Every finding on record at Suncrest Omni

An unannounced recertification survey was conducted on 01/10 to 01/14/2022 at Suncrest Omni a Home Health Agency. The Home Health Agency was not in compliance with with 42 CFR 484 sub part A-C, requirements for Home Health Agencies.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on record review, interview and policy and procedure review the facility failed to ensure patients received all services outlined in the plan of care were followed for two of 19 records reviewed. Patient #9 and patient #11. Specific to missed visits. Based on a record review of patient #9 plan of care for the certification period of 11/2/2021 to 12/31/2021 read for the patient to receive Occupational Therapy services 1 day week 1 A review of the patients calendar read, that Staff A Occupational Therapist (OT) had a scheduled appointment with the patient for 11/05/2021. A review of the missed visit report read, the OT documented a missed visit with this patient on 11/5/2021. There was no documentation that the appointment was rescheduled or that the patient was evaluated by OT as ordered. The patient was discharged from the home health agency on 11/12/2021. During an interview on 1/10/2022 at 11:30 AM, with the Clinical Director she stated, Patient number one was not seen and evaluated by Occupational Therapy. (OT) The office missed the need for the patient to be seen and evaluated by OT after the missed visit. The office did not notify the physician that the patient was not seen and evaluated by OT after the missed visit. The office did not get an order to discontinue the need for the patient to receive OT services. The patient has been discharged from the home health agency. Based on a record review of patient #11 plan of care for the certification period of 11/26/2021 to 1/24/2022 read for the patient to received Skilled Nursing (SN) 1 WK 9 and Physical Therapy (PT) effective 11/28/21 1 WK 1, 2 WK 3, and 1 WK 4. A review of Patient #11 missed visit report read, patient #11 had missed visits from PT on 12/8/21, 12/10/21, 12/17/21, 12/18/21, and 1/6/2022. The patient had missed visits with the nurse on 12/10/21, 12/17/21, and 1/7/2022. During an interview on 1/13/2022 at 3:08 PM with the Clinical Director she stated after reviewing the patients medical record and missed visit report, " I see that patient #11 had missed visits from PT and skilled nursing." A review of the policy and procedure " Coordination of Care, From Admit through Discharge " last revised 8/1/19 read, the Executive Director and Clinical Director coordinate patient care and services. To the greatest extent possible, patients receive care from a limited number of staff. coordinating patient care among various disciplines to ensure that services are continuous and coordinated from admission through discharge.

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: Based on record review and interview, the facility failed to coordinate care for two of 19 patients reviewed, patient #9 and #11. Record review patient #9 plan of care for the certification period of 11/2/2021 to 12/31/2021 read for the patient to receive Occupational Therapy services for 1 visit in 1 week, week 1. A review of the patients missed visit report read, that Staff A Occupational Therapist (OT) had a scheduled appointment with the patient for 11/05/2021. The OT documented a missed visit with this patient. There was no documentation that the appointment was rescheduled or that the patient was evaluated by OT as ordered. The patient was discharged from the home health agency on 11/12/2021. During an interview on 1/10/2022 at 11:30 AM, with the Clinical Director she stated, Patient number #9 was not seen and evaluated by Occupational Therapy. (OT) The office missed the need for the resident to be seen and evaluated by OT after the missed visit. The office did not notify the physician that the patient was not seen and evaluated by OT after the missed visit. The office did not get an order to discontinue the need for the patient to receive OT services. I am the person responsible for the coordination of care for patient services. The patient has been discharged from the home health agency. Based on a record review of patient #11 plan of care for the certification period of 11/26/2021 to 1/24/2022 read for the patient to received Skilled Nursing (SN) 1 WK 9 and Physical Therapy (PT) effective 11/28/21 1 WK 1, 2 WK 3, and 1 WK 4. A review of Patient #11 missed visit report read, patient #11 had missed visits From PT on 12/8/21, 12/10/21, 12/17/21, 12/18/21, 1/6/2022. The patient had missed visits with the nurse on 12/10/21, 12/17/21, and 1/7/2022. During an interview on 1/13/2022 at 3:00 PM, with the Clinical Director, she stated after reviewing the patients medical record and missed visit report, " i see that patient #11 had missed visits from PT and skilled nursing." A review of the policy and procedure " Coordination of Care, from Admit through Discharge" last revised 8/1/19 read, the Executive Director and Clinical Director coordinate patient care and services. To the greatest extent possible, patients receive care from a limited number of staff. Coordinating patient care among various disciplines to ensure that services are continuous and coordinated from admission through discharge. At admission, throughout care and at discharge, coordination of services is promoted through routine communication with patient's physician that includes a missed visit.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview the home health agency failed to obtain physicians signature as required in patient records for patient # 11 and # 12 of 19 records reviewed. . A clinical record review read that patient #11, and patient # 12 form 485, showed no physicians signature as required. Patient # 11 certification period was from 11/26/2021 to 1/24/2022. Start of care 11/26/2021. Patient #12 certification period was from 12/31/2021 to 2/28/2022 with a start of care of 12/31/2021. During an interview on 1/13/2022 at 3:00 PM, with the clinical manager she stated, "I don't see where the form 485's have been signed by the physician. There was no policy and procedure addressing the required signature from the physician regarding the form 485 per the Clinical Coordinator.