Clarity Home Health

The agency failed to ensure its Emergency Preparedness Plan was reviewed and updated at least annually as evidenced by not having the plan reviewed and updated since 07/12/2021. This deficient practice had the potential to affect any of the 98 active patients.

The facility failed to update the Emergency Preparedness Policies and Procedures at least every two years.

The facility's Emergency Preparedness Plan failed to include a training and testing program that was reviewed and updated at least every 2 years.

Agency failed to ensure existing staff, including contract staff, providing services received initial training in Emergency Preparedness policies and procedures, had training at least every 2 years, and documentation of training was maintained with demonstration of staff knowledge of emergency…

The agency failed to participate in a full-scale exercise that is community-based every two years or analyze the agency’s response to and maintain documentation of all drills, tabletop exercises, emergency events, and revised the emergency plan, as needed.

The agency failed to ensure each OASIS (Outcome and Assessment Information Set) was successfully transmitted to the CMS system within 30 days of completion.

The agency failed to maintain documentation the Governing Body conducted ongoing monitoring of the agency's Quality Assurance and Performance Improvement (QAPI) program for quality improvement and patient safety.

The agency failed to ensure staff followed accepted standards of infection control practices for 1 (#1) of 4 (#1, #2, #3 and #4) patients observed during home visits.

The agency failed to ensure each patients’ comprehensive assessment included a review of all medications the patients were currently using.

The agency failed to assure communication with all physicians involved in the Plan of Care.

The agency failed to provide services as ordered by the physician in the Plan of Care for 1 (#3) of 10 (#1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) patient records reviewed.

The agency failed to ensure the accuracy of skilled nurse documentation as evidenced by inaccurate documentation found on the Skilled Nurse Visit note dated 05/05/2025 for Patient #1 out of a total of 10 sampled patients.

The agency failed to ensure each patient’s clinical record contained pertinent current findings in accordance with accepted professional standards for 1 (#6) of 10 (#1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) patient records reviewed.

The agency failed to ensure a completed discharge summary was sent to the patients primary care practitioner within 5 business days of the patient’s discharge from the agency for 1 (#10) of 3 (#8, #9, and #10) discharged patient records reviewed.

The agency failed to comply with accepted professional standards and principles by failing to have a Registered Nurse assess a patient's pressure wound, including the size and stage, weekly for 1 (#5) of 2 (#3, #5) patients reviewed with pressure wounds.

The agency failed to communicate with the NP/MD for 1(#1) of 7(#1 - #7) patients reviewed.

The agency failed to measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the home health agency to assess processes of care, services, and operations as evidenced by no documentation of QAPI activities in 2018. Findings…

The agency failed to ensure performance improvement activities included tracking adverse patient events, analyzing their causes, and implementing preventive actions as evidenced by no documentation of QAPI activities in 2018. Findings: Review of the agency's Quality Assurance information revealed…

The agency failed to ensure performance improvement projects were conducted beginning January 13, 2018 as evidenced by no documentation of performance improvement projects conducted in 2018. Findings: Review of the agency's Quality Assurance information revealed there was no documentation available…

The agency's governing body failed to ensure that an ongoing program for quality improvement and patient safety was defined, implemented, and maintained as evidenced by no documentation of quality improvement activities performed in 2018. Findings: Review of the agency's Quality Assurance…

The agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that was an integral part of the home health agency's QAPI program as evidenced by failure to monitor, evaluate…

The agency failed to ensure the Registered Nurse prepared written instructions for the Home Health Aide for 1 (#3) of 1(#3) patients receiving home health aide services.

The home health agency failed to ensure a comprehensive assessment was updated for 1 (#6) of 7 (#1-#7) patients reviewed.

The agency failed to ensure all patient care orders were recorded in the plan of care for 1 (#6) of 7 (#1-#7) patients reviewed.

The agency failed to ensure the total plan of care was signed and dated by the patient's physician in a timely manner for 5 (#2, #4, #5, #6, #7) of 7 (#1-#7) sampled patients.

The agency failed to provide services ordered by the physician for 1 (#3) of 7 (#1 - #7) sampled patients.

The home health agency failed to ensure the RN provided HHA services in accordance with current clinical practice guidelines and accepted professional standards for 1 (#6) of 7 (#1-#7) patients reviewed.

The agency failed to ensure the contents of the clinical record included all interventions, including medication administration, treatments, and services, and responses to those interventions for 1 (#6) of 7 (#1-#7) patients reviewed.