Sunrise Home Health Care Services Inc

The agency failed to include in its policies the use of volunteers in an emergency and the role for integration of State and Federally designated health care professionals to address needs during an emergency.

The agency failed to maintain an emergency training program.

The agency failed to conduct a community or facilty -wide exercise to test the emergency plan at least every 2 years.

The agency’s Quality Assessment and Performance Improvement (QAPI) Program failed to track quality indicators to include all documented Patient infections in 1 of 1 active clinical records reviewed with a suprapubic catheter (Patient #1).

The agency failed to ensure the comprehensive assessment included a complete patient’s health status in 1 of 1 active clinical records reviewed of a patient with a suprapubic catheter (Patient #1).

The agency failed to ensure all treatments were included on the plan of care in 1 of 3 active clinical records reviewed with a diagnosis of diabetes (Patient #3).

The agency failed to ensure verbal orders for start of care or recertification were obtained or documented in the patient’s clinical record in 2 of 4 active clinical records reviewed with skilled nursing care ordered (Patient #3,Patient #8), and in 1 of 2 active clinical records reviewed with…

The agency failed to ensure home health aide supervisory assessments were conducted onsite in 1 of 2 active clinical records reviewed with home health aide services (Patient #4).

The home health agency failed to include in the individualized plan of care the types of services, supplies, equipment required, nutritional requirements, all medications and treatments, and patient specific interventions and safety measures ( see tag G574); failed to have the physician review and…

The home health agency failed to include a process for cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation.

The home health agency failed to ensure an individualized plan for each patient during a natural or man-made disaster was included in the patient’s comprehensive assessment in 8 of 8 clinical records reviewed.

The home health agency failed to ensure they included the procedures to inform State and local emergency preparedness officials about patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical, psychiatric, and home environment…

The home health agency failed to ensure the procedures were included to inform the State and local officials of any on-duty staff or patients that the agency were unable to contact.

The home health agency failed to develop and maintain an emergency preparedness communication plan that included contact information for the Federal, State, tribal, regional, and local emergency preparedness staff.

The home health agency failed to develop and maintain an emergency preparedness communication plan that included primary and alternate means for communication with the facility, staff, federal, state, tribal, regional, and local emergency management.

The home health agency failed to provide emergency preparedness training at least every 2 years and failed to maintain documentation of all emergency preparedness training.

The home health agency failed to conduct or participate in a full-scale community drill every 2 years or conduct a facility-based functional exercise every 2 years.

The home health agency failed to transmit accurate OASIS (outcome and assessment information set) with the current status of the patient at the time the OASIS was completed in 3 of 4 clinical records reviewed with skilled nurse visits.

The home health agency failed to ensure they sent all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective…

The home health agency’s governing body failed to approve the frequency and detail of the data collection for Quality Assessment Performance Improvement (QAPI) program.

The home health agency failed to conduct at least one performance improvement project yearly.

The home health agency failed to ensure they provided infection control education to all staff annually.

The home health agency failed to implement policies and procedures to ensure the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who were not fully vaccinated.

The home health agency failed to obtain the legal representative’s signature confirming that he or she had received a copy of the notice of rights and responsibilities in 2 of 2 discharged clinical records reviewed.

The home health agency failed to provide a comprehensive assessment that accurately reflected the patient’s status in 2 of 6 active clinical records reviewed (#2, #5) Findings include: 1. Record review evidenced an undated agency policy received on 02/01/2023, titled, “Comprehensive Client…

The home health agency failed to ensure all current patient medications were reviewed as part of the comprehensive assessment, to identify any potential adverse effects, drug reactions, significant drug interactions, and duplicate drug therapy in 2 of 4 clinical records reviewed with skilled nurse…

The home health agency failed to ensure the individualized plan of care included the types of services, supplies, and equipment required; nutritional requirements, all medications and treatments, patient specific interventions and safety measures in 8 of 8 clinical records reviewed.

The home health agency failed to ensure the physician reviewed and revised the plan of care as frequently as the patient’s conditions required in 1 of 3 transferred/discharged clinical charts reviewed.

The home health agency failed to ensure they promptly alerted the physician to any changes in the patient’s condition or needs that suggest the outcomes were not being achieved and/or the plan of care should be altered in 4 of 6 active clinical records reviewed.

The home health agency failed to ensure integrated services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines…

The home health agency failed to provide a written visit schedule to the patient consistent with the patient’s most current plan of care in 2 of 4 home visits.

The home health agency failed to ensure they provided the patient written information regarding the patient’s medication regimen in plain language that does not include medical abbreviations in 4 of 4 home visits.

The home health agency failed to ensure the performance improvement activities led to an immediate correction of any identified problems that directly or potentially threaten the health and safety of patients.

The home health agency failed to ensure they provided services ordered by the physician as indicated in the plan of care in 4 of 5 clinical records reviewed with physical therapy services.

The home health agency failed to ensure communication with all physicians involved in the current plan of care for 1 of 1 clinical records reviewed of patients receiving warfarin (blood thinning medication).

The home health agency failed to ensure the home health aide provides services that were included in the plan of care in 1 of 2 home visits with a home health aide.

The home health agency failed to ensure they provided a supervisory aide visit no less frequently than every 14 days for patients receiving home health aide services in 1 of 3 active patients who received home health aide services.

The home health agency failed to ensure services were provided in accordance with current clinical practice guidelines and accepted professional standards of practice.

The agency failed to ensure the home health aide followed infection control policies for 1 of 3 home visits observed (#2).

The Director of Nursing failed to ensure a HHA (home health aide) care plan was individualized with specific, not generic tasks to be completed for each shift the aides provided care for 1 of 7 charts reviewed (#2) and failed to ensure all tasks assigned to the home health aide were performed as…

The agency failed to maintain documentation of all complaints and actions made by the agency to investigate and resolve the complaints for 1 of 1 agency.

The registered nurse (RN) failed to ensure the comprehensive assessment contained a complete review of medications and the medication list was maintained for 7 of 7 records reviewed (#1, 2, 3, 4, 5, 6, 7).

The agency failed to ensure the plan of care (POC) included all DME (durable medical equipment) and measurable goals in 7 of 7 records reviewed (#1,2, 3, 4, 5, 6, 7).

The agency failed to ensure orders for patient care and services were provided only by a physician for 1 of 1 agency.

The agency failed to ensure a written visit schedule was provided to the patient for review for 3 of 3 home visits observed (#1, 2, 3).