Excel Home Health

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the Quality Assurance and Performance Improvement (QAPI- data-driven, proactive approach to improve quality of care and services) program was fully developed, implemented, and maintained when the documents were undated, lacked signatures of the participant attendance, and the document contained no evidence of tracking, monitoring, or analysis. These failures led to the agency being unable to demonstrate an ongoing QAPI program or quality improvement because the required documentation and analysis were not provided. Findings: On 7/8/26 at 2:30 P.M., a joint interview and record review of the agency’s QAPI program binder was conducted with the Director of Patient Care Alternate (DPCSA). The DPCSA stated that she had been responsible for the QAPI program since January 2025. The DPCSA reviewed the QAPI binder under the binder tab labeled PIP - Performance Improvement Program. There were four programs. Program (1) Transfer and discharge summaries: This document was undated, lacked participant signatures, and contained no documented evidence of tracking, monitoring, or analysis. Program (2) Discharge Medication List: This document was undated, lacked participant signatures, and contained no documented evidence of tracking, monitoring, or analysis. Program (3) Coordination of Care Conference: This document was dated 3/15/25, lacked participant signatures, and contained no documented evidence of tracking, monitoring, or analysis. Program (4) NOMNC (Notice of Medicare Non-Coverage): This document was dated 10/15/25, lacked participant signatures, and contained no documented evidence of tracking, monitoring, or analysis. The DPCSA stated that monthly and quarterly QAPI meetings were held but could not provide documentation of data tracking or evaluation of these programs. The DPCSA further said she was still learning her role and responsibilities. Per the undated agency’s policy and procedure, titled Quality Assessment and Performance Improvement (QAPI) Plan, “…The QAPI function is designed to assess, measure and improve performance of clinical and administrative process and ultimately patient outcomes…””

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure hand hygiene (keeping hands clean) was performed prior to accessing the clinical supply bag for one of three home visits observed (Patient 2). This deficient practice has the potential to contaminate the inside of the supply bag and increase the risk of cross-contamination and spreading infectious diseases to other patients. Findings: Per review of the Home Health Certification and Plan of Care (POC), dated 6/18/26 through 8/16/26, Patient 2 was admitted to the agency on 12/20/25 with diagnoses that included a pressure ulcer (wound) of the right elbow. On 7/8/26 at 9:50 A.M., Skilled Nurse (SN) 1 was observed wearing gloves while assessing Patient 2’s tailbone area. At the caregiver’s request, SN 1 then examined Patient 2’s left heel. After completing the assessment, SN 1 was observed reaching into the clinical supply bag with the contaminated gloves still on to get a dressing. A follow-up interview was conducted with SN 1 on 7/8/26. SN 1 stated she should have removed the contaminated gloves and performed hand hygiene prior to retrieving wound supplies from the bag to prevent cross-contamination and spread of infectious diseases to other patients. On 7/8/26 at 2:15 P.M., an interview was conducted with the Director of Patient Care Services Alternate (DPCSA). The DPCSA stated that skilled nurses were required to perform hand hygiene and change gloves before accessing the supply bag to prevent cross-contamination. Per the agency’s undated policy and procedure, titled “Bag Technique,” failed to indicate that the nurse should perform hand hygiene before accessing the supply bag. Per the agency’s undated document, titled “Your 5 Moments for Hand Hygiene,” indicated to, “...Clean your hands after touching a patient and her/his immediate surroundings, when leaving the patient side...””