Every finding on record at Suncrest Omni

A Federal Emergency Preparedness survey was conducted on 5/28/2024 through 5/29/2024 at Suncrest Omni, a Home Health Agency. The provider was in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.22, Conditions of Participation for Home Health Agencies.

A recertification survey was conducted at Suncrest Omni, a Home Health agency on 5/28/2024 through 5/29/2024. An extended survey was conducted on 6/20/2024. The agency was not in compliance with Code of Federal Regulations (CFR) 42, Part 484, Conditions of Participation for Home Health Agencies.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on a staff interview and a review of the current client roster report, the agency failed to provide skilled nursing services and at least one other therapeutic service to patients. (Refer to G572)

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 a staff interview and a review of the current client roster report, the agency failed to develop an individualized plan of care with patient-specific measurable outcomes and goals for skilled patients. Findings included: Skilled record reviews and skilled home visits were not able to be completed as the agency had no skilled admissions to review and observe. The current client roster report was reviewed, date generated 6/20/2024 at 11:40 a.m., total count 76. All services are noted to be non-skilled. An interview was conducted on 6/20/2024 at 10:00 a.m. with the administrator, she stated “they have never admitted any skilled patients or provided skilled care at this location”.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and a staff interview: The agency failed to develop, implement, evaluate and maintain an effective, on-going QAPI program to ensure the Federal Conditions of Participation were met, including the provision of skilled nursing services and one other therapeutic service to skilled patients. (Refer to G642). The agency failed to utilize quality indicator data, including OASIS, to monitor effectiveness and safety of services and quality of care and identify opportunities for improvement. (Refer to G644) The agency failed to track adverse patient events, analyze cause and implement preventative actions. (Refer to G654) The agency failed to ensure that actions aimed at performance improvement measure success and track performance to ensure improvements are sustained. (Refer to G656) The governing body failed their responsibilities regarding QAPI. (Refer to G660)

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review, a letter, and a staff interview, the agency failed to utilize measurable improvement indicators and measure, analyze, and track quality indicators (adverse patient events). (Refer to G644) Findings included: A review of the QAPI Meeting Q4 2022 dated 10/31/2022, no time noted, revealed the topic of focus was Compliance in Charts. The QAPI agenda and meeting minutes did not have a sign-in sheet attached, there were 6 people in attendance. There were no other items discussed. A review of the QAPI Meeting Q1 2023 dated 01/10/2023, no time noted, revealed the topic or focus was Human Resource (HR) Chart audits. The QAPI agenda and meeting minutes did not have a signature sheet of the persons in attendance attached to it. The meeting had 3 people in attendance. There were no other items discussed. A review of the QAPI Meeting Q2 2023 dated 4/24/2023, no time noted, revealed the topic/focus was Patient Satisfaction. The QAPI agenda and meeting minutes did not have a signature sign-in sheet of the persons in attendance. The meeting showed 2 people in attendance. There were no other items discussed. An interview was conducted on 6/20/2024 at 1:00 p.m. with the administrator, who stated “we use the Home and Community Based Services (HCBS) Quarterly Executive Summary as our QAPI.” A letter dated 6/20/2024, written by the Regional Vice-President, stated “This letter is being written to verify there have been no complaints logged by Suncrest Home Health of Tampa, LLC in the last 6 months”.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on QAPI record review and IQIES data, the agency failed to utilize quality indicator data, including OASIS, to monitor effectiveness and safety of services and quality of care and identify opportunities for improvement. (Refer to G654) On 5/24/2024, reports for Quality Measures were run in IQIES through https://iqies.cms.gov and “no results for these criteria were found”. The reports included: Potentially Avoidable Event Report for the last 12 months, Potentially Avoidable Event: Patient Listing Report for the last 12 months and Agency Patient-Related characteristics (Case Mix) Report for the last 12 months. A review of the QAPI Meeting agenda Q4, dated 10/31/2022, contained no quality indicator data to monitor effectiveness and safety of services and quality of care and identify opportunities for improvement. The topic of discussion was compliance in charts. A review of the QAPI Meeting agenda Q1, dated 01/10/2023, contained no quality indicator data to monitor effectiveness and safety of services and quality of care and identify opportunities for improvement. The topic of discussion was compliance in HR charts. A review of the QAPI Meeting agenda Q2, dated 4/24/2023, contained no quality indicator data to monitor effectiveness and safety of services and quality of care and identify opportunities for improvement. The topic of discussion was patient satisfaction.

Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This STANDARD is not met as evidenced by: Based on QAPI record review and IQIES data, the agency failed to track adverse patient events, analyze cause and implement preventative actions. (Refer to G656) On 5/24/2024, reports for Quality Measures were run in IQIES through https://iqies.cms.gov and “no results for these criteria were found”. The reports included: Potentially Avoidable Event Report for the last 12 months, Potentially Avoidable Event: Patient Listing Report for the last 12 months and Agency Patient-Related characteristics (Case Mix) Report for the last 12 months. A review of the QAPI Meeting agenda Q4, dated 10/31/2022, contained no tracking of adverse patient events, causes, or preventative actions. A review of the QAPI Meeting agenda Q1, dated 01/10/2023, contained no tracking of adverse patient events, causes, or preventative actions. A review of the QAPI Meeting agenda Q2, dated 4/24/2023, contained no tracking of adverse patient events, causes, or preventative actions.

Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This ELEMENT is not met as evidenced by: Based on a staff interview and record reviews, the agency failed to ensure that actions aimed at performance improvement measure success and track performance to ensure improvements are sustained. Findings included: An interview was conducted on 5/28/2024 at 2:00 p.m. with the administrator, she stated, "we don't have any PIPS (Performance Improvement Projects) at this time. A review of the QAPI Meeting agenda Q4, dated 10/31/2022, contained no performance improvement measure success and no tracking of performance to ensure improvements are sustained. A review of the QAPI Meeting agenda Q1, dated 01/10/2023, contained no performance improvement measure success and no tracking of performance to ensure improvements are sustained. A review of the QAPI Meeting agenda Q2, dated 4/24/2023, contained no performance improvement measure success and no tracking of performance to ensure improvements are sustained.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on a staff interview, the agency failed to conduct Performance Improvement (PI) projects and document projects undertaken and progress achieved. (Refer to G660) Findings included: An interview was conducted on 5/28/2024 at 2:00 p.m. with the administrator, she stated, "we don't have any PIPS (Performance Improvement Projects) at this time. A review of the QAPI Meeting agenda Q4, dated 10/31/2022, only contained a topic on, "Compliance in Charting." A review of the QAPI Meeting agenda Q1, dated 01/10/2023, only contained a topic on, "Compliance in HR Charts." A review of the QAPI Meeting agenda Q2, dated 4/24/2023, only contained a topic on, "Patient Satisfaction review".

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on a staff interview and a review of the organizational chart, the governing body failed their responsibilities regarding QAPI. Findings included: An interview was conducted on 6/20/2024 at 1:30 p.m. with administrator who stated, “Regulations don’t require a governing body, but this is what we are required at this level.” A review of the organizational chart revealed the names of the State Director, Administrator, Director of Nursing, Case Coordinator and Direct Care Staff. The governing body failed to ensure the facility's QAPI program had a scope that tracked measurable improvement indicators for the facility (refer to G642); failed to include quality indicator data as part of their QAPI program (refer to G644); failed to track adverse patient events (refer to G654); failed to measure and track performance of performance improvement projects (refer to G656); and failed to conduct any performance improvement projects (refer to G658). failed to

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on policy review, letters, and a staff interview, the agency failed to provide skilled professional services to skilled patients. (Refer to G702)

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on policy review, letters, and a staff interview, the agency failed to provide skilled professional services to skilled patients. Findings included: An Interview was conducted on 6/20/2024 at 9:35 a.m. with the Administrator, who stated the agency has not admitted any skilled home health patients ever. She continued with the statement, “We are not currently doing skilled, only private duty sector, some Humana, and Medicaid. No skilled services, none, no PT, no OT, no MSW, and no RN skilled.” A review of the policy and procedure manual revealed an agency policy numbered 2.013, revised 10/1/2021, Chapter: “Provision of care, Treatment and Services”, titled “Skilled Services”. The policy showed, “All Home and Community Based Services locations will follow Home Health policies and regulatory requirements when providing and/or billing for skilled services. A letter dated 6/20/2024, written by the Regional Vice-President stated, “there is no record of OASIS assessments or skilled care being ever provided by this location”. A letter dated 6/20/2024, written by the RN Executive Director stated, “as per review of reports Suncrest Omni Tampa Florida has no unduplicated skilled admissions for the last 12 months prior to the survey”. A review of the Florida Patient Orientation for Home Based and Community Services booklet used by the agency for admission, revealed on page 8 under Services Provided, a paragraph listed “Skilled Nursing Care”. Skilled Nursing Care services may include evaluation of patient needs, performance of skilled nursing procedures such as dressing changes and trach care, education of the patient, family and caregivers on disease processes, and coordinating patient care services with your physician and other health care team members.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on a staff interview, agency policy, and letters, the agency failed to provide skilled nursing services and at least one other therapeutic service to patients. (Refer to G982)

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: Based on a staff interview, agency policy, and letters, the agency failed to provide skilled nursing services and at least one other therapeutic service to patients. Findings included: An Interview was conducted on 6/20/2024 at 9:35 a.m. with the Administrator, who stated the agency has not admitted any skilled home health patients ever. She continued with the statement, “We are not currently doing skilled, only private duty sector, some Humana, and Medicaid. No skilled services, none, no PT, no OT, no MSW, and no RN skilled.” A review of the policy and procedure manual revealed an agency policy numbered 2.013, revised 10/01/21, Chapter “Provision of care, Treatment and Services”, titled “Skilled Services”. The policy showed, “All Home and Community Based Services locations will follow Home Health policies and regulatory requirements when providing and/or billing for skilled services”. A letter written by the Regional Vice-President stated, “there is no record of OASIS assessments or skilled care being ever provided by this location”. A letter written by the RN Executive Director stated, “as per review of reports Suncrest Omni Tampa Florida has no unduplicated skilled admissions for the last 12 months prior to the survey.

A complaint survey for complaint number 2022013027 was conducted on 10/06/2022 at SunCrest Omni. The agency was not in compliance with the Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation 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 interviews and record reviews, the home care agency failed to provide the care and services identified at the time of admission and written on the Service Agreement for 3 (#1, #2, #3) patients out of 3 sampled. Findings included: 1. A review of the policy and procedure titled Service Agreement and service/Care Plan with an effective date of 8/01/10 and a review date of 4/01/21 documented under Purpose: to ensure an appropriate service agreement and service/ care plan is developed and revised in a timely manner with a patient or patient representative. Policy: each patient has a written service agreement and individualized service/ care plan developed in consultation with the patient Ford slash family and staff. The plan addresses patient/ family needs, as well as the specific care/ services being provided by the agency. Procedure: 1. the home and community-based services executive director or designee will conduct an initial evaluation of the patient. The evaluation shall be documented, dated, and signed by the individual who conducted the evaluation and maintained in the patient's agency record. 2. A written and individualized service/ care plan is developed for all patients prior to the initiation of care/ services by the executive director or designee, in conjunction with the patient for slash patients representative and the state program case manager as applicable. The service Ford care plan shall be signed and dated by the agency representative when it is complete and acceptable to all individuals participating in the development of the plan. The patient/ family shall receive a copy of the completed service/ care plan, including any changes or updates. The Service plan for each paraprofessional discipline or service will be documented on the paraprofessional assignment according to the service agreement. 4. Patients will receive the appropriate number of visits as outlined in the service agreement. In the event that a care provider is unable to attend a visit, an alternate care provider will be made available whenever possible. If no alternative caregiver is available or if the patient declines the alternate caregiver, every attempt will be made to reschedule the visit in accordance with the service agreement. If an aide misses a scheduled visit, there should be documentation that the patient was contacted prior to the missed visit. 5. The patient/ patient caregiver will be informed and included in any changes made to the individualized service/ care plan. Documentation in the medical record will reflect notification and acknowledgment from the patient/ patient caregiver. 6. The service/ care plan will be updated based on the needs of the patient and as indicated by the contract or state program. The aide/ care provider will notify the nurse/ designee of any changes in the patient's condition. 2. A medical record review for patient #1 revealed an admission date of 6/22/2022. A review of the Agreement for Services dated 6/22/2022, signed by the patient's daughter, documented the patient is receiving respite care. A review of the Personal Care Service Plan dated 6/22/2022 documents that the reason for services is respite with a frequency of Sunday 0, Monday 9-12 and 2:30-5, Tuesday 9-12, Wednesday 9-12 and 2:30-5, Thursday 9-12 and 2:30-5, Friday 9-12 and Saturday 0. The service plan is for 22.5 hours a week. A review of the Client Schedule Report from 8/01/2022 to 10/06/2022 documents missed visits from 8/30/2022 through 9/07/2022. A medical record review revealed no documentation; the agency notified the patient they could not provide services. During an interview on 10/06/2022 at 10:40 a.m. with the administrator, Staff A confirmed she had been on vacation from 8/29/2022 through 9/07/2022. Staff A stated that before she left, she called and notified the family that she would be on vacation. Staff A, Aide was unsure if Staff B Case Coordinator contacted the family or made arrangements to cover her visits while she was gone. 2. A review of the medical record for patient #2 revealed an admission date of 7/05/2022. A review of the Service Agreement dated 7/05/2022 reflected the need for personal care, Homemaker, and respite care for 13 hours a week: Monday through Friday. A review of the Personal Care Service Plan documents the 13 hours a week, Monday through Friday, for assistance with Activities of Daily Living (ADLs), personal care, and Homemaker Tasks. A review of the Client Schedule Report revealed missed visits on 9/18/2022 through 9/23/2022 and 10/03/2022 through10/05/2022. A medical record review revealed no documentation; the agency notified the patient they could not provide services. A telephone interview was conducted with patient #2 on 10/07/2022 at 2:00 p.m. "Sometimes they come, and sometimes they don't." 3. A review of the medical record for patient #3 revealed an admission date of 6/29/2022. A review of the Service Agreement dated 6/29/2022 documents that the patient requests 5 hours a week of personal care and 5 hours a week of homemaking for 10 hours a week. A review of the Personal Care Service Plan documents the patient has requested on Mondays -Fridays 2 hours a day for assistance with Activities of Daily Living (ADLs), personal care, and Homemaker Tasks. A review of the Client Schedule Report revealed the patient had not received services since 9/25/2022. A medical record review revealed no documentation; the agency notified the patient they could not provide services. Patient #3's daughter was interviewed on 10/13/2022 at 2:19 p.m., confirming that the staff did not show up. "They call and say they are coming, but no one does. My Dad has gone weeks without someone coming out." 4. During an interview with the agency administrator on 10/06/2022 at noon, she confirmed the findings.