Every finding on record at Ware Visiting Nursing Service, Inc

A Recertification survey was conducted at SunCrest Home Health Services on April 14, 2025, and concluded on April 16, 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 Services on April 14, 2025, and concluded on April 16, 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 43. 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, review of policy titled “Oasis Data Capture, Transmission, Verification, Display and Reports,” and staff interview, it was determined that the agency failed to electronically transmit Outcome and Assessment Information Set (OASIS) data to CMS within 30 days of completing the assessment. Findings include: Review of the policy titled “Oasis Data Capture, Transmission, Verification, Display and Reports,” number 7.002, revised 3/01/2021, 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,” report period 01/01/2024-12/31/2024 and a run date of 04/14/2025, revealed the agency failed to transmit OASIS data to CMS system within 30 days. On 4/15/2025 at approximately 11:00 a.m., a telephone interview with Regional Vice President (RVP) revealed that the agency is aware of late OASIS submissions. The RVP revealed that a change in the agency’s OASIS submission process has now resolved the issue.

At the time of the survey, Atkinson Visiting Nurses Service Inc in Pearson, Ga. was in compliance with 42 CFR Part 484.22 Emergency Preparedness for Home Health Agencies as a result of a standard recertification survey conducted on May 18, 2022. A Focus Infection Control Survey was completed at the time of the survey. No deficiencies were cited.

At the time of the survey, Atkinson Visiting Nurses Service Inc in Pearson, Georgia was in substantial compliance with 42 CFR Part 484, Requirements for Home Health Agencies as a result of the survey conducted on May 18, 2022. A Focus Infection Control Survey was completed at the time of the survey. Current census 16. The follow deficiencies were cited.

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, staff interview and agency policy labeled “Home Care Infection Prevention and Control Program Cleaning and Disinfection, Bag Technique” it was determined the agency failed to follow basic health standards of infection control for 1 of 2 home visit patients (P) observed during the survey (P#2). Review of plan of care for P#2 with a recertification period of 4/1/22 to 5/30/22 and a relevant diagnosis of aphasia following cerebral infarction revealed during a home visit observation on 5/17/22 at 11:18 am., this surveyor noted that the Speech Therapist failed to practice Infection Control Technique. According to the agency policy labeled “Home Care Infection Prevention and Control Program Cleaning and Disinfection, Bag Technique” page 10, when a bag is brought into the home and not placed on a surface barrier the clinician is instructed to place the bag on a clean and dry surface. During the home visit observation, the clinician was observed placing the bag directly on the floor and picking up the bag and placing it directly in the lap. This process serves as a vehicle for transmission of microorganisms. During an interview on 5/18/22 at 10:30 am, the administrator confirmed that the Speech Therapist failed to follow the agency’s policy regarding infection control.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, it was determined the agency failed to ensure the patients' clinical record contained complete, clear, and accurate documentation of all services including: evaluations, treatments, and clinical notes to address the patients' needs for 3 of 7 (#3, #6, and #7) sampled patients (P). Findings were: 1. Review of the plan of care for P#3 with a recertification period of 4/1/22 to 5/30/22 and pertinent diagnosis of low back pain revealed an incomplete physician's verbal order which reads as follows: Skilled nurse (SN) to assess and monitor pain intensity every visit using pain rating scale with "0" being no pain and "10" being the highest and notify the physician of a pain rating scale above ____. This area was left blank. The SN failed to document a complete pain assessment order which would identify when pain interventions needed to be reevaluated. During an interview on 5/18/22 at 10:00 a.m., the Administrator and Assistant Administrator did confirm the pain assessment order was incomplete. 2. Review of the plan of care for P#6 with a certification period of 3/31/21 to 5/29/21 (closed record) and a diagnosis of postprocedural intestinal obstruction revealed the patient requested discharge from the agency on 5/3/21 during the licensed practical nurse (LPN) visit. The LPN notified the Registered Nurse (RN) of the patient's request for discharge however, the RN failed to complete a discharge summary to close out the episode of care. During an interview on 5/18/22 at 10:00 a.m., the Administrator and Assistant Administrator both confirmed that the LPN cannot complete a discharge and it was acknowledged the RN failed to document a discharge summary after the patient was discharged from nursing services. 3. Review of the plan of care for P#7 with a certification period of 1/3/21 to 3/3/21 and a diagnosis of Type 2 Diabetes mellitus with hypoglycemia without coma revealed an order which reads as follows: assess blood sugar monitoring and results and notify physician of a blood sugar below 60 or greater than 250. The patient is on insulin therapy. However, the order does not contain a frequency of blood glucose monitoring which would alert staff of potential complications and early intervention. The SN failed to obtain a complete order for monitoring of diabetic status. During an interview on 5/18/22 at 10:00 a.m., the Administrator and Assistant Administrator both confirmed that the order lacked a blood glucose monitoring frequency.