Suncare Home Health

The agency failed to develop and maintain an Emergency Preparedness training and testing program that is reviewed and updated at least every two years.

The agency failed to provide evidence that initial infection control education was provided for 1 (Staff-E) of 11 staff records reviewed.

The agency failed to ensure the Home Health Aide provided care and services as ordered in the plan of care for 1 (P-6) of 1 patient records reviewed in which Home Health Aide services were provided, resulting in the potential of unmet patient needs.

The agency failed to ensure clinical notes were maintained for 4 (P-3, P-4, P-5 and P-6) of 7 records reviewed, resulting in the potential to negatively affect the health and well-being of these patients.

The agency failed to submit the discharge summary to the physician within 5 days of the patients discharge from the agency for 1 (P-1) of 2 discharged records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care needs.

The Agency failed to ensure Occupational Therapy services were provided as ordered by the Physician for 2 (MR's #1, 2) patients who required Occupational Therapy services, and failed to ensure Skilled Nursing provided care at the ordered frequency in the plan of care in 1 (MR #5) of 6 records which…

The Agency failed to ensure that the Quality Assessment and Performance Improvement data was used to monitor the effectiveness and safety of services provided with opportunities for improvement; and failed to ensure the Governing Body approved the program's frequency and detail of data collection…

The Agency failed to ensure the skilled nursing followed accepted standards of practice in assuming responsibility for the care of 1 (MR #6) of 5 patients with heart failure, from a total of 8 sampled patient records reviewed (see G704); failed to ensure the Registered Nurse performed baseline…

The Agency failed to review and update an emergency preparedness plan at least annually, which included strategies to address the Covid-19 global pandemic, resulting in no directions for Agency personnel in the event of an actual emergency or disaster.

The Agency failed to develop and maintain an emergency preparedness plan centered on both agency-based and community-based risk assessments, resulting in a lack of direction and duties for agency personnel in the event of an actual disaster.

The Agency failed to ensure Occupational Therapy services were provided as ordered by the Physician for 2 (MR's #1, 2) patients who required Occupational Therapy services, and failed to ensure Skilled Nursing provided care at the ordered frequency in the plan of care in 1 (MR #5) of 6 records which…

The Agency failed to provide Occupational Therapy services as ordered by the physician for 2 (MR#’s 6, 8) of 7 records reviewed in which therapy services were ordered from a total sample of 8 records reviewed, resulting in the potential for unrecognized therapeutic needs and sub-optimal outcomes…

The Agency failed to ensure that the Quality Assessment and Performance Improvement data was used to monitor the effectiveness and safety of services provided with opportunities for improvement; and failed to ensure the Governing Body approved the program's frequency and detail of data collection…

The Agency failed to develop Performance Improvement activities, as part of the Agency's Quality Assessment Performance Improvement program, in order to track and trend adverse patient events, analyze the cause and implement preventive interventions, resulting in the potential for the rendering of…

The Agency failed to develop a Quality Assessment Performance Improvement program that documented the annual quality improvement projects, the reasons for conducting these projects with measurable progress achieved on these projects for the 2022 calendar year, resulting in the Agency's inability to…

Based record review and interview, it was determined the Governing Body failed to ensure the Agency had an active and functioning Quality Assessment and Performance Improvement program that addressed priorities for improved quality of care and patient safety and was evaluated for effectiveness…

The Agency failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of the Agency's Quality Assessment Performance Improvement program and; failed to develop a method of screening…

The Agency failed to notify the physician of a significant change in the patient's clinical status in 1 (MR# 6) of 5 records reviewed with congestive heart failure out of out of a total sample of 8 records reviewed, resulting in a poor patient outcome and unmet clinical care needs.

The Agency failed to ensure physical therapy (PT) provided appropriate oversight and communication with the physical therapy assistant (PTA) in 1 (MR#7) of 7 records reviewed in which the patient had PTA services assigned to provide care, from a total sample of 8 records reviewed, resulting in the…

The Agency failed to ensure that 2 (MR's #1, 2) of 3 patients observed during home visits, were included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided, resulting lack of inclusion in planning, the potential for…

The Agency failed to ensure the comprehensive assessment included an accurate reflection of the patient’s current health, psychosocial, and functional status in 2 of 8 records reviewed (MR#’s 5 and 7) resulting in incomplete clinical information to aid in determining the needs of these patient.

The Agency failed to ensure the patient's activities of daily living needs were adequately met in the patient's home for 1 (MR #4) patient who required assistance with grooming, from a total of 8 sampled records reviewed, resulting in the potential for low self-esteem and poor hygiene.

The Agency failed to ensure the Comprehensive Assessment included a thorough review of all the patient's medications to identify any adverse drug interactions and failed to ensure the Physician was notified of any untoward findings for 2 (MR's #1, 2) of 2 records, from a total of 8 sampled records…

The Agency failed to ensure the plan of care addressed the individualized needs of the patient and included all pertinent interventions with reportable parameters and objectively measurable goals for 5 (MR#'s 5, 6, 8, 2, 4) records, from a total of 8 sampled records reviewed, resulting in patients…

The Agency failed to ensure all treatments and services were administered only as ordered by the physician, and failed to ensure the plan of care was initiated prior to the provision of care and services for 1 (MR# 2) record, from a total of 8 sampled records reviewed, resulting in the potential…

The Agency failed to ensure the Physician was promptly notified of a change in clinical status for 2 (MR#'s 4, 6) patients, and failed to ensure the Physician was promptly notified of adverse drug interactions in 1 (MR# 8) record, from a total of 8 sampled records reviewed, resulting in the…

The Agency failed to coordinate the delivery of skilled nursing (SN), physical therapy (PT), and occupational therapy (OT) services for 1 (MR #6) of 5 records reviewed in which more than one discipline was ordered to provide care, out of a total sample of 8 records reviewed.

The agency failed to provide 2 (MR#'s 1, 2) of 3 patients observed during home visits, with a Medication Profile that included the names, dosages and frequencies of the patient's prescribed medications, in plain language, from a total of 8 sampled records reviewed, resulting in lack of direction…

The Agency failed to measure the success of its performance improvement projects to ensure the improvements were sustained, resulting in the potential for unidentified health concerns and the rendering of substandard care and poor patient outcomes.

The Agency failed to ensure the Registered Nurse performed baseline assessments and re-assessments of the patient's health status and needs in 1 (MR #4) record of a patient with a diagnosis of congestive heart failure and Diabetes Mellitus, from a total of 8 sampled records reviewed, resulting in…

The Agency failed to ensure Skilled Nursing (SN) assisted the physician in evaluating and helped to develop the plan of care to meet the patient’s needs for 1 (MR #5) of 5 records reviewed with congestive heart failure, from a total sample of 8 records reviewed, resulting in the potential for poor…

The Agency failed to ensure the skilled nurse provided services ordered within the patient's Plan of Care (POC) in 1 (MR# 6) of 5 records reviewed with congestive heart failure out of out of a total sample of 8 records reviewed, resulting in a poor patient outcome and unmet clinical care needs.

The Agency failed to ensure the Discharge Summary was complete, detailed the course of care and status at the time of discharge and forwarded to the Physician within 5 days from the date of discharge, for 2 (MR #3, 4), records in which the patient was discharged from the Agency's care or services…

The agency failed to maintain a coordinated agency-wide program for the surveillance, identification, and prevention of COVID-19; failed to develop a method of screening visitors and all current staff employed by this agency who were currently providing services, and failed to develop an infection…

The agency failed to develop, establish and maintain a comprehensive Emergency Preparedness Program that meets the requirements of this section (See E0004); failed to ensure their emergency plan was based on both a facility-based and community-based risk assessment, resulting in the potential for…

The agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects and duplicate drug therapy in 6 records (MR's #1,3,4,5,6, and 7) from a total of 7 sampled records reviewed, resulting in the potential for harmful medication effects for…

The agency failed to ensure the plan of care covered all pertinent interventions with reportable parameters and objectively measurable goals specific to the needs of the patient for 1 (MR #3) record of a patient with a diagnosis of Heart Failure, from a total of 7 sampled records reviewed, (G574)…

The Agency failed to measure, track and analyze it's quality indicators in order to assess processes of care and services, resulting in the inability to determine the scope of services provided (G642); failed to develop Performance Improvement activities, as part of the Agency's QAPI (Quality…

The Agency failed to ensure the skilled nurse followed accepted Infection Control standards of practice during wound care for 1 of 1 patient requiring wound care treatment, from a total sample of 7 sampled records reviewed (MR #2) (G682); failed to coordinate an agency-wide program for the…

The Registered Nurse and Physical Therapist failed to prepare clearly written patient care instructions and include all safety measures on the aide's care plan (See G0798); the home health aide failed to provide services that were ordered by the physician and documented on the plan of care (See…

The agency failed to develop, establish and maintain a comprehensive Emergency Preparedness Program that meets the requirements of this section, resulting in the potential for being unprepared to respond effectively in the event of an emergency.

The agency failed to develop an Emergency Preparedness Plan that was based on both a facility-based and community-based risk assessment, resulting in the potential for being unprepared to respond effectively in the event of an emergency.

The agency failed to develop, implement, review and update the policies and procedures for the emergency preparedness plan, that was based on the risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section, for a potential for the staff to be…

The agency failed to develop and maintain a communication plan for the emergency preparedness plan affecting all patients served by the agency including staff, resulting in the facility not being able to communicate effectively with facility staff, volunteers, other health care providers and…

The agency failed to develop and maintain a communication plan for the emergency preparedness program, including names and contact information for staff, community, state and federal entities providing services, patients' physicians and volunteers, and reviewed for years 2018 or 2019, affecting all…

The agency failed to develop and maintain an emergency preparedness training and testing program that was reviewed and updated at least every 2 years (2018 and 2019), resulting in the potential for staff being unprepared to respond effectively in the event of an actual emergency, which had the…

The agency failed to develop and maintain an emergency preparedness training program that was reviewed and updated at least every 2 years (2018 and 2019), that meets the requirements of this section; failed to ensure initial training in emergency preparedness policies and procedures was provided…

The agency failed to perform testing of their emergency preparedness program as required for 2018 and 2019 and failed to analyze the staff's response to and maintain documentation of all drills, training and tabletop exercises, and failed to revise the emergency plan, as needed, affecting all…

The Agency failed to provide evidence of its efforts to measure, track and analyze it's quality indicators in order to assess processes of care and services, resulting in the inability to determine the scope of services provided and the potential unmet care needs for al 26 patients currently…

The Agency failed to develop Performance Improvement activities, as part of the Agency's Quality Assessment Performance Improvement program, in order to track and trend adverse patient events, analyze the cause and implement preventive interventions, resulting in the potential for the rendering of…

The Agency failed to develop a Quality Assessment Performance Improvement program that documented the quality improvement projects, the reasons for conducting these projects with measurable progress achieved on these projects for the 2017, 2018 and 2019 calendar years, resulting in the Agency's…

Based interview, it was determined the Governing Body failed to ensure the Agency had an active and functioning Quality Assessment and Performance Improvement program that addressed priorities for improved quality of care and patient safety and was evaluated for effectiveness, resulting in the…

The Agency failed to ensure the skilled nurse followed accepted Infection Control standards of practice during wound care for 1 of 1 patient (MR #2) observed during a home visit, who required wound care treatment, from a total sample of 7 sampled records reviewed, resulting in the potential for…

The Agency failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of the HHA's Quality Assessment Performance Improvement program, resulting in the potential for increased, untreated…

The Registered Nurse and the Physical Therapist failed to prepare clearly written patient care instructions and include all safety measures on the aide's care plan in 2 of 2 records reviewed in which Home Health Aide services were provided (M.R. #6 and 7), from a total sample of 7 records reviewed…

Receive All Services In Plan Of Care

The Agency failed to advise their patients of the names, addresses and telephone numbers of federally funded and state-funded entities that serve the area where the patient resides, resulting in the potential for unmet patient care needs.

The agency failed to document both the existence of the complaint, the follow up and resolution of the complaint, in 1 of 1 complaint reviewed (Complaint #1) out of a total sample of 1 complaint received March 2020, for a potential of leaving unresolved complaints recieved by all…

The agency failed to ensure the comprehensive assessment included a review of all medications to determine any potential adverse effects, drug reactions or significant drug interactions, duplicate drug therapy and noncompliance with drug therapy in 6 of 7 records reviewed (MR#s 4, 5, 6, 7, 1 and 2)…

Primary Caregiver(S), If Any

The agency failed to ensure the comprehensive assessment was updated to include an assessment of the patient's current health status and continuing needs for home health services for 1 (MR #2) of 1 record in which the patient was recertified for home care, from a total sample of 7 records reviewed…

The agency failed to ensure the plan of care covered all pertinent interventions with reportable parameters and objectively measurable goals specific to the needs of the patient for 1 (MR #3) record of a patient with a diagnosis of Heart Failure, from a total of 7 sampled records reviewed…

The Agency failed to ensure all treatments, medications and services were administered only as ordered by the physician, and failed to ensure the plan of care was reviewed by the physician for 1 (MR #2) of 7 records reviewed, resulting in the potential for the rendering of unsafe, inappropriate…

The agency failed to ensure the physician was notified of changes in the patient's condition in 1 of 1 record reviewed (MR#1) in which the patient complained new onset shoulder pain, resulting in the potential for unrelieved pain and poor patient outcomes for this patient.

The Agency failed to include contact information for the Home Health Agency's Clinical Manager in the Patient Admission/Orientation Packet, resulting in the potential for unaddressed patient concerns.

The home health aide failed to provide services that were ordered by the physician and documented on the plan of care in 2 of 3 records reviewed in which Home Health Aide services were provided (M.R. #6 and 7), from a total sample of 7 records reviewed, resulting in the potential for unmet care…

The agency failed to ensure that a registered nurse completed an on-site annual supervisory visit to observe and assess each home health aide while performing care in 2 of 2 aides providing care (Aide #1 and 2), from a total sample of 7 records reviewed, for a potential of unqualified home health…