Crescent Home Health Agency, LLC

The home health provider failed to ensure emergency preparedness (EP) training was completed on hire in four of four employee records reviewed (Employees #1, #2, #3, and #4).

The home health provider failed to ensure infection control training was completed on hire and annually in three of four employee records reviewed (Employees #2, #3, and #4).

The home health provider failed to ensure the plan of care (POC) was signed and dated by the physical therapist (PT) in one of five full records reviewed (Record/Patient #3).

The provider failed to ensure the right to be informed of the state toll-free home health telephone hotline number hours of operation in three of three home visit observations (Records/Patients #1, #2, and #4).

The home health provider failed to ensure staff maintained an accurate and updated medication profile in, but not limited to, one of three home visit observations (Record/Patient #1).

The home health provider failed to notify the physician of blood pressures outside of ordered parameters in one of five full records reviewed (Record/Patient #1).

The home health provider failed to provide the patient with written instructions to report vital signs outside of parameters, measures to alleviate edema (swelling), monitor an area of skin concern on the left lower extremity for deterioration, dietary/fluid restrictions and the importance of…

The home health provider failed to furnish the patient and caregiver, in writing, with the name and contact information of the clinical manager in, but not limited to, one home visit observation conducted (Record/Patient #1).

The home health provider failed to assess the patient’s blood sugar every visit as ordered by the physician in one of five full records reviewed (Record/Patient #5).

The home health provider failed to ensure the Employee Disqualification List (EDL) was checked prior to hire on one of four employee files reviewed (Employee #2).

The home health provider failed to ensure the patient’s discharge summary was sent to the patient’s physician within five business days of discharge in one of five full records reviewed (Record/Patient #3).

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 09/02/2021. One condition level deficiency was identified at 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

The agency failed to develop and provide the patient and/or representative with a written notice of patient rights that included all required information.

The agency failed to: - Provide an individualized plan of care that included, but not limited to, all pertinent diagnoses, the types of services, supplies, and equipment required, the frequency and duration of visits to be made, all medications and treatments (G574); - Provide drugs, services, and…

The agency failed to ensure there was evidence of a Quality Assurance and Performance Improvement (QAPI) program for the agency.

The agency failed to organize, manage, and administer it's resources to attain and maintain the highest practicable functional capacity, including providing optimal care when the agency failed to showed adequate governing body, administrative, and clinical manager oversight to patients resulting in…

The agency failed to ensure they developed and maintained an Emergency Preparedness (EP) plan that was reviewed and updated at least annually based on a facility based and community based risk assessment utilizing an all hazards approach which contained all elements.

The agency failed to include a comprehensive process for cooperation and collaboration with local, regional, state and federal EP officials.

The agency failed to ensure a policy for emergency staffing strategies was developed for the agency's Emergency Preparedness (EP) plan.

The agency failed to develop a comprehensive communication plan that included names and contact information of staff, physicians, and other service provider to be accessed during an emergency.

The agency failed to ensure names and contact information for staff, entities providing services under arrangement, patient's physicians, and volunteers was included in the EP plan.

The agency failed to ensure contact information was included and updated for federal, state, tribal, regional, or local emergency preparedness staff and other sources of assistance.

The agency failed to ensure staff were provided annual Emergency Preparedness (EP) training in three (Employee #1, #2, and #4) of five employee files reviewed.

The agency failed to conduct exercises to test the emergency plan annually and analyze the agency's response to and maintain documentation of all drills, table top exercises, and emergency events, and revise the agency's emergency plan as needed.

The agency failed to update the written notice of patient rights to include that information must be provided to patients in a language and in a manner that is accessible and timely to persons with disabilities, including accessible web sites and the provision of auxiliary aids services are at no…

The agency failed to put in place a program for screening visitors/non-employees who entered the home health agency office and patients prior to home visits for COVID-19 (pandemic infection) signs and symptoms.

The home health agency failed to ensure that the clinical manager/director of nursing was available for oversight of all patient care services and personnel, assuring the patient's needs were continually assessed, and assuring the development, implementations and updates of individualized plans of…

The agency failed to update the written notice of patient rights to include: - Transfer and discharge policies; - Rights and responsibilities that are understandable to persons who have limited English proficiency; and - Rights and responsibilities accessible to individuals with disabilities.

The agency failed to update the written notice of patient rights to include the rights of the patient and representative (if any) regarding contact information for the home health agency administrator to receive complaints.

The agency failed to provide written notice of patient rights regarding their right to have a copy of the patient's rights and responsibilities provided to a patient-selected representative within four business days of the initial evaluation visit.

The agency failed to include the patient has the right to be free from verbal, mental, sexual and physical abuse, including injuries of unknown source, neglect and misappropriation of property.

The agency failed to include the patient has the right to make complaints to the home health agency regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the home health agency.

The agency failed to update the written notice of patient rights to include the patient has the right to participate in, be informed about, and consent or refuse care, with respect to completion of all assessments, care to be furnished based on the comprehensive assessment, and expected outcomes.

The agency failed to update the written notice of patient rights to include the patient has the right to receive all services outlined in the plan of care.

The agency failed to ensure the patient was advised orally and in writing of the extent to which payment for services may be expected from Medicare, Medicaid, or any other federally-funded aid program, the charges of services that may not be covered in one (Record/Patient #2) of three home visit…

The agency failed to include the patient has the right to receive proper written notice, in advance of a specific service being furnished, if the agency believes that the service may be non-covered care; or in advance of the agency reducing or terminating on-going care.

The agency failed to ensure staff provided the written notice of the updated state toll free home health telephone hotline hours of operation in the admission folder of three (Record/Patient #1, #2, and #3) of three home visit observations.

The agency failed to update the written notice of patient rights to include the name, address and phone number of the current Quality Improvement Organization (QIO) that serves the area where the patient resides.

The agency failed to provide the written notice of patient rights to include the patient has the right to be informed of the right to access auxiliary aids and language services and how to access these services.

The agency failed to update the written notice of patient rights to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the agency can no longer meet the patient's needs.

The agency failed to update the written notice of patient rights to include the agency may discharge or transfer from the agency if the patient or payer will no longer pay for services provided by the agency.

The agency failed to update the written notice of patient rights to include the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the physician and agency agree that the outcomes and goals have been achieved and the patient no…

The agency failed to update the written notice of patient rights to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the patient refuses services or elects to be transferred or discharged.

The agency failed to update the written notice of patient rights to include that the agency policy for discharge for cause: - Determines that the patient's or other persons in the home, behavior is disruptive, abusive or uncooperative to extent that the delivery of care to the patient or the…

The agency failed to update the written notice of patient rights to include that the agency must advise the patient or representative, physicians, and healthcare professionals who will be responsible for providing care after discharge, that a discharge for cause is being considered.

The agency failed to update the written notice of patient rights to include that the agency must document the problem and efforts made to resolve the problem, if the patient is considered for discharge for cause.

The agency failed to update the written notice of patient rights to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the patient dies.

The agency failed to update the written notice of patient rights to include the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the agency ceases to operate.

The agency failed to conduct the initial assessment of the patient within 48 hours of the referral to home care, or 48 hours after the patient's return home, or on the physician ordered start of care date in two (Record/Patient #3 and #4) of five full records reviewed.

The agency failed to ensure the patient's medications were reconciled during the start of care comprehensive assessment in, one (Records/Patients # 3) of five full records reviewed.

The agency failed to ensure that each patient's written individualized plan of care (POC) included all required elements in three (Record/Patient #1, #2 and #3) of five full records reviewed.

The agency failed to ensure staff obtained physician signed plans of care for orders and treatments and verbal or telephone orders in a timely manner which affected two (Record/Patient #4 and #6) of five full records reviewed.

The agency failed to ensure coordination of care delivery to meet the patient's needs in one (Record/Patient #3) of five records reviewed.

The agency failed to ensure staff provided patient's ongoing education and training in, but not limited to, one (Records/Patients #1) of five records reviewed.

The agency failed to provide a written visit schedule that included disciplines that would visit and the frequency of visits in two (Record/Patient #1 and #2) of three home visit observations performed.

The agency failed to provide the patient/caregiver with an updated/current copy of written instructions outlining the patient's medication schedule, including medication name, dosage, and frequency in one (Record/Patient #1) of three home visit observations performed.

The agency failed to provide the patient/caregiver with a copy of written instructions of any treatments being administered by the agency in two (Record/Patient #1 and #2) of three home visits performed.

The agency failed to ensure staff provided in writing the name and contact information of the clinical manager in, three (Record/Patient #1, #2, and #3) of three home visit observations.

The agency failed to ensure staff provided services as ordered by the physician in one (Record/Patient #4) of five full clinical records reviewed.

The agency may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey.

The agency failed to show the administrator or alternate administrator were responsible for all day to day operations of the agency.

Findings include: Based on current survey findings, the clinical manager/director of nursing (CM/DON) failed to: - Assure complete and accurate plan of care; - Assure reconciliation of medications were accurate; - Assure comprehensive assessments were completed within 48 hours of referral; - Assure…

The agency failed to ensure a complete comprehensive discharge summary containing relevant information was sent to the primary care practitioner or other health care professional who will be responsible for providing care to the patient after discharge within five business days of the patient's…