (RN) BB, did not notify physician. On 4/8/22, at 10:15 a.m., an interview was conducted with (RN) BB, who stated that P#15 refused, due to patient being unable to stand. Also (RN) BB, confirmed that she did not perform body measurement of calf two inches below the knee, and did not notify the physician.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, it was determined that the agency failed to ensure the plans of care which contained verbal orders were signed by the physician within the required 30-day time frame for two (2) of nineteen (19) sampled patients. (P#5 and #18). The Findings include: 1. Review of a plan of care for P#5 with a certification period of 9/29/20 to 11/27/20, revealed that the physician did not sign the plan of care until 12/14/20. The agency failed to obtain the physician's signature on plan of care within the 30-day timeframe as required. 2. Review of the plan of care for P#18 with a certification period of 1/21/22 to 3/21/22, revealed the physician did not sign the plan of care until 3/3/22. The agency failed to obtain the physician's signature on plan of care within the 30-day timeframe as required. During an interview on 4/7/22 at 1:07 p.m., the clinical manager (CM) acknowledged and confirmed that the plan of care was not countersigned by the physician within 30 days of receipt of orders.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, clinical record reviews and staff interviews, it was determined that the hospice agency failed to use standard precaution to prevent infection for wound care dressing by using dirty gloves to perform clean wound dressing for one (1) of nineteen (19) sampled patients (P) (#3). The Findings include: On 4/6/22 at 11:30 a.m., surveyor observed Registered Nurse (RN) AA, perform wound care to P#3 right heel. (RN) AA used dirty gloves to touch clean gauze, and used it to wipe right heel open wound three times, then used the same dirty gloves to apply Santyl ointment, and covered it with gauze to complete the wound care dressing. On 4/6/22 at 11:58 a.m., an interview was conducted with (RN) AA, stated that she did know better but was nervous; and would take the blame for using dirty gloves to touch the clean gauze three times, and used the same dirty gloves to clean the wound and complete the dressing.