Every finding on record at Sunrise Home Health & Supplies LLC

During the recertification survey that was conducted on 4/17/23 through 4/18/23 at Sunrise Home Health & Supplies LLC, a home health agency, Emergency Preparedness regulations were reviewed. Sunrise Home Health & Supplies LLC is in compliance with the Code of Federal Regulations (CFR) 42, Section 484.102, Condition of Participation, Emergency Preparedness for Home Health Agencies (HHAs).

An unannounced recertification survey was conducted on 4/17/23 to 4/18/23 at Sunrise Home Health & Supplies LLC, a Home Health Agency in Port Charlotte, Florida. Sunrise Home Health & Supplies LLC is not in compliance with Code of Federal Regulations (CFR) 42, Part 484, Conditions of Participation for Home Health Services. The following is a description of the standard level of noncompliance.

Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This ELEMENT is not met as evidenced by: Based on Medical record reviews and interviews, the home health agency failed to notify the patient’s physician for 1(patient #11) of 3 discharge patients sampled, of the family refusing services. The findings include: Review of Patient #11 medical record revealed a Start of Care date of 11/5/22. The Home Health Comprehensive Assessment and the Home Health Certification and Plan of Care document the home health agency is to provide Skill Nursing, Physical Therapy, and Occupational Therapy. The service’s goal is for the patient to improve in his present functional limitations of, ambulation, incontinence, endurance, paralysis, and speech. On 4/18/22, at 1:15 p.m. during an interview, the patient's spouse said, "My husband is a big man and the Home Health Aide on the first visit she attempted to transfer my husband without a gait belt, and almost dropped him. I told her I did not need her. Physical Therapy came and had my husband performing marching steps without weights on his ankle. In the rehabilitation center he had advanced to lifting his legs with weights on his ankles. I felt I could do the therapies myself. I have all the equipment at home. He has improved and is able to transfer, pivot, and sidestep". On 4/18/23, at 2:52 p.m. during an interview, Registered Nurse Staff C said she wrote the communication on 11/18/22, “Wife complained to Physical Therapy and Occupational Therapy for delay getting to see patient and requests to cancel service. Clinical supervisor notified.” She said she did not notify the patient's physician. Staff C said the communication went to the office, not to the patient’s physician. On 4/18/23, at 3:00 p.m. during an interview, the administrator said they should have notified the patient’s physician of discharge due to the spouse refusal of services.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview and record review the agency failed to inform the physician of abnormal vital signs for two patients (Patient #4, and Patient #5) of ten patients surveyed. The agency failed to inform the physician of a diastolic blood pressure of greater than 90 (Patient #4) and the agency failed to inform the physician of a pulse of less than 60 (Patient #5). Abnormal vital signs can be a symptom of a cardiovascular problem which has the potential to need treatment options ordered from a physician, for this reason the physician should be informed when a patient has abnormal vital signs. Findings included: 1. Review of the Care Plan for Patient #4 shows a start of care on 1/27/23. The Care plan shows the physician is to be informed if Patient #4’s diastolic pressure is greater than 90. Review of the of the “Skilled Nursing Visit” dated 3/21/23 shows Patient #4’s diastolic blood pressure was recorded as being 97 millibars of mercury. There is no documentation noted on the documentation of the skilled nursing the physician was informed of the patient’s abnormal diastolic blood pressure. On 4/18/23 at 1:25 p.m. Staff A said she did not know why she had not documented calling the physician related to the resident having a high diastolic blood pressure. 2. a. The Skilled Nursing Visit Note dated 4/3/23 shows Patient #5’s Heart Rate (HR) was 50 beats per minute (BPM). A normal heart rate ranges between 90 to 60 BPM. The documentation under the “Cardiovascular” assessment shows no documentation of abnormal pulses. There was no documentation in the narrative note that Registered Nurse Staff B had contacted the physician regarding the resident having Bradycardia (slow heart rate). The Skilled Nursing Visit Note dated 4/11/23 shows Patient #5’s heart rate was 51 BPM. Review of the documentation from Staff B shows no documentation of abnormal pulses under “Cardiovascular” assessment. Review of the narrative notes show no documentation the physician was notified the patient was having Bradycardia. On 4/18/23 at 2:30 p.m., Staff B said he had notified the physician of the patient having a low heart rate at each visit. He stated he did not know why he had not documented the physician had been notified. b. Review of Patient #5’s Physical Therapy note dated 3/30/23 shows Patient 5 was assessed with a HR of 55 BPM. The Patient is also assessed as having shortness of breath and edema. There is no documentation on the Physical Therapy note that the physician was notified of these abnormal findings. On 4/18/23 at 2:40 p.m., the Administrator verified staff had not followed up with abnormal findings and documented appropriately.