Crystal Home Healthcare

The agency failed to develop and maintain an emergency preparedness plan based on both an agency-based and community-based risk assessment (See E0006); failed to develop written emergency preparedness policies and procedures that were based on an emergency preparedness plan, risk assessment, and…

The agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs; and…

The agency failed to ensure the plan of care included reportable parameters, safety precautions, and measurable outcomes and goals in 6 of 8 records (MR # 3, 4, 5, 6, 7, 8) reviewed.

The agency failed to document any Quality Assessment Performance Improvement (QAPI) program activities for 2022 (G-660), to optimize patient outcomes, and to have at least one performance improvement project (PIP) this year.

The agency failed to ensure effective infection prevention and control measures were utilized (G-682); failed to document any infection control meeting minutes for 2020, 2021 and 2022 (G-684); and failed to establish Vaccine protocol written policies and procedures that included (iii)…

The agency failed to develop and maintain an emergency preparedness plan centered on both agency-based and community-based risk assessments, resulting in a lack of direction and duties for agency personnel in the event of an actual disaster.

The agency failed to develop written emergency preparedness policies and procedures that were based on an emergency preparedness plan, risk assessment, and communication plan.

The agency failed to develop and maintain an Emergency Preparedness communication plan that complies with Federal, State, and local laws, resulting in the agency's inability to ensure the coordination of patient care in the event of an actual emergency.

The agency failed to develop and maintain an Emergency Preparedness training and testing program that is based on the emergency plan, risk assessment, policies, procedures, and communication plan.

The agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs; and…

The Agency failed to ensure the comprehensive assessment was updated and revised for 2 of 2 (MR #2, #8) records reviewed in which patients were transferred to the hospital or care was resumed after a hospital stay, resulting in lack of information in determining the patient's care and support needs.

The agency failed to initiate a performance improvement project (PIP) within their Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for the rendering of substandard care and unmet care needs.

The Governing Body failed to ensure the agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that fulfilled all the regulatory requirements of this section, that addressed priorities for improved quality of care and patient safety and was evaluated for…

The Agency failed to ensure its disciplines utilized Infection Control standards of practice during the provision of care and services for 2 (MR #2, 7) of 2 patients observed during home visits from a total of 8 sampled records reviewed, resulting in the potential for the development and spread of…

The agency failed to maintain an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of the agency's Quality Assessment Performance Improvement (QAPI) program, resulting in the potential spread of…

The Agency failed to establish Vaccine protocol written policies and procedures that included (iii) implementation of additional precatutions to mitigate the transmission and spread of Covid-19; (vii) a process for tracking/documenting information provided by staff who have reqursted/been granted…

The home health agency failed to have an active Governing Body that met at least annually, and assumed full legal authority and responsibility for the agency's overall management and operations, all services provided, the fiscal operations, review of the agency's budget and operations plans and…

The agency failed to ensure that at least one qualifying service was provided directly by agency employees, resulting in the agency contracting for all patient services.

The Agency failed to ensure the patient's needs were met for 1 (MR #1) of 1 patient who required Skilled Nursing services, and 1 (MR #2) of 1 patient who required Occupational Therapy services, from a total of 8 sampled records reviewed, resulting in unaddressed/untreated health concerns and unmet…

The agency failed to ensure a registered nurse conducted a review of the patient's medications for any potential adverse effects such as: side effects, drug interactions, and duplicate drug therapy for 8 of 8 (MR# 1, 2, 3, 4, 5, 6, 7, 8) records reviewed, resulting in the potential for harmful…

The Agency failed to ensure the Resumption of Care Comprehensive Assessment was conducted within 48 hour of the patient's return home post hospitalization in 1 (MR #2) of 2 patients who resumed care under the Agency's services, from a total of 8 sampled patients reviewed, resulting in delay in…

The Agency failed to ensure the Comprehensive Assessment was updated and completed at the time of discharge from the Agency's services in 2 (MR #1, 5) of 2 discharged records, from a total of 8 sampled records reviewed, resulting in no indication of the patient’s progression towards their…

The agency failed to ensure the plan of care included reportable parameters, safety precautions, and measurable outcomes and goals for 6 of 8 (MR# 3, 4, 5, 6, 7, 8) records reviewed, resulting in the potential for poor patient outcomes due to a lack of safety precautions, and quantifiable measures…

The agency failed to ensure services were provided in accordance with a physician's order in 1 of 8 records reviewed (MR #6) in which skilled nursing (SN) and physical therapy (PT) services provided care, from a total of 8 records reviewed, resulting in the potential for the patient to receive…

The Agency failed to ensure the Physician was promptly notified of 2 (MR's #1, 2) of 2 patients who experienced a significant change in condition and elevated vital signs, from a total of 8 sampled records reviewed, resulting in unadressed/untreated health concerns and the potential for unmet…

The Agency failed to ensure the Registered Nurse conducted a thorough assessment and reassessment of the patient's health status for 1 (MR #2) of 1 patient observed during a home visit with a low heart rate and lower estremity swelling, from a total of 8 sampled records reviewed, resulting in the…

The agency failed to ensure physical therapy (PT) services were provided as ordered by the physician in the plan of care (POC) for 1 of 6 (MR# 6) records reviewed with PT services ordered, from a total sample of 8 records, resulting in the potential for physical decline and negative patient…

The agency failed to ensure to have a written agreement with 10 of 10 (OT#1, SW#1, PT#2, PTA#1, RN#1, PT#3, RN#3, PTA#4, PT#5, and LPN#1)) independent contractors furnishing services under arrangement to agency patients, resulting in a lack of overall responsibility by the agency for the services…

The agency failed to ensure the clinical record contained all clinical notes for 1 of 8 (MR#4) records reviewed, resulting in a lack of information for the physician and all agency staff caring for this patient.

The Agency failed to ensure the Transfer/Discharge summaries were completed, detailed, and provided the patient's current health status at the time of Transfer/Discharge, included information on progress toward goals, and forwarded to the receiving facility within 2 days, and forwarded to the…