Every finding on record at Crystal Home Health Care, LLC

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 11/14/24. The Agency was in compliance with the Condition, 42 CFR 484.22, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 11/14/24.Standard level deficiencies cited. Abbreviations: Pt / Pts = Patient / Patients SOC = Start of Care POC / PsOC = Plan of Care / Plans of Care RN = Registered Nurse SN = Skilled Nurse OT = Occupational Therapy OASIS = Outcome and Assessment Information Set

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on a review of the Agency's OASIS submission report and Staff interview it was determined that the Agency failed to submit OASIS assessments within the required time frame. Findings include: 1. The Agency's past 12 months (11/12/23 to 11/12/24) OASIS submission report was reviewed on 11/12/24. The report contained information that out of the 1317 Agency's OASIS assessment reports, 284 (21.56 %) were submitted beyond the required time frame of 30 days. 2. During an interview with the Clinical Manager and Quality Assurance Nurse on 11/13/24 at 12:00 PM the Clinical Manager confirmed the Agency's late OASIS submission.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical records review and staff interview it was determined that in 4 of 13 (Pts # 9,10,7 and 8) clinical records reviewed Agency staff failed to provide services ordered in the Plans of Care. 3. Pt. #7 was admitted for home health services with the diagnosis of Hypertensive Health and Chronic Kidney Disease with Heart Failure Stage 1 to 4. The clinical record was reviewed on 11/13/24. The POC effective 9/10/24 required, “Orders…for Treatment: Notify Physician of vital sign parameters out of range: Blood Sugar, Fasting - Greater than 180 Less Than 70, Blood Sugar, Random – Greater than 250 Less than 70. The SN notes in the clinical record lacked blood glucose assessment. 4. Pt. #8 is admitted for home health services with the diagnosis of Neurocognitive Disorder with Lewy Body Dementia. The clinical record was reviewed on 11/13/24. The POC effective 9/9/24 required, “PT Frequency: 1 wk 9 as of Effective Date 09/09/24.” The clinical record included documentation of 2 PT visits dated 10/02/24 and 10/03/24 for the week of 09/29/24 to 10/05/24. The clinical record lacked documentation of a physician order for the second visit. 5. During an interview with the Director/Clinical Manager and Quality Assurance Specialist on 11/13/24 at 12:00 PM, and on 11/14/24 at 10:30 AM, the above findings were confirmed. Findings include: 1. Pt # 9 was admitted to home health services on 9/26/24 with diagnosis of Hemiplegia. The clinical record was reviewed on 11/12/24. The clinical record contained a POC for certification period of 9/26/24 to 11/24/24 that required " Notify Physician of fasting blood sugar: greater than 200mg /dl less than 60mg/dl and random blood sugar: greater than 170mg/dl less than 60mg/dl." The clinical record contained SN visit notes dated 10/25/24 and 11/01/24 that lacked blood sugar assessment. 2. Pt # 10 was admitted to home health services on 9/7/24 with diagnosis of Hypertensive Heart Disease. The clinical record was reviewed on 11/12/24. The clinical record contained a physician order addendum to the POC dated 11/01/24 for PT and OT to evaluate and treat. As of 11/13/24 no PT or OT evaluation have been provided.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record reviews and record reviews, it was determined that for 2 of 5 home visits conducted (Pts. #2 and #5), the Agency failed to obtain Physician orders prior to providing care or treatment. Findings include: 1.Pt. #2 was admitted for home health services with the diagnosis of Hypertensive Heart Disease with Heart Failure. During the home visit with the PT on 11/12/24, Pt. #2 was wearing a cervical collar brace. Pt. #2 was interviewed and stated that the brace had been in use for last 2 or 3 weeks and said that the only time it is taken off is during baths. During the home visit, the PT stated that Pt. #2 has been using the neck brace/collar since returning from the hospital after a fall incident. The clinical record was reviewed on 11/12/24. The clinical record included SN notes dated 11/1/24 that included the documentation, "SN educated patient and caregiver on monitoring skin under neck brace for redness or open areas, to wash (with) soap and water, pat dry and to call SN if skin breakdown." During the review of findings with the Quality Assurance Specialist and the Director on 11/13/24, the clinical record lacked a physician order for the use and care of a cervical collar brace. 2. Pt. #5 was admitted for skilled home health services with the diagnosis of Venous Insufficiency (Chronic) (Peripheral). A home visit was conducted with RN on 11/13/24. During the home visit, the following was observed: for the left lower leg, the RN took off the dressing, cleansed the wound with normal saline, applied zinc oxide, gentamycin 01. % ointment and (bordered foam dressing) and a self-adhesive dressing; for the right lower leg, the RN took the dressing off, cleansed the wound with normal saline, applied (collagenase), zinc oxide, xeroform dressing, silicon and hydro conductive dressing, applied a rolled gauze and covered it with an adhesive dressing. The clinical record was reviewed on 11/12/24. As of 11/12/24, the clinical record lacked a physician order for the wound treatment. 3. During an interview with the Director/Clinical Manager and Quality Assurance Specialist on 11/13/24 at 2:30 PM, and on 11/14/24 at 10:30 AM, the above findings were confirmed.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on review of clinical records, policy review and staff interviews, it was determined that for 6 of 13 (Pts. #1, 3, 5, 7, 8 and 13) clinical records reviewed, the Agency failed to assess the need for Pneumococcal Pneumonia and Influenza immunization. Findings include: 1. As of 11/14/24, the following clinical records reviewed lacked documentation of Influenza and/or Pneumococcal Pneumonia inquiry: Pt. #1. SOC 02/27/24 – lacked Pneumococcal Pneumonia immunization assessment. Pt. #3. SOC 11/5/24 - lacked Influenza immunization assessment. Pt. #5. SOC 10/02/24 – lacked Pneumococcal Pneumonia immunization assessment. Pt. #7. SOC 09/10/24 – lacked Influenza immunization assessment. Pt. #8. SOC 09/09/24 – lacked Pneumococcal Pneumonia immunization assessment. Pt. #13. SOC 04/18/24 – lacked Pneumococcal Pneumonia immunization assessment. 2. The Policy “Pneumonia Vaccination Program” was reviewed on 11/14/24 and required, “ The Agency shall administer or arrange for administration of a pneumococcal vaccination, in accordance with CDC recommendations to each client/patient who is age 65 or over and who has not received this immunization prior or upon service initiation, unless the patient refuses the offer for vaccination or the vaccination is medically contraindicated….The agency shall document in each client’s medical record that a vaccination against pneumococcal pneumonia was offered, and was administered, arranged, refused or medically contraindicated or that the client is not a member of a vaccination priority population… a. individual client record entries identifying the assessment for the need of the vaccination; date of offer or referral, client/patient response; administration; contraindication or refusal and any follow up activities; b. Standardized check-off form recording client/patient specific information, including the assessment for the need of vaccination; date of offer or referral; client/patient response; administration; contraindication, or refusal; and any follow up activities.” 3. During an interview was conducted during a home visit on 11/12/24, the Registered Nurse stated that patient Influenza immunization assessment is done during the Influenza season and are documented on the patient records. 4. During an interview with the Managing Partner/Administrator, Director/Clinical Manager and Quality Assurance Specialist on 11/14/24 at 11:00 AM, and it was stated that the Influenza and Pneumococcal Pneumonia immunization status inquiry are conducted and documented in the clinical record. During the same interviews, the above findings were confirmed.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on clinical records reviewed and staff interviews it was determined that in 4 of 13 (Pts # 9,1,5, and 7) clinical records reviewed the Agency failed to ensure clinical records were complete and accurate. 3. Pt. #1 was admitted to home health services on 02/07/24 with a diagnosis of Hypertensive Chronic Kidney Disease. The clinical record was reviewed on 11/13/24. During the home visit conducted on 11/12/24, the Admission Booklet which contained the form “Notice of Medicare Non-Coverage.” The forms were signed by the Pt. on 02/07/24, but the areas containing “Effective Date of Coverage your current home health services will end” was left blank. 4. Pt. #5 was admitted to home health services on 10/02/24 with a diagnosis of Venous Insufficiency (chronic) (peripheral). The clinical record was reviewed on 11/13/24. The clinical record lacked the consent for treatment. 5. Pt. #7 was admitted to home health services on 09/10/24 with a diagnosis of Hypertensive Heart Disease and Chronic Kidney Disease with Heart Failure Stage 1 to 4. The clinical record was reviewed on 11/13/24. As of 11/14/24, the PT POC lacked the Physician’s signature. 6. During an interview with the Director/Clinical Manager and Quality Assurance Specialist on 11/13/24 at 12:00 PM, and on 11/14/24 at 10:30 AM, with the Director, Quality Assurance Specialist and Managing Partner/Administrator, the above findings were confirmed. 1. Pt # 9 was admitted to home health services on 9/26/24 with diagnosis of hemiplegia. The clinical record was reviewed on 11/12/24. The clinical record contained a document titled " Notice of Medicare Provider Non-Coverage" the document lacked the date home health services will end. 1. Pt # 9 was admitted to home health services on 9/26/24 with diagnosis of hemiplegia. The clinical record was reviewed on 11/12/24. The clinical record contained a document titled " Notice of Medicare Provider Non-Coverage" the document lacked the date home health services will end. 2. Pt. #1 was admitted to home health services on 02/07/24 with a diagnosis of Hypertensive Chronic Kidney Disease. The clinical record was reviewed on 11/13/24. During the home visit conducted on 11/12/24, the Admission Booklet which contained the form “Notice of Medicare Non-Coverage.” The forms were signed by the Pt. on 02/07/24, but the areas containing “Effective Date of Coverage your current home health services will end” was left blank. 3. Pt. #5 was admitted to home health services on 10/02/24 with a diagnosis of Venous Insufficiency (chronic) (peripheral). The clinical record was reviewed on 11/13/24. The clinical record lacked the consent for treatment. 4. Pt. #7 was admitted to home health services on 09/10/24 with a diagnosis of Hypertensive Heart Disease and Chronic Kidney Disease with Heart Failure Stage 1 to 4. The clinical record was reviewed on 11/13/24. As of 11/14/24, the PT POC lacked the Physician’s signature. 5. During an interview with the Director/Clinical Manager and Quality Assurance Specialist on 11/13/24 at 12:00 PM, and on 11/14/24 at 10:30 AM, with the Director, Quality Assurance Specialist and Managing Partner/Administrator, the above findings were confirmed.