Staff Mates Homecare

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on agency record review and interview with agency personnel, the Governing Authority failed to ensure an ongoing program for Quality Assurance Performance Improvement (QAPI) was reestablished, implemented, and maintained. The findings include. Review of the agency documentation, with the Administrator/Governing Authority/Owner and Supervisor of Clinical Services (SCS) on 6/24/24 at 11:00am, identified that the agency has been without an active Quality Assurance Performance Improvement (QAPI) committee since March 2023, due to unforeseen circumstances. The Administrator identified, they have attempted to fill the vacancies, within the committee, but as of this date, they have no active members or candidates. The agency failed to ensured participation of active members within the QAPI program and failed to ensure that the required agency clinical record review was conducted quarterly since March 2023 in accordance with agency policy Review of the agency policy identifies that at least quarterly, a committee of health professionals in active practice, or by peer review process, select a sample of active and discharged clinical records to be reviewed, to assure that the agency policies are followed, and that agency services are delivered within the agency’s defined scope of practice, safety practices and current standards. Subsequent to this surveyor inquiry, the agency Administrator produced Professional Advisory Committee meeting minutes for the years 2023 and 2024, disclosing annual clinical and organizational reviews with quality improvement plan submission for the agency.”

“12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This Standard is not met as evidenced by: Based on review of the agency in-service educational records, and personnel interviews, for six of six aide staff members, and three of five skilled nursing personnel, the agency failed to ensure at least 12 hours of In-service training for each 12 month period. The findings include. Interview and review of the aide and skilled professional staff educational records for January 2022 through December 2022 and January 2023 through December 2023, with the agency Business/Human Resources partner on 6/25/24 at 10:50am, identified that in-service education was afforded to all aide and skilled professional staff personnel, but failed to identify the agency and Supervisor of Clinical Services ensured the completion of the required 12 hours of in-service training in a 12 month period for the years 2022 and 2023. Interview with the Supervisor of Clinical Services on 6/26/24 at 2:30 pm identified aide and skilled professional staff are expected to completed all in-service training annually, but failed to identify the completion of the 12 hours of in-service training requirement within a 12 month period for 2022 and 2023.”

“Documentation of inservice training CFR(s): 484.80(d)(2) The HHA must maintain documentation that demonstrates the requirements of this standard have been met. This Element is not met as evidenced by: Based on review of the agency in-service educational records, and personnel interviews, for six of six aide staff members, the agency and Supervisor of Clinical Services failed to ensure at least 12 hours of aide staff In-service training for each 12 month period. The findings include. Review and interview of the aide and skilled professional staff educational records for January 2022 through December 2022 and January 2023 through December 2023, with the agency Business/Human Resources partner on 6/25/24 at 10:50am, identified that in-service education was afforded to the aide and skilled professional staff personnel, but failed to identify the Home Health Agency ensured the completion of the required 12 hours of in-service training in a 12 month period for the years 2022 and 2023. Interview with the Supervisor of Clinical Services on 6/26/24 at 2:30 pm, identified that aide and skilled professional staff are to complete 12 hours of in-service training every 12 month period, but failed to identify the completion of the aide in-service training requirement within a 12 month period for 2022 and 2023.”