Sapphire Home Health Care LLC

The agency failed to demonstrate an operational QAPI program.

The agency failed to ensure the emergency preparedness (EP) plan included cooperation and collaboration with regional, state, and federal EP officials to ensure an integrated response during a disaster for 1 of 1 home health agency.

The agency did not demonstrate any Emergency Preparedness policies and procedures that define a process for notifying state emergency officials about homebound patients needing evacuation assistance during an emergency for 1 of 1 home health agency.

The agency failed to ensure emergency preparedness policies and procedures included processes to follow up with on-duty staff and patients during an emergency in order to inform state and local officials of any on-duty staff or patients the agency was unable to contact for 1 of 1 home health agency.

The agency did not demonstrate that its Emergency Preparedness policies included strategies for emergency staffing, including the use of volunteers, during an emergency for 1 of 1 home health agency.

The agency failed to ensure the Emergency Preparedness communication plan included contact information for regional, state, and federal emergency preparedness staff for 1 of 1 home health agency.

The agency failed to ensure an infection control policy was implemented appropriately to prevent cross-contamination of equipment used and ensure safety of personnel and patients for 3 of 4 home visits conducted (Patient #2, 3, 4).

The agency failed to ensure an initial RN assessment was completed within 48 hours of referral for 5 of 10 clinical records reviewed (Patient #3, 4, 5, 6, 9).

The agency failed to ensure that current written visit schedules, including visit type and frequency, were provided in patient’s homes for 2 of 4 home visits conducted (Patient #3, 4).

The agency failed to provide written medication instructions to patients and caregivers for 2 of 4 home visits conducted (Patient #3, 4).

The agency failed to ensure all patients received a list of all current treatments to be performed by agency staff for 3 of 4 skilled home visits conducted (Patient #2, 3, 4).

The agency failed to ensure the RN monitored the care provided to patients by the LPN for 8 of 10 clinical records reviewed (Patient #1, 3, 4, 5, 6, 8, 9, 10).

The agency failed to ensure home health aides provide services that are consistent with home health aide training for blood glucose checks for 3 of 3 HHA personnel records reviewed (HHA 1, HHA 2, HHA 3) and 1 of 1 CNA personnel record reviewed (CNA 1).

The agency failed to ensure HHA supervisory visits were completed every 14 days for patients receiving skilled professional services for 2 of 7 active clinical records with HHAs reviewed (Patient #3, 8).

The agency failed to ensure staff included the patient’s most up to date assessments in the patient’s visit notes for 4 of 10 clinical records reviewed (Patient #1, 2, 6, 9).

The agency failed to ensure the discharge summary was sent to the primary care provider within the 5-business day timeframe for 1 of 2 closed records reviewed (Patient #10).