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It includes survey context, facility identifiers, and corrective action expectations, with deficiency details referencing specific clinical records and multiple missed or undocumented notifications during timed visits.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/cms-2567-statement-of-deficiencies-and-plan-of-correction/252857/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/cms-2567-statement-of-deficiencies-and-plan-of-correction/252857.png","ImageObject",442,249,{"name":42,"@type":43},"Lucas Martin","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-30","2026-09-13",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",16,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What survey is this form related to?","Question",{"text":63,"@type":64},"It relates to a federal home health recertification survey with a partial extended survey for Sunshine Home Assistance Services.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"Which deficiency is described in the document text?",{"text":68,"@type":64},"The document describes deficiency G 158 related to failing to ensure ordered visits were made and failing to document notification to the heart center when blood pressure was outside specified parameters.",{"name":70,"@type":61,"acceptedAnswer":71},"How many clinical records are referenced for the deficiency?",{"text":72,"@type":64},"The text states the issue affected 3 of 10 records reviewed, specifically clinical records #1, #2, and #7.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},252857,1790695751,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,108,112,117,122],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":55,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":135,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":33},8796095360427,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES  \nPRINTED: 04/18/2012  \nFORM APPROVED OMB NO. 0938-0391  \n\n| STATEMENT OF DEFICIENCIES\u003Cbr>AND PLAN OF CORRECTION |  | (X1) PROVIDER/SUPPLIER/CLIA\u003Cbr>IDENTIFICATION NUMBER:\u003Cbr>15K002 |  | (X2) MULTIPLE CONSTRUCTION A. BUILDING\u003Cbr>B. WING   |  |  | (X3) DATE SURVEY\u003Cbr>COMPLETED\u003Cbr>01/12/2012 |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| NAME OF PROVIDER OR SUPPLIER\u003Cbr>SUNSHINE HOME ASSISTANCE SERVICES |  |  |  |  | STREET ADDRESS, CITY, STATE , ZIP CODE\u003Cbr>222 W WAYNE ST\u003Cbr>FORT WAYNE, IN 46802 |  |  |  |\n| (X4) ID\u003Cbr>PREFIX\u003Cbr>TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) |  | ID\u003Cbr>PREFIX\u003Cbr>TAG |  |  | PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) |  | (X5)\u003Cbr>COMPLETION\u003Cbr>DATE |\n| G 000\u003Cbr>G 158 | INITIAL COMMENTS\u003Cbr>This was a home health federal recertification survey. This was a partial extended survey.\u003Cbr>Survey dates: January 9-12, 2012\u003Cbr>Faciliy \\#: 005869\u003Cbr>Medicaid \\#: 100265660A Surveyor: Miriam Bennett RN, PHNS\u003Cbr>Census: 57\u003Cbr>Quality Review: Joyce Elder, MSN, BSN, RN January 19, 2012\u003Cbr>This survey was modified as the result of an IDR [3/14/12. je](3/14/12. je)\u003Cbr>484.18 ACCEPTANCE OF PATIENTS, POC, MED SUPER\u003Cbr>Care follows a written plan of care established and periodically reviewed by a doctor of medicine, osteopathy, or podiatric medicine.\u003Cbr>This STANDARD is not met as evidenced by: Based on clinical record review and interview, the agency failed to ensure visits were made and notification of the heart center was completed when blood pressure was outside the identified parameters as ordered on the plan of care for 3 of 10 records reviewed with the potential to affect all the agency's 57 patients. (\\#1, 2, and 7)\u003Cbr>Findings include: |  | G 000\u003Cbr>G 158 |  |  |  |  | 3/2/12 |\n\nLABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE  \nAny deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions. ) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.  \nFORM CMS-2567(02-99) Previous Versions Obsolete Event ID:6BMY11 Facility ID: IN005869 If continuation sheet Page 1 of 10  \nDEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES  \nPRINTED: 04/18/2012  \nFORM APPROVED OMB NO. 0938-0391  \n\n| STATEMENT OF DEFICIENCIES\u003Cbr>AND PLAN OF CORRECTION |  | (X1) PROVIDER/SUPPLIER/CLIA\u003Cbr>IDENTIFICATION NUMBER:\u003Cbr>15K002 |  |  | (X2) MULTIPLE CONSTRUCTION A. BUILDING\u003Cbr>B. WING   |  |  | (X3) DATE SURVEY\u003Cbr>COMPLETED\u003Cbr>01/12/2012 |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| NAME OF PROVIDER OR SUPPLIER\u003Cbr>SUNSHINE HOME ASSISTANCE SERVICES |  |  |  |  |  | STREET ADDRESS, CITY, STATE , ZIP CODE\u003Cbr>222 W WAYNE ST\u003Cbr>FORT WAYNE, IN 46802 |  |  |  |\n| (X4) ID\u003Cbr>PREFIX\u003Cbr>TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) |  |  | ID\u003Cbr>PREFIX\u003Cbr>TAG |  |  | PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) |  | (X5)\u003Cbr>COMPLETION\u003Cbr>DATE |\n| G 158 | Continued From page 1\u003Cbr>1. Clinical record \\#1 contained a plan of care for certification period 6/28/ 11-8/28/ 11. An order dated 7/29/ 11 was noted to increase aide visits to twice a day. Ther","cbCaibb8D58LZFwg","https://ap.wps.com/l/cbCaibb8D58LZFwg","pdf",67958,10,"English","# Initial Comments\n## Survey context and compliance basis\n# Deficiency Summary (G 158)\n## Missed visits and failure to notify heart center\n## Clinical record findings and blood pressure readings","[{\"question\":\"What survey is this form related to?\",\"answer\":\"It relates to a federal home health recertification survey with a partial extended survey for Sunshine Home Assistance Services.\"},{\"question\":\"Which deficiency is described in the document text?\",\"answer\":\"The document describes deficiency G 158 related to failing to ensure ordered visits were made and failing to document notification to the heart center when blood pressure was outside specified parameters.\"},{\"question\":\"How many clinical records are referenced for the deficiency?\",\"answer\":\"The text states the issue affected 3 of 10 records reviewed, specifically clinical records #1, #2, and #7.\"}]","CMS-2567 - Statement of Deficiencies and Plan of Correction | PDF",1789263181]