Gracelight Home Health

The Agency failed to ensure that the Condition of Participation: G 640 Quality Assessment and Performance Improvement (QAPI) was in compliance as follows: 1. Based on interview and record review, the facility failed to create and implement a plan for the monitoring, evaluation, and interpretation…

The agency failed to ensure that the Condition of Participation: G 680 484.70: Infection prevention and control was in compliance when: 1. Based on interview and record review, the facility failed to maintain an infection control program in order to: identify infection trends (analysis of a…

The agency failed to ensure the Condition of Participation: G 940 484.105 Organization and administration of services was in compliance when: Based on interview, and record review, the facility failed to ensure its governing body exercised operational oversight of the facility when: 1a) The…

The facility failed to develop and maintain an emergency preparedness plan when: 1) Contact information for local, state, federal, tribal and regional emergency preparedness officials were not available as part of the emergency preparedness plan as specified in the facility’s policies and…

The facility failed to ensure it implemented an infection control program when the facility had no formal process for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases and the facility’s Quality Assurance and Process Improvement program…

The facility failed to create and implement a plan for the monitoring, evaluation, and interpretation of quality indicator data (data or information collected by the facility regarding quality measures used in order to identify areas of improvement, analyze contributing factors, and implement…

The facility failed to ensure patient medical supplies were appropriate for use when multiple supplies were expired, not removed from the storage area, and were available for use on patients.

The facility failed to ensure it implemented an infection control program when the facility had not created a process for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases.

The facility failed to ensure their personnel development policy was being implemented for six of fifteen sampled home health aides (HHA- HHA 1, 2, 3, 4, 5, 6) when six HHAs did not have twelve hours of in-service education in twelve months for the year 2023. This failure had the potential for the…

The facility failed to ensure its license granted by the California Department of Public Health was displayed in a conspicuous area within the agency as specified as a requirement in Title 22 for home health agencies (HHAs).

The facility failed to ensure its governing body exercised operational oversight of the facility when: 1a) The Governing body did not ensure the Quality Assurance and Performance Improvement (QAPI - is a data driven and proactive approach to quality improvement) program created and implemented a…

The facility failed to ensure a review of all medications the patients were taking was conducted (medication reconciliation) for four of seven sampled patients (Patients 1, 2, 4, and 6).

The facility failed to ensure their hiring of personnel policy was being implemented for one of nine staff members (Alternative Administrator) when the facility failed to have the Alternative Administrator have an initial physical exam and tuberculosis (TB- an infectious respiratory disease) exam…