First Quality Home Care Inc.

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on attempted record review and staff interview, the agency failed to ensure the Condition of Participation for Quality Assessment/Performance Improvement (QA/PI) requirement was met by failing to ensure the implementation of an ongoing Quality Assessment Program to monitor effectiveness, safety of services, and quality of care. The agency failed to collect data and had no program activities to identify patients who were high risk, high volume or problem-prone areas. The findings include: Based on interview and attempted record review, the home health agency failed to provide documented evidence of an ongoing QAPI program that would measure, analyze, track quality indicators, adverse patient events, complaints, and other aspects of performance that enable the agency to assess processes of care, services, and operations. Cross Reference G642.”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on interviews and attempted record review, the Home Health Agency failed to organize, manage, and provide Skilled Nursing (SN) services as required; the Home Health Agency failed to provide skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) directly. Refer to (G982). The findings include: Based on interviews and attempted record review, the Home Health Agency failed to provide skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) directly. Refer to (G982).”

“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 attempted record review, the home health agency failed to provide documented evidence of an ongoing Quality Assurance Program Improvement Program that would measure, analyze, track quality indicators, adverse patient events, complaints, and other aspects of performance that enable the agency to assess process of care, services, and operations. The findings include: On 4/30/25 at approximately 1:20 PM, an interview was conducted with the Director of Nursing/Owner and the Administrator during which they were asked about the Quality Assurance Performance Improvement Program (QAPI). The Director of Nursing/Owner stated that they had not been doing QAPI because they do not have the staff. She offered that they do not currently have a QAPI committee and do not regularly meet, but they used to. She offered that the home health agency had moved twice in the last year and was only able to do orientation with new staff. She also stated that she had done a few “samplings” in 2024, explaining that these were chart reviews, but she was not currently doing anything. She stated they are waiting on the construction of the conference room and will establish the QA program then, offering that this may be done at the end of May. She further offered that they would use the results of the survey to “get it (QA) back in order”. When asked about the last time she had done “sampling,” she stated that she did not remember doing any sampling. “There have been so many moves I cannot remember when we got to this building, but we have not done any QA since we have been here”. The Administrator stated at this time “There is no committee, no meetings, we have to start doing this”. They offered that they do not get complaints and have not had one in over 2 years, therefore there is nothing for them to track. Review of the Health Care Licensing Application Home Health Agency - Change Licensure [provider address] form revealed the home health agency notified the Agency for Health Care Administration of the change of address to their current location on 4/10/24 with an effective date of 4/1/24.”

“Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient’s home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This Standard is not met as evidenced by: Based on interviews and attempted record review, the Home Health Agency failed to provide skilled nursing services and at least one other therapeutic service (physical therapy, speech-language, or occupational therapy; medical social services; or home health aide services) directly. The findings include: A review of Provider Profile retrieved from https://quality.healthfinder/fl/gov revealed the Home Health Agency provides Skilled Services that include Certified Nursing Assistant, Home Health Aides, IV therapy, Nursing Care, and Physical Therapy. A review of the Home Health Agency Survey Report (CMS-1572) dated 4/30/25, and not to have been completed by the Administrator, revealed under section 11. Services Provided: For each type of care service provided, indicated how this service is provided: next to Skilled Nursing, Physical Therapy, Occupational Therapy, Speech Therapy, and Infusion Services, a “1” was noted, which indicated that the services were provided by HHA (Home Health Agency) staff. Next to Home Health Aide was a “2” indicating the service was provided under contract. On 4/29/25 at approximately 9:00 AM, the Director of Nurse/Owner was asked to provide a list of patients who were receiving skilled and/or special services from the home health agency. At this time the DON/Owner stated that she was not able to provide this information because the home health agency was not providing skilled services at this time. On 4/29/25 at approximately 11:44 AM, an interview was conducted with the Administrator, who stated the agency had not provided skilled nursing services or therapy (physical, speech or occupational) in over 2 years. She stated that they could provide those skilled services if needed, but they had not been required to in the previous 2 years. They have a case manager who provides social services, such as scheduling and activation, for community program contracts they have with other state agencies. They employ a registered nurse (RN) who also provides activation of the community-based care contracts, but does supervisory visits for the home health aides. She clarified that the RN does not provide skilled care. On 4/20/25 at approximately 1:20 PM, a follow-up interview was conducted with the administrator, who confirmed that the last time the home health agency had provided skilled care to a patient was “4/20/23”. She was then asked what other services the RN currently performs, outside of supervisory visits, to which she replied that the nurse does “welcome visits,” during which she introduces the agency, gets consents signed, and provides the admission packet. The administrator again stated, “No skilled services are being provided at this time,” And offered that these visits were “Not clinical.””