Mountain Crest Home Health

The home health agency (HHA) failed to 1) develop, implement, and maintain an ongoing home health agency-wide data driven quality assessment and performance improvement (QAPI) program; 2) failed to measure, analyze and track quality indicators from all aspects of performance to enable the HHA to…

The Home Health Agency (HHA) failed to conduct a full-scale exercise every two years that was community based or an individual, facility based functional exercise, or a mock disaster drill or a tabletop exercise to activate the emergency plan and ensure that staff respond to emergencies as…

The home health agency (HHA) failed to develop, implement, and maintain an ongoing, data driven quality assessment and performance improvement (QAPI) program which reviewed patient outcomes, patient safety and quality of care provided by the agency.

The HHA failed to utilize quality indicator data, including measures derived from the OASIS (Outcome and Assessment Information Set).

The home health agency failed to implement and maintain documentation of performance improvement projects (PIPs) being conducted currently, the reasons for conducting these projects, and measurable progress achieved on these projects.

The home health agency (HHA) failed to ensure the HHA-wide quality assessment and performance improvement (QAPI) efforts addressed priorities for improved quality of care and patient safety, and that patient care delivery was evaluated for effectiveness.

The home health agency (HHA) failed to ensure each home health aide completed at least 12 hours of in-service training during each 12-month period for 2 of 2 (Home Health Aide1, Home Health Aide 2) Home Health Aides that had been employed 12 months or longer.

The Home Health Agency (HHA) failed to ensure at least one of the services provided to the patients was direct HHA employees.

The Home Health Agency (HHA) failed to ensure the plan of care, including evaluations, assessments, goals, and interventions, were complete for three of seven patients (Patients (P) 1, P2, and P5) whose records were reviewed.

The home health agency (HHA) failed to take actions aimed at performance improvement and, after implementing those actions, objectively measure the success and track performance to ensure improvements were sustained.

The Home Health Agency (HHA) failed to ensure a system was in place for timely submission of “Home Health Aide – Progress Visit Note” for one of seven patients’ (Patients(P) 1) whose records were reviewed.

The HHA failed to collaborate with the local, state, regional, or federal emergency preparedness officials or document efforts to contact officials to maintain an integrated response during a disaster or emergency.

The HHA failed to maintain a current list of contact information that included federal, state, and local emergency preparedness staff and agencies in their Emergency Preparedness Communication Plan.

The agency failed to analyze, track, and monitor the effectiveness of quality indicators or demonstrate improvement in outcomes and quality of care during the entirety of 2019. Findings include: Upon request for the home health agency's QAPI policy, the Director of Nursing (DON)/Registered Nurse…

The home health agency (HHA) was not in compliance with regulatory requirements safeguarding personal health information, and failure to protect patient information from risk of loss or unauthorized use.