Suncrest Omni

The agency failed to provide skilled nursing services and at least one other therapeutic service to patients.

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.

The agency failed to provide skilled professional services to skilled patients.

The agency failed to provide skilled nursing services and at least one other therapeutic service to patients.

The agency failed to develop an individualized plan of care with patient-specific measurable outcomes and goals for skilled patients.

The agency failed to utilize measurable improvement indicators and measure, analyze, and track quality indicators (adverse patient events).

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.

The agency failed to track adverse patient events, analyze cause and implement preventative actions.

The agency failed to conduct Performance Improvement (PI) projects and document projects undertaken and progress achieved.

The governing body failed their responsibilities regarding QAPI.

The agency failed to provide skilled professional services to skilled patients.

The agency failed to provide skilled nursing services and at least one other therapeutic service to patients.

The agency failed to ensure that actions aimed at performance improvement measure success and track performance to ensure improvements are sustained.

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.

The home care agency failed to provide the care and services idenitifed at the time of admission and written in the home health aide care plan for 4 (#2, #3, #4, #6) out of 7 patients sampled (Refer to G436); Failed to investigate a complaint regarding the need for additional care and services for…

The agency failed to notify the physician for 1 (#2) of 7 sampled patients, who suffered a fall in her home and was found on the floor by the agency caregiver, and failed to notify the physician of a change in mental status and changes to the plan of care for 3 (#3, #4, #6 ) out of 7 patients…

The form indicated that as a plan for resolution "I offered to look into re-staffing." The actions towards resolution indicated that "VA called they are sending termination with today's date" Interview with the Administrator on 3/8/19 at 11:30 AM revealed that the family was not happy as aides…

The home care agency failed to provide the care and services identified at the time of admission and written in the home health aide care plan for 4 out of 7 (#2, #3, #4, #6) patients sampled.

The form indicated that as a plan for resolution "I offered to look into re-staffing." The actions towards resolution indicated that "VA called, they are sending termination with today's date." Interview with the Administrator on 3/8/19 at 11:30 AM revealed that the family was not happy, as aides…

The agency failed to notify the physician for one (#2) of 7 sampled patients, who suffered a fall in her home and was found on the floor by the agency caregiver, and failed to notify the physician of a change in mental status and changes to the plan of care for 3 (#3, #4, #6 ) out of 7 patients…

The home care agency failed to include the patients in their plan of care and to include on the agency agreement for services the frequency of visits to be performed by the home health agency for 3 (#1, #2, #3) out of 7 pateint records reviewed.

The agency failed to follow their policy and failed to provide supervision of home health aides every 14 days for 7 (#1, #2, #3, #4, #5, #6, #7) patients out of 7 sampled.

The home health agency failed to follow their policy and procedure to conduct on site aide supervisory visits with the aides present every 60 days for the care provided for 7 (#1, #2, #3, #4, #5, #6, #7) out of 7 patient records reviewed.