Suncrest Home Health Services Inc

The agency failed to ensure that the Condition of Participation: G 640 484.65 Quality assessment and performance improvement (QAPI) was in compliance as follows: 1. Based on interview and record review, the agency failed to measure and analyze quality indicators (a measurable element of the…

The agency failed to measure and analyze quality indicators (a measurable element of the agency’s practice that can be used to assess the quality of care provided) in order to assess the agency’s processes of care, services, and operations, from January 1, 2021, to May 17, 2022, in a universe of…

The agency failed to use quality indicator (a measurable element of the agency’s practice that can be used to assess the quality of care provided) data from OASIS (Outcome and Assessment Information Set) to monitor the quality of the agency’s services.

The agency failed to conduct and document performance improvement projects (PIP - a concentrated effort on a particular problem in one area of the agency or agency wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements) the agency had…

The agency’s Governing Body (GB) failed to provide oversight for its Quality Assessment and Performance Improvement (QAPI) Program from January 1, 2021, to May 17, 2022, in a universe of 237 patients when: 1. The QAPI program failed to measure and analyze quality indicators (a measurable element of…

The agency failed to ensure COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) un-vaccinated staff followed additional transmission-based precautions (precautions used to help stop the spread of germs from one person to another) as indicated in the agency’s “COVID-19 Vaccination,”…

The agency failed to ensure registered nursing staff signed and certified accuracy for OASIS nursing assessments (Outcome and Assessment Information Set: a patient-specific, standardized assessment used in home health care to plan care, determine reimbursement, and measure quality) for five of 17…

The agency failed to ensure a medication reconciliation was conducted at the initial and recertification visit for two of 17 sampled patients (Patients 3 and 4) when: 1. For Patient 3: one medication the patient was taking were not indicated on the Medication Profile (MP-a current list of all…

The agency failed to ensure the one of 17 sampled patients (Patient 13’s) individualized plan of care contained all medications and treatments.

The agency failed to ensure that the Condition of Participation: E 001 484.22 Establishment of the Emergency Program (EP) was in compliance as follows: 1. Based on interview and record review, the agency failed to collaborate with local, regional, State, and Federal emergency preparedness officials…

The agency failed to ensure that the Condition of Participation: G 640 484.65 Quality assessment and performance improvement (QAPI) was in compliance as follows: 1. Based on interview and record review, the agency failed to choose quality indicators (a measureable element of the agency's practice…

The home health agency failed to ensure the Condition of Participation G 680 484.70: Infection prevention and control was in compliance.

The agency failed to collaborate with local, regional, State, and Federal emergency preparedness officials to cooperate in the planning efforts to maintain an integrated response during a disaster or emergency in a universe of 108 patients.

The agency failed to develop individual patient emergency preparedness plans based on and included in the patients' comprehensive assessments for six (6) of seven (7) sampled patients (Patients 1, 2, 3, 5, 6 and 7).

The agency failed to implement procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process in a universe of 108 patients.

The agency failed to develop a communication plan that complies with the federal, state and local laws in the event of a disaster or emergency, in a universe of 108 patients failure had the potential to place the agency's patients at risk when the agency was not adequately prepared to respond in an…

The agency failed to develop a back-up plan in the event of communications (phone service) failure during a disaster or emergency, in a universe of 108 patients.

The agency failed to provide training to all staff, as well as contracted staff, on the emergency preparedness policies and procedures and "Emergency Management Plan," in a universe of 108 patients.

The agency failed to choose quality indicators (a measureable element of the agency's practice that can be used to assess the quality of care provided) to measure, track and analyze in order to assess the agency's processes of care, services and operations, in a universe of 108 patients.

The agency failed to collect data from quality indicators (a measurable element of the agency's practice that can be used to assess the quality of care provided) to identify opportunities for improvement, in a universe of 108 patients.

The agency failed to conduct performance improvement projects, in a universe of 108 patients.

The agency's governing body failed to ensure the Performance Improvement Program was implemented and maintained and the program addressed priorities for improved quality of care and patient safety, in a universe of 108 patients.

The agency failed to implement and maintain an infection control program which included surveillance, identification, prevention, control and investigation of infections, in a universe of 108 patients.

The Home Health Agency (HHA) failed to ensure medication was reconciled during the recertification assessment for one (1) of seven (7) patients (Patient 2).

The agency failed to conduct performance improvement activities that focused on high risk, high volume or problem prone areas, in a universe of 108 patients.

The agency failed to conduct performance improvement activities that considered incidence, prevalence, and severity of problems in the areas for improvement, in a universe of 108 patients.