Bonny Crest Home Healthcare, Inc

The agency failed to ensure the existence of and/or documentation of contact information given to patients for the purpose of making complaints with the agency for all patients and caregivers.

The agency failed to ensure development of a QAPI Program with efforts for improvement in indicators to improve health, patient safety and quality of care for all patients and agency staff.

The agency failed to ensure development and implementation of an infection control program, policies, procedures and standard precautions to prevent transmission of infections for all patients and staff.

The agency failed to ensure the governing body maintained and/or documented responsibility for the agency's overall management and operation to include fiscal operations, review of the agency's budget, operational plans and the QAPI program for all agency staff and patients.

The agency failed to ensure maintenance and availability of clinical records for an unknown number of patients on service with the agency during calendar years 2019, 2019, and 2021. This failed practice had the potential for a delay in assessment and clinical information on patient request (for an…

The agency failed to ensure development of an Emergency Preparedness Plan and program for all agency employees and patients.

The agency failed to ensure development, review and maintenance of an emergency preparedness plan based on a facility and community-based assessment and utilizing an all-hazards approach for all patients and agency staff.

The agency failed to ensure emergency plan testing and participation in community based or facility based exercises for all agency patients and staff.

The agency failed to ensure development of a QAPI Program with efforts for improvement in indicators to improve health, patient safety and quality of care for all patients and agency staff.

The agency failed to ensure development and utilizetion of a QAPI program using OASIS and quality indicator data for self identification and correction of agency problems for all patients and agency staff.

The agency failed to ensure conduction of at least one PIP during the calendar years of 2019, 2020 and 2021 for all agency staff and patients.

The agency's governing body failed to ensure: 1. development and implementation of an ongoing QAPI program: 2. QAPI efforts addressed priorities form improvement in patient care and safety; 3. all improvement efforts were evaluated for effectiveness; 4. expectations for patient safety were…

The agency failed to ensure development and implementation of an infection control program, policies, procedures and standard precautions to prevent transmission of infections for all patients and staff.

The agency failed o ensure: 1. Development and maintenance of a coordinated agency-wide infection control program for identification, prevention, control and investigation of infections and communicable diseases and 2. The infection control program was an integral part of an agency QAPI program for…

The agency failed to ensure infection control education was provided and documented for all agency staff, patients, and caregivers.

The agency failed to ensure the governing body maintained and/or documented responsibility for the agency's overall management and operation to include fiscal operations, review of the agency's budget, operational plans and the QAPI program for all agency staff and patients.

The agency failed to ensure their services included skilled nursing services and at least one other therapeutic service for all patients who may be referred to the agency.

The agency failed to ensure the governing body maintained documentation of agency overall plan, budget, and capital expenditure plan.

The agency failed to ensure the existence of and/or documentation of contact information given to patients for the purpose of making complaints with the agency for all patients and caregivers.

The agency failed to ensure development or maintenance of a complaint program and agency efforts for all patient/caregivers to make complaints to the agency regarding concerns, care or lack thereof.

The agency failed to ensure the existence of records were kept and/or available to show clients were advised of payment expectations and charges for services not covered by Medicare, Medicaid or other federally-funded programs for all patients currently on services.

The agency failed to ensure (and or document) patients were advised of the state toll free home helath telephone hotline or its purpose to receive complaints or questions for all patients on service.This failed practice had the potential to stave off the access of information or additional source…

The agency failed to ensure development and maintenance of a QAPI program that focused on performance improvement activities for all staff and patients.

The agency failed to ensure agency documentation of qualified personnel and the development and documentation of personnel qualifications, policies and procedures for all agency personnel.

The agency failed to ensure maintenance and availability of clinical records for an unknown number of patients on service with the agency during calendar years 2019, 2019, and 2021. This failed practice had the potential for a delay in assessment and clinical information on patient request (for an…

The agency failed to ensure contact information for patients, patient's representatives and patient's primary caregivers were available in the clinical record for all patients on service during calendar years 2018, 2019 and 2021. This failed practice had the potential for an incomplete Medicare…

The agency failed to ensure documentation of patient discharge and transfer was available in clinical records at surveyor request for an unknown number of patients on service with the agency during calendar years 2018, 2019, and 2021. This failed practice had the potential to thwart survey efforts…

The agency failed to conduct emergency drills from January 1, 2018 - January 15, 2019 for all current employees.

The agency failed to ensure: 1) evaluation/re-evaluation of PIPs for two of two PIPS (#1 and 2) 2) identification and implementation of PIP interventions for two of two PIPS (#1 and 2) 3) identification of a reasonable expected completion date for two PIPS (#1 and 2) Findings: A review of QAPI…

The agency failed to ensure: 1) their Infection Control Program was included in QAPI activities 2) infection control and QAPI activities for patients with known infections showed interventions to reduce future infections and promote learning and preventative measures throughout the agency for all…

The agency failed to ensure the POC included a visit frequency for skilled nursing visits for one (Pt #4) of 11 patients.

The agency failed to ensure coordination with the physician on missed visits and the possible need for changes in the POC frequency of nursing, physical therapy CHHA visits for one (Pt #2) of 11 patients.

The agency failed to ensure: 1) SN services were provided in accordance with the POC frequency for one (Pt #5) of 11 patients 2) wound care was provided as ordered for one (Pt #6) of 11 patients.

The agency failed to ensure preparation and availability of clinical notes for one (Pt #4) of 11 patients.